Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
49% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that staff manipulate residents and instill fear to get what they want.
Complaint Details
The complaint alleged that staff manipulate residents and instill fear to obtain things, including financial matters such as stock investments. The investigation included interviews with 11 staff and 11 residents, all of whom denied the allegations. The complaint was found to be unsubstantiated due to lack of evidence.
Findings
Interviews with all staff and residents denied the allegations of manipulation and financial abuse. There was no evidence found to corroborate the complaint, and the allegation was determined to be unsubstantiated.
Report Facts
Capacity: 310
Census: 152
Staff interviewed: 11
Residents interviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during investigation and exit interview |
| Mayra Cota | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 310
Deficiencies: 0
Date: Oct 7, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not ensuring proper infection control practices were being followed, including concerns about COVID cases and communal dining without proper precautions.
Complaint Details
The complaint alleged improper infection control practices related to COVID-19, including five COVID cases and communal dining without facial coverings or precautions. The investigation found no evidence to substantiate the allegation.
Findings
The investigation included interviews with staff, residents, and a public health representative, review of infection control plans and COVID protocols, and a facility tour. The allegation was found to be unsubstantiated as staff followed proper infection control measures, including isolation of positive cases, use of PPE, suspension of communal dining, and regular cleaning and testing.
Report Facts
COVID cases: 5
Staff interviewed: 7
Residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during investigation and exit interview |
| Mayra Cota | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Annual Inspection
Census: 151
Capacity: 310
Deficiencies: 2
Date: Oct 3, 2025
Visit Reason
An unannounced Case Management - Annual Continuation visit was conducted to continue the annual inspection initiated on 2025-09-19 using CARE tools.
Findings
The inspection reviewed personnel records, medical and dental care, resident records, and special health needs. Deficiencies were noted related to medication storage and resident reappraisals, with plans of correction required.
Deficiencies (2)
Resident #6 had an as needed prescribed medication out of original container without pharmacy label.
Four out of ten residents did not have a reappraisal done within the last 12 months.
Report Facts
Residents on hospice: 5
Staff files reviewed: 10
Residents files reviewed: 10
Residents interviewed: 5
Residents with medication deficiency: 1
Residents with reappraisal deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during the inspection. |
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Wei Siew Ho | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Annual Inspection
Census: 151
Capacity: 310
Deficiencies: 2
Date: Oct 3, 2025
Visit Reason
An unannounced Case Management - Annual Continuation visit was conducted to continue the annual inspection initiated on 2025-09-19 using CARE tools.
Findings
The inspection reviewed personnel records, staff training, medication storage and administration, resident records, and special health needs. Deficiencies were noted related to medication storage and timely resident reappraisals.
Deficiencies (2)
Resident #6 had a prescribed medication (clotrimazole 1% cream) out of its original container without a pharmacy label.
Four out of ten residents did not have a pre-admission appraisal updated within the last 12 months.
Report Facts
Staff files reviewed: 10
Residents' medication reviewed: 10
Residents' files reviewed: 10
Residents on hospice: 5
Residents interviewed: 5
Residents with outdated appraisals: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during inspection and named in medication deficiency finding |
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and signed the report |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 151
Capacity: 310
Deficiencies: 0
Date: Sep 19, 2025
Visit Reason
Licensing Program Analyst Mary Flores conducted an unannounced annual visit at the facility using the CARE tool to evaluate compliance with licensing requirements.
Findings
No deficiencies were noted during this visit; however, a Technical Violation was observed. The facility was found to be operating within the limitations of their license with good physical plant conditions, proper infection control, and adequate staffing.
Report Facts
Fire extinguisher last checked date: May 9, 2025
Emergency disaster drill last conducted: Jul 23, 2025
Administrator certificate expiration: Sep 3, 2026
Residents allowed bedridden: 25
Hospice waiver residents: 30
Staff on duty during night shift: 5
Water temperature range: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during inspection and named in staffing and exit interview |
| Mary Flores | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
Inspection Report
Annual Inspection
Census: 151
Capacity: 310
Deficiencies: 0
Date: Sep 19, 2025
Visit Reason
An unannounced annual inspection visit was conducted using the CARE tool to evaluate compliance with licensing requirements and facility operations.
Findings
No deficiencies were noted during this visit; however, a technical violation was observed. The facility was found to be in good repair, operating within license limitations, and maintaining proper infection control, safety, and operational standards.
Report Facts
Licensed capacity: 310
Current census: 151
Fire extinguisher last checked: May 9, 2025
Emergency drill last conducted: Jul 23, 2025
Administrator certificate expiration: Sep 3, 2026
Number of employees on night shift: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during inspection; certificate reviewed |
| Mary G Flores | Licensing Evaluator | Conducted the unannounced annual visit and inspection |
| Wei Siew Ho | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 310
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that a resident sustained a severe pressure injury due to staff neglect and that staff were not properly trained.
