Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. However, some substantiated issues arose, including medication administration errors found in October 2024 and July 2025, and safety concerns such as locked emergency exit gates without fire clearance and accessible hygiene products in dementia residents’ rooms, which posed immediate health and safety risks. Staffing and supervision deficiencies were also cited in late 2024 related to inadequate one-on-one care for an aggressive resident. The facility addressed medication discrepancies through a Plan of Correction, and the most recent inspection on July 17, 2025, found no deficiencies, showing improvement in that area. No fines or license suspensions were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Census: 27
Capacity: 82
Deficiencies: 0
Jul 17, 2025
Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection conducted to verify correction of deficiencies issued on 2025-07-08 during a prior Complaint Investigation visit.
Findings
No deficiencies were cited during this POC visit. The facility had submitted a Plan of Correction for medication discrepancies found during the complaint investigation, and staff medication training was reviewed. A Letter of Deficiencies Citations Cleared was provided during the visit.
Complaint Details
The original complaint investigation on 2025-07-08 was related to medication discrepancies found during a random audit of 4 residents' medications, specifically for Resident 8. A Plan of Correction was developed and submitted by the due date of 2025-07-09.
Report Facts
Residents audited: 4
Facility capacity: 82
Census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcella Tarin | Licensing Program Analyst | Conducted the Plan of Correction visit and reviewed staff medication training |
| Jessica Pryor | Regional Operations Specialist | Met with Licensing Program Analyst during the visit and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 82
Deficiencies: 0
Jul 8, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to multiple allegations received on 2025-01-27 regarding infection control practices, food quality, resident falls due to staffing, medication ordering timeliness, and laundry services at the facility.
Findings
Based on investigation, records reviewed, and interviews conducted, all allegations were found to be unsubstantiated. The facility was found to be following infection control protocols, providing adequate laundry services, maintaining sufficient staffing, and ensuring residents received their medications timely.
Complaint Details
The complaint investigation addressed allegations including improper infection control practices, inadequate laundry services, poor food quality, multiple resident falls due to insufficient staff, and untimely medication ordering. After interviews with residents, staff, and facility leadership, and review of documentation, all allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 82
Resident census: 24
Staff observed: 3
Residents observed: 12
PPE purchase months: 3
Sanitation log period: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenia Padilla | Executive Director | Interviewed regarding Norovirus outbreak, staffing, and medication ordering |
| Manuel Monter | Licensing Program Analyst | Conducted the complaint investigation |
| Krystal Jenkins | Regional Operations Specialist | Met with during the inspection |
| Simi Rai | Licensing Program Analyst | Conducted interviews and observations during the investigation |
| Carmen | Wellness Director | Interviewed regarding medication ordering delays |
| Romeo Manzano | Licensing Program Manager | Named in report header and signature |
| Marcella Tarin | Interviewed staff with LPA Manuel Monter | |
| Health Services Director | Health Services Director | Interviewed regarding infection control, staffing, and medication administration |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 82
Deficiencies: 0
Jul 8, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation based on complaints received on 2025-06-17 alleging that facility staff did not complete required training, hazardous items were accessible to residents, and staff did not assist a resident under hospice with feeding.
Findings
The investigation found all allegations to be unfounded or unsubstantiated. Staff had completed required training, no hazardous items were accessible to residents, and staff assisted residents under hospice with feeding as needed. Interviews and records review supported these conclusions.
Complaint Details
The complaint investigation addressed three allegations: 1) Facility staff did not complete required training, 2) Hazardous items were accessible to residents, and 3) Staff did not assist a resident under hospice with feeding. The first two allegations were found to be unfounded, meaning they were false or without reasonable basis. The third allegation was found to be unsubstantiated, indicating insufficient evidence to prove the allegation.
Report Facts
Facility capacity: 82
Census: 24
Staff training hours: 40
Residents under hospice: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manuel Monter | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kenia Padilla Sanchez | Administrator | Facility administrator named in the report |
| Krystal Jenkins | Regional Operations Specialist | Met with during inspection |
| Jessica Pryor | Regional Operations Specialist | Interviewed regarding hazardous items allegation |
| Romeo Manzano | Licensing Program Manager | Named in report as licensing program manager |
| Health Services Director | Health Services Director | Interviewed regarding staff training and feeding assistance |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 82
Deficiencies: 0
Jul 8, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-10-24 alleging insufficient staffing and lack of staff training in medication assistance.
