Inspection Report Summary
Most inspections found deficiencies, though several complaint investigations were unsubstantiated. The most recent report from October 28, 2025, cited a deficiency for late reporting of suspected elder abuse following an allegation that a staff member punched a resident; the investigation was ongoing at that time. Earlier reports noted issues with rate increase notification, staff training and staffing shortages, safety hazards like weak smoke alarms and unsafe kitchen conditions, and administrative problems including an expired business license and inadequate administrator presence. There were no fines or license suspensions listed in the available reports. While some improvements appeared, such as no deficiencies in infection control in 2023 and a clean annual inspection in April 2025, the facility has had recurring concerns related mainly to resident care, staff qualifications, and safety compliance.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 14
Capacity: 15
Deficiencies: 1
Oct 28, 2025
Visit Reason
An unannounced case management incident visit was conducted following an allegation that a staff member punched a resident during care. The visit was to investigate the incident and review related documentation.
Findings
The licensee failed to submit a written report of suspected adult/elder abuse within seven days of the occurrence, which poses an immediate health and safety risk to residents. The investigation was ongoing, and a deficiency was cited for the reporting failure.
Complaint Details
The complaint involved an allegation by a resident that a staff member punched them during a brief change. The staff member was placed on administrative leave pending investigation. A Report of Suspected Dependent Adult/Elder Abuse (SOC341) was submitted late, on 10/23/2025, after the incident on 10/15/2025. The complaint investigation was ongoing at the time of the visit.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a written report of suspected adult/elder abuse within seven days of the occurrence as required by reporting regulations. | Type A |
Report Facts
Facility Capacity: 15
Census: 14
Deficiencies cited: 1
Plan of Correction Due Date: Oct 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily A. Gerr | Administrator | Administrator involved in reporting and interview regarding the incident |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection and investigation |
| Lisa Gerr | Licensee who reported the incident and requested guidance |
Inspection Report
Complaint Investigation
Census: 12
Capacity: 15
Deficiencies: 1
Apr 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including improper rate increase without proper notice, failure to follow admission agreements, insufficient staffing, and uncomfortable facility temperature.
Findings
The investigation substantiated the allegation that the facility increased a resident's rate without proper notice, citing a violation of California Health and Safety Code 1569.657(a). Other allegations regarding admission agreement violations, insufficient staffing, and uncomfortable temperature were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility increased Resident 1's rent by $1,000 without proper notice and failed to provide a copy of the admission agreement. Other allegations about admission agreement violations, insufficient staffing, and uncomfortable temperature were unsubstantiated due to insufficient evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide written notice of rate increase within two business days after initially providing services at the new level of care, including detailed explanation and itemization of charges. | Type B |
Report Facts
Capacity: 15
Census: 12
Rate increase amount: 1000
Incontinence supplies charge: 350
POC due date: Apr 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and issued findings |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
| Emily Gerr | Administrator | Facility administrator involved in investigation and findings |
| Dana Newquist | Administrator | Named as facility administrator in report header |
Inspection Report
Annual Inspection
Census: 12
Capacity: 15
Deficiencies: 0
Apr 21, 2025
Visit Reason
The inspection was a Case Management - Annual Continuation visit to evaluate compliance and care at the Residential Care Facility for the Elderly specializing in memory care.
Findings
The facility was observed to be clean, with a comfortable room temperature and proper fire safety equipment. The inspection was not completed due to time restraints and will be continued at a later date.
Report Facts
Fire extinguishers last serviced: 3
Residents receiving hospice services: 3
Staff on duty: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily A. Gerr | Administrator | Met with Licensing Program Analyst during inspection |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Annual Inspection
Census: 13
Capacity: 15
Deficiencies: 2
Feb 21, 2025
Visit Reason
An unannounced annual required inspection was conducted to evaluate the facility's compliance with licensing regulations and ensure resident safety and care standards.
Findings
The inspection found the facility to be generally clean and well-maintained with appropriate activities for residents. However, deficiencies were cited related to staff criminal record clearance and lack of First Aid/CPR training documentation for staff, posing safety risks.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure that Staff 1 (S1) was properly associated to the facility prior to working, residing, and/or volunteering, posing an immediate safety risk to persons in care. | Type A |
| Licensee was unable to provide First Aid/CPR training documents for facility staff, posing a potential health, safety or personal rights risk to persons in care. | Type B |
Report Facts
Fire extinguishers: 3
Smoke alarms: 15
Carbon monoxide detectors: 1
Staff on duty: 4
Residents on hospice: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily A. Gerr | Administrator | Met with Licensing Program Analyst during inspection and named in plan of correction |
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 14
Capacity: 14
Deficiencies: 1
Feb 16, 2024
Visit Reason
Licensing Program Analyst Kristin Kontilis conducted a Case Management - Annual Continuation visit to evaluate compliance with regulations at the facility.
Findings
Four smoke alarms were observed to have no signals or extremely weak signals, posing an immediate health and safety risk. Staff records were reviewed and found compliant with health screenings, trainings, and background clearances.
Deficiencies (1)
| Description |
|---|
| Four smoke alarms were observed to have no signals and/or extremely weak signals, posing an immediate health, safety or personal rights risk to persons in care. |
Report Facts
Capacity: 14
Census: 14
Hospice residents: 3
Smoke alarms deficient: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
| Emily Gerr | Administrator | Facility administrator met during inspection |
Inspection Report
Annual Inspection
Census: 14
Capacity: 14
Deficiencies: 5
Jan 31, 2024
Visit Reason
An unannounced annual required inspection was conducted to evaluate compliance with regulations for the Residential Care Facility for the Elderly (RCFE).