Complaint Details
The complaint involved allegations that a resident sustained a severe pressure injury due to staff neglect and that staff were not properly trained. The investigation included review of resident and staff records, interviews with staff and family members, and observation of care practices. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Records and interviews indicated that the resident was under hospice care, staff followed instructions for repositioning every 2-3 hours, and training was provided. The resident's pressure injury was present upon admission and worsened due to health conditions. The allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 310
Resident census: 148
Visit start time: 900
Visit end time: 1010
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during inspection and named in report |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 310
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident sustained a severe pressure injury due to staff neglect and that staff were not properly trained.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a resident sustaining a severe pressure injury due to staff neglect and staff not being properly trained. The investigation included review of resident and staff records, interviews with staff and family members, and observation of care practices. Hospice staff confirmed proper care was provided. The resident passed away due to Atherosclerotic Cardiovascular disease. No violations were substantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The resident was under hospice care with documented instructions for staff to rotate the resident every 2-3 hours, and staff training and documentation supported compliance. The resident's pressure injury was present upon admission and worsened due to health conditions despite care. The allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 310
Census: 148
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during investigation and named in report |
| Nune Margaryan | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 310
Deficiencies: 0
Date: Mar 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations of staff neglect resulting in a resident's death and staff mishandling residents' medications.
Complaint Details
The complaint alleged that staff neglect resulted in a resident sustaining a death and that staff mishandled residents' medications by giving wrong medications and taking medications home. The investigation included interviews with the Executive Director, Wellness Director, staff, residents, and a family member, as well as review of records and observation of medication administration processes. The allegations were found unsubstantiated due to lack of evidence.
Findings
The investigation found no corroborative evidence to support the allegations. Interviews with staff, residents, and family members, as well as record reviews, indicated that the resident died a natural death and medications were administered properly and securely. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 310
Census: 146
Number of allegations: 2
Number of staff interviewed: 4
Number of residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Interviewed regarding allegations and during exit interview |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 310
Deficiencies: 0
Date: Mar 28, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations of staff neglect resulting in a resident's death and staff mishandling residents' medications.
Complaint Details
The complaint involved two allegations: 1) Staff neglect resulted in a resident sustaining a death; 2) Staff mishandled residents' medications. Both allegations were found to be unsubstantiated after interviews and record reviews.
Findings
The investigation found no corroborative evidence supporting the allegations. Interviews with staff, residents, and family members, as well as record reviews, indicated that the resident died a natural death and medications were administered properly with no discrepancies found.
Report Facts
Capacity: 310
Census: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Interviewed regarding allegations and investigation findings |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Named in report signature and oversight |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 310
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that unqualified staff were administering injections and taking residents' vital signs.
Complaint Details
The complaint alleged that unqualified staff were administering injections and taking vital signs. The allegations were unsubstantiated after interviews with staff and residents and review of protocols and observations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the claims, and observations showed that med-techs assisted residents with self-injections without administering injections themselves, and only licensed medical professionals recorded and reported vital signs.
Report Facts
Staff interviewed: 6
Residents interviewed: 9
Staff interviewed: 6
Residents interviewed: 9
Med techs reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during investigation and exit interview |
| Sanjay Vaid | Licensing Program Analyst | Conducted complaint investigation |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 310
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that unqualified staff were administering injections and taking residents' vital signs without proper training.
Complaint Details
The complaint was unsubstantiated. Allegations included unqualified staff administering injections and taking vital signs. Interviews with staff and residents, review of records, and observations did not support the allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the claims, and observations showed that med-techs assisted residents with self-injections without administering injections themselves. Vital signs were taken by licensed medical professionals following physician orders and protocols.
Report Facts
Staff interviewed: 6
Residents interviewed: 9
Staff interviewed: 6
Residents interviewed: 9
Capacity: 310
Census: 147
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during inspection and exit interview |
| Sanjay Vaid | Licensing Program Analyst | Conducted the complaint investigation |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 141
Capacity: 310
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
An unannounced annual required visit was conducted to evaluate compliance with licensing requirements for the facility serving elderly residents.
Findings
The facility was found to be clean, well-maintained, and compliant with regulations. No deficiencies were cited. Safety equipment was functional, staff files and resident files were in order, and infection control plans and liability insurance were current.
Report Facts
Licensed capacity: 310
Current census: 141
Bedridden residents allowed: 25
Hospice waiver residents allowed: 30
Staff files reviewed: 10
Staff interviewed: 9
Resident files reviewed: 8
Residents interviewed: 10
Water temperature range: 105
Water temperature range: 120
Administrator license expiration date: Sep 3, 2024
Liability insurance expiration date: Sep 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst and participated in inspection |
| Sanjay Vaid | Licensing Program Analyst | Conducted the inspection and evaluation |
| Fernando Fierros | Supervisor | Supervisor of Licensing Program Analyst |
Inspection Report
Annual Inspection
Census: 141
Capacity: 310
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
An unannounced annual required visit was conducted to evaluate compliance with licensing requirements for the facility serving elderly residents.
Findings
The facility was found to be clean, well-maintained, and compliant with regulations. No deficiencies were cited during the inspection. Staff personnel and resident files were reviewed without discrepancies. Safety equipment and emergency plans were in place and functional.