Findings
The investigation found that staff and the Health Services Director stated there was sufficient staffing to meet residents' needs. Training records showed all med-tech staff had completed medication training. Resident and staff interviews indicated mixed responses but overall no evidence supported the allegations. The complaint was unsubstantiated.
Complaint Details
The complaint alleged insufficient staffing and lack of staff training in medication assistance. The investigation included interviews with staff and residents and review of training records. The allegations were found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 82
Census: 24
Staff interviewed: 6
Residents interviewed: 14
Med-tech training records reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenia Padilla Sanchez | Administrator | Named as facility administrator |
| Marcella Tarin | Licensing Program Analyst | Conducted the complaint investigation |
| Jin Jackie | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Krystal Jenkins | Regional Operations Specialist | Met with during the inspection visit |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 82
Deficiencies: 2
Jul 8, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of staff mismanaging residents' medication received on 2024-10-24.
Findings
The investigation found substantiated medication administration errors, including medications not administered as documented and medications not listed on the centrally stored medication log. These discrepancies posed immediate health, safety, and personal rights risks to residents.
Complaint Details
The complaint was substantiated based on medication audits and interviews. Medication M1 was not administered to residents R1 and R8 as documented, and medications for residents R7 to R10 were not listed on the centrally stored medication log. The Health Services Director was unable to explain the discrepancies.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel were not competent to provide necessary services to meet resident needs, evidenced by medication administration errors. | Type A |
| Failure to maintain a record of centrally stored prescription medications for each resident for at least one year. | Type B |
Report Facts
Capacity: 82
Census: 24
Deficiencies cited: 2
Plan of Correction Due Dates: 7
Plan of Correction Due Dates: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcella Tarin | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Jin Jackie | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 82
Deficiencies: 0
Jun 26, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following allegations received on 2025-05-15 regarding inadequate supervision, staff under the influence of substances, medication mismanagement, and insufficient administrator presence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with staff, residents' responsible parties, and record reviews indicated adequate supervision, no observed substance abuse by staff, proper medication administration, and sufficient administrator presence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate supervision, staff under the influence of alcohol and drugs, medication mismanagement, and insufficient administrator presence. Interviews and record reviews did not support these claims.
Report Facts
Resident records reviewed: 5
Staff added: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jessica Pryor | Regional Operations Specialist | Met with Licensing Program Analyst during the investigation |
| Kenia Padilla Sanchez | Administrator | Facility administrator mentioned in relation to allegations of insufficient presence |
| Jackie Jin | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Annual Inspection
Census: 25
Capacity: 82
Deficiencies: 0
Jun 26, 2025
Visit Reason
An unannounced annual visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in good repair with adequate food supplies, updated resident and staff records, and proper medication storage. No deficiencies were cited during this inspection.
Report Facts
Capacity: 82
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the inspection visit |
| Jessica Pryor | Regional Operations Specialist | Met with the Licensing Program Analyst during the inspection |
| Jackie Jin | Licensing Program Manager | Named in the report |
| Kenia Padilla Sanchez | Administrator | Facility administrator named in the report |
Inspection Report
Follow-Up
Census: 25
Capacity: 82
Deficiencies: 0
Jun 18, 2025
Visit Reason
The visit was an unannounced case management follow-up to verify correction of a previously cited deficiency regarding chemicals and hygiene products observed in dementia resident bedrooms and to ensure adherence to the submitted plan of correction.
Findings
During the visit, 7 out of 12 resident bedrooms observed contained hygiene products accessible to residents diagnosed with dementia, but based on record review, these residents were not at risk. No deficiencies were cited per California Code of Regulations, Title 22.
Report Facts
Residents with hygiene products observed: 7
Resident bedrooms toured: 12
Previously cited deficiency date: May 21, 2025
Plan of correction submission date: May 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Pryor | Regional Operations Specialist | Met with Licensing Program Analyst during the visit and reviewed the report |
| Christine Kabariti | Licensing Program Analyst | Conducted the unannounced case management follow-up visit |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 82
Deficiencies: 1
May 21, 2025
Visit Reason
The visit was an unannounced case management - deficiencies inspection conducted due to violations observed during a complaint investigation for complaint control number 26-AS-20240923130821.