Findings
The facility was generally clean and well-maintained with adequate lighting and safety equipment; however, deficiencies were noted including an electrical outlet within reach of a resident's bed, soiled kitchen items in the sink, cluttered kitchen counters with mildew/debris, and unused washer and dryer stored on the patio posing health and safety risks. Additionally, the facility's business license was expired.
Deficiencies (5)
| Description |
|---|
| Electrical outlet within reach of a resident's bed. |
| Soiled items in the kitchen sink. |
| Cluttered kitchen counters with dark mildew/debris between tile pieces. |
| Unused washer and dryer stored on the west patio posing immediate health, safety or personal rights risk. |
| Facility business license expired as of 5/12/2023. |
Report Facts
Staff on duty: 5
Residents on hospice: 3
Fire extinguishers: 4
Fire extinguisher service date: Mar 29, 2023
Business license expiration date: May 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
| Emily Gerr | Administrator | Facility administrator met with LPA during inspection |
Inspection Report
Complaint Investigation
Census: 12
Capacity: 14
Deficiencies: 2
Mar 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/14/2022 regarding staff training deficiencies and insufficient staffing at the facility.
Findings
The investigation substantiated that staff did not have sufficient or current medication training and that the facility had insufficient staffing at times, including incidents of staff sleeping on shift or not showing up. Other allegations regarding resident falls due to staff neglect, uncleared staff, and failure to report incidents were found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations of improper staff training and insufficient staffing. It was unsubstantiated for allegations of resident falls due to staff neglect, uncleared staff caring for residents, and failure to report incidents.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as staff fell asleep on shift or did not show up, posing a potential health and safety risk. | Type B |
| Training requirements for medication assistance were not met as five staff (S1, S2, S3, S4, licensee) did not have adequate current medication training. | Type B |
Report Facts
Capacity: 14
Census: 12
Medication training hours: 8
Medication training hours: 7
Medication training hours: 8
Medication training hours: 8
Medication training hours: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Emily Gerr | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Dana Newquist | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 12
Capacity: 14
Deficiencies: 4
Mar 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/12/2022 regarding the facility not meeting resident needs, failure to arrange timely medical attention, failure to notify authorized representatives of bruising, absence of the facility administrator, and untimely communication responses.
Findings
The investigation substantiated several allegations including inappropriate dressing of a resident during a heatwave, failure to arrange timely medical attention for a resident, failure to notify the resident's authorized representative about bruising in a timely manner, absence of the designated administrator on site, and untimely responses to communications from the responsible party. Some allegations related to staff neglect and medication administration were unsubstantiated, though a technical violation was issued for medication record discrepancies.
Complaint Details
The complaint investigation was substantiated for allegations that the facility did not meet resident needs, failed to arrange timely medical attention, failed to notify the resident's authorized representative of bruising, the administrator was not present adequately, and the administrator did not respond timely to communications. The allegations of staff neglect causing bruising and medication not given as prescribed were unsubstantiated.
Severity Breakdown
Type B: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Observation of the Resident: Failure to document and notify changes in resident's physical condition timely. | Type B |
| Administrator Qualifications and Duties: Administrator not present sufficient hours to manage the facility. | Type B |
| Personal Rights: Failure to respond promptly and appropriately to communications from resident's representatives. | Type B |
| Incidental Medical and Dental Care: Facility staff did not arrange medical attention, instructing family members instead. | Type B |
Report Facts
Facility Capacity: 14
Census: 12
Deficiencies cited: 4
Temperature: 99
Temperature: 85
Days without response: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dana Newquist | Administrator | Named as administrator on record but not present adequately |
| Lisa Gerr | Licensee and Administrator | Met with Licensing Program Analyst; identified as Administrator |
| Emily Gerr | Administrator | Back-up Administrator; met with Licensing Program Analyst |
| Kristin Kontilis | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Kelly Burley | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Annual Inspection
Census: 12
Capacity: 14
Deficiencies: 0
Feb 27, 2023
Visit Reason
The inspection was a required 1-year unannounced infection control annual visit to assess compliance with infection control protocols.
Findings
No deficiencies were observed during the visit. All infection control protocols were implemented and followed, including screening, PPE use, isolation procedures, and staff training.
Report Facts
PPE supply duration: 30
Number of bedrooms: 12
Number of resident rest-rooms: 5
Administrator certificate expiration date: Feb 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily Gerr | Administrator | Met with Licensing Program Analyst during inspection and responsible for infection control and staffing |
| Rachael De Leon | Licensing Program Analyst | Conducted the inspection visit |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 12
Capacity: 14
Deficiencies: 0
Nov 15, 2021
Visit Reason
An announced pre-licensing visit was conducted to evaluate the facility for licensing as a Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be compliant with Title 22 Regulations at the time of inspection. The physical plant, safety equipment, and resident accommodations were all in good condition and appropriate for licensing.
Report Facts
Fire extinguishers serviced date: Mar 20, 2021
Hospice waiver requested: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Gerr | Administrator | Met with Licensing Program Analyst during pre-licensing visit |
| Kristin Kontilis | Licensing Program Analyst | Conducted the pre-licensing visit and authored the report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Original Licensing
Census: 13
Capacity: 14
Deficiencies: 0
Oct 19, 2021
Visit Reason
The visit was conducted as part of the original licensing process for the facility, including a telephone call with the applicant/administrator to verify identity and confirm understanding of Title 22 regulations.
Findings
The applicant/administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, staff qualifications, program policies, and application document requirements. No deficiencies or violations were noted in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Gerr | Administrator | Applicant/administrator who participated in the licensing process and telephone call. |
| Julia Kim | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Nicole Rouse | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
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