Findings
The Licensing Program Analyst observed that 9 out of 11 resident rooms on the 2nd floor had hygiene products accessible to residents with dementia, which should have been locked. This posed an immediate health, safety, and personal rights risk to persons in care, resulting in a cited deficiency under California Code of Regulation, Title 22.
Complaint Details
The visit was triggered by a complaint investigation for complaint control number 26-AS-20240923130821. The deficiency cited was related to violations observed during the complaint investigation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Chemicals and hygiene products were observed in 9 out of 11 dementia resident rooms, posing an immediate health, safety, and personal rights risk to persons in care. | Type A |
Report Facts
Resident rooms with accessible hygiene products: 9
Total resident rooms observed: 11
Facility census: 25
Facility capacity: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenia Padilla Sanchez | Executive Director | Met with Licensing Program Analyst during inspection and involved in interview regarding deficiencies |
| Christine Kabariti | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 82
Deficiencies: 0
Dec 15, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-10-24 regarding allegations of neglect and injury to a resident.
Findings
The investigation found the allegations to be unsubstantiated, with no deficiencies observed or cited. It was determined that the resident's injuries were due to their own aggressive behavior and cognitive issues, and staff were available to assist residents as needed.
Complaint Details
The complaint alleged that a resident was covered in feces due to staff neglect and sustained a laceration with unclear details. The investigation concluded the allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint received date: Oct 24, 2023
Facility capacity: 82
Resident census: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Jennifer DeLeon | Weekend Manager and Memory Care Coordinator | Facility representative interviewed during the investigation |
| Mark T. Gasgonia | Administrator | Facility administrator named in the report |
| Liza King | Licensing Program Manager | Named in the exit interview section |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 82
Deficiencies: 1
Dec 15, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted due to a complaint received on 2023-11-16 regarding neglect and lack of supervision by staff to a resident who assaulted another resident.
Findings
The investigation found that a resident (R1) was aggressive and prone to physical confrontations, causing fear among residents and staff. The facility failed to provide adequate one-on-one supervision until after several incidents occurred. The complaint was substantiated and deficiencies related to staffing and supervision were cited.
Complaint Details
The complaint was substantiated based on the preponderance of evidence. The allegation involved neglect and lack of supervision by staff to a resident who assaulted another resident.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The facility was deficient as a resident required more one on one care and supervision, which posed an immediate threat to the health, safety, and personal rights of residents. | Type A |
Report Facts
Capacity: 82
Census: 30
Deficiency count: 1
Plan of Correction Due Date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Jennifer DeLeon | Weekend Manager and Memory Care Coordinator | Facility representative interviewed during the investigation |
| Mark T. Gasgonia | Administrator | Facility administrator named in the report |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 82
Deficiencies: 0
Oct 17, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff left medication unattended and accessible to residents in care.
Findings
The investigation included interviews with staff and observations of the facility. It was found that the alleged medication left unattended were empty bubble packs being discarded, and no medications were left accessible to residents. The allegation was determined to be unfounded.
Complaint Details
The complaint alleged that staff left medication unattended and accessible to residents. After investigation including interviews and observation, the allegation was found to be unfounded.
Report Facts
Capacity: 82
Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenia Sanchez | Executive Director | Met with Licensing Program Analysts during the investigation and reviewed the report |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Santino Fortes | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 82
Deficiencies: 1
Oct 17, 2024
Visit Reason
The inspection visit was an unannounced initial complaint investigation triggered by complaint control number 26-AS-20241007160553, which then prompted a case management - other visit due to observed violations.
Findings
During the facility tour, it was observed that 2 out of 2 side exit gates in the patio, considered emergency exits, were locked with combination locks without fire clearance approval, posing an immediate health, safety, and personal rights risk to persons in care. A deficiency was cited per California Code of Regulations, Title 22.
Complaint Details
The visit was initiated as an initial complaint investigation for complaint control number 26-AS-20241007160553. The deficiency related to locked emergency exit gates was substantiated.
Deficiencies (1)
| Description |
|---|
| 2 out of 2 side gates in the patio were locked using a combination lock without fire clearance approval, posing an immediate health, safety, and personal rights risk. |
Report Facts
Deficiency Type: 1
Plan of Correction Due Date: Oct 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenia Sanchez | Executive Director | Met with Licensing Program Analysts during the inspection and discussed the deficiency. |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Santino Fortes | Licensing Program Analyst | Conducted the inspection. |
| Sarah Yip | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 25
Capacity: 82
Deficiencies: 0
Jun 21, 2024
Visit Reason
Licensing Program Analyst Manuel Monter conducted an unannounced annual inspection visit to evaluate the facility's compliance with regulatory requirements.
Findings
The inspection found no deficiencies. The facility was toured inside and out, including residential areas and activity spaces. Safety equipment and food storage were compliant, and medication storage was secure. Fire safety equipment was up to date and drills were current.
Report Facts
Fire extinguisher service date: 2024
Fire alarm system test date: 2024
Last drill date: 2024
Resident medications reviewed: 3
Staff records reviewed: 3
Resident records reviewed: 3
Staff interviewed: 2
Residents interviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenia Sanchez | Administrator | Met with Licensing Program Analyst during inspection and provided facility census information |
| Manuel Monter | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 82
Deficiencies: 1
Aug 1, 2023
Visit Reason
The visit was an unannounced case management incident investigation triggered by an incident report received on 07/19/2023 involving a resident who was allegedly pinched by staff during a redirection attempt.
Findings
The investigation found that staff member S1 pinched and twisted the resident's nose causing bleeding, with no evidence that the resident bit the staff. The incident was reported late to the Department, and staff S1 was terminated. The facility conducted in-service training and notified the resident's physician and family. A deficiency was cited for failure to report the incident within seven days.
Complaint Details
The complaint investigation substantiated that staff member S1 pinched and twisted the resident's nose causing injury. The incident was not reported to the Department within the required seven days. Staff S1 was placed on leave and subsequently terminated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency within seven days of an incident threatening the welfare, safety, or health of a resident, including psychological abuse. | Type A |
Report Facts
Capacity: 82
Census: 19
Plan of Correction Due Date: Aug 2, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ignacio Lopez | Executive Director | Met with Licensing Program Analyst during the visit and involved in incident report and staff association issues |
| Christine Dolores | Licensing Program Analyst | Conducted the unannounced case management incident visit and authored the report |
| Mark T. Gasgonia | Administrator | Facility administrator listed in the report |
| Sarah Yip | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the evaluation |
Inspection Report
Original Licensing
Capacity: 82
Deficiencies: 0
May 24, 2023
Visit Reason
An unannounced pre-licensing inspection visit was conducted to evaluate the facility prior to licensing.
Findings
The facility was toured and inspected, including bedrooms, common areas, and safety equipment. All observed safety features such as fire alarms, detectors, and locked storage rooms were functioning properly. Infection Control Plan was reviewed and no deficiencies were noted.
Report Facts
Facility capacity: 82
Census: 0
Fire extinguisher service date: Apr 7, 2023
Room temperature: 71
Hot water temperature: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ignacio Lopez | Administrator | Met with Licensing Program Analyst during inspection |
| Phil Altman | Regional VP of Operation | Met with Licensing Program Analyst during inspection |
| Steve Chang | Licensing Program Analyst | Conducted the pre-licensing inspection visit |
Inspection Report
Original Licensing
Capacity: 82
Deficiencies: 0
May 5, 2023
Visit Reason
The visit was an initial licensing evaluation conducted via telephone interview to verify the applicant/administrator's understanding of community care facility licensing laws and readiness for licensing.
Findings
The applicant and administrator demonstrated understanding of licensing laws, facility operation, admission policies, staffing requirements, emergency preparedness, complaints reporting, and pre-licensing readiness. Identification was verified and required documentation was obtained.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Gasgonia | Administrator | Participated in COMP II interview and confirmed understanding of licensing laws. |
| Phil Altman | Licensee Designee | Participated in COMP II interview and confirmed understanding of licensing laws. |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Marisa Holabird | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
Loading inspection reports...