Report Facts
Licensed capacity: 310
Current census: 141
Bedridden residents allowed: 25
Hospice waiver residents allowed: 30
Staff files reviewed: 10
Staff interviewed: 9
Resident files reviewed: 8
Residents interviewed: 10
Water temperature range: 105
Water temperature range: 120
Infection control plan expiration: Sep 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Sanjay Vaid | Licensing Evaluator | Conducted the inspection and authored the report |
| Fernando Fierros | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 310
Deficiencies: 5
Date: Jul 26, 2024
Visit Reason
The visit was an unannounced office inspection related to complaint investigation #28-AS-20230503110725 concerning staffing, accommodations, night supervision, facility disrepair, and COVID-19 outbreak reporting.
Complaint Details
Complaint investigation findings for complaint #28-AS-20230503110725 were discussed, identifying multiple violations including staffing, accommodations, supervision, facility condition, and reporting failures.
Findings
The facility was found to have insufficient staff to meet residents' needs, was not providing reasonable accommodations, had night supervision issues preventing emergency access, was in disrepair, and failed to report a COVID-19 outbreak as required by Title 22 regulations.
Deficiencies (5)
Facility did not have sufficient staff to meet residents needs
Facility is not providing reasonable accommodations to residents in care
Night supervision - Emergency personnel could not access facility
Facility in Disrepair
Facility did not report COVID-19 outbreak to the department per Title 22 Regulations
Report Facts
Annual Licensing Fees: 3300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Named in relation to plan of corrections and exit interview |
| Fernando Fierros | Licensing Program Manager | Present during meeting and supervisor |
| Sanjay Vaid | Licensing Program Analyst | Present during meeting and licensing evaluator |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 310
Deficiencies: 5
Date: Jul 26, 2024
Visit Reason
The visit was conducted as a complaint investigation related to complaint #28-AS-20230503110725, addressing issues such as insufficient staffing, lack of reasonable accommodations, night supervision problems, facility disrepair, and failure to report a COVID-19 outbreak.
Complaint Details
Complaint investigation findings for complaint #28-AS-20230503110725 were discussed, confirming multiple regulatory violations.
Findings
The investigation found multiple deficiencies including insufficient staff to meet residents' needs, failure to provide reasonable accommodations, emergency personnel access issues during night supervision, facility disrepair, and failure to report a COVID-19 outbreak as required by Title 22 regulations.
Deficiencies (5)
Facility did not have sufficient staff to meet residents needs
Facility is not providing reasonable accommodations to residents in care
Night supervision - Emergency personnel could not access facility
Facility in disrepair
Facility did not report COVID-19 outbreak to the department per Title 22 Regulations
Report Facts
Annual Licensing Fees: 3300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Named in relation to plan of corrections and exit interview |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 310
Deficiencies: 0
Date: Feb 26, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff mismanaged a resident's medication record.
Complaint Details
The allegation was that someone signed initials for a med tech who was not present and that the department director was not addressing the issue. Staff interviews and record reviews did not support this claim, and no witnesses were found. The allegation was unsubstantiated.
Findings
The investigation found no evidence to support the allegation. Staff denied the claim, records reviewed showed no errors, and no discrepancies were found in the Medication Administration Records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 310
Census: 148
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during the investigation and named in the report |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 310
Deficiencies: 0
Date: Feb 26, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff mismanaged a resident's medication record.
Complaint Details
The allegation was that someone signed initials for a med tech who was not present and that the department director did not address this. Staff denied the allegation and stated that each has their own password and cannot sign for another. No witnesses or supporting documents were found. The allegation was unsubstantiated.
Findings
The investigation found no evidence to support the allegation. Medication Administration Records were reviewed with no errors observed, and staff denied the allegation. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 310
Census: 148
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during the investigation and named in the report |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 310
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that the facility was not complying with Covid-19 regulations by requiring staff to return to work 3-5 days after testing positive and that the administrator was opening the dining room during a Covid outbreak.
Complaint Details
The complaint was unsubstantiated based on interviews with residents and staff, review of logs, and public health guidelines. There was no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that staff followed quarantine protocols requiring 5 days quarantine and negative test results before returning to work, with clearance letters required. Dining room protocols during outbreaks included limited seating, social distancing, and sanitization. There was insufficient evidence to prove the allegations, so they were unsubstantiated.
Report Facts
Capacity: 310
Census: 146
Staff interviewed: 7
Residents interviewed: 10
Daily COVID-19 logs reviewed: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Named in relation to allegations and interviews regarding Covid-19 protocols |
| Sanjay Vaid | Licensing Program Analyst | Conducted complaint investigation |
| Mary Flores | Licensing Program Analyst | Conducted complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 310
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to allegations that the facility was not complying with Covid-19 regulations regarding staff return to work after testing positive and that the administrator was opening the dining room during a Covid outbreak.
Complaint Details
The complaint alleged noncompliance with Covid-19 regulations by requiring staff to return to work 3-5 days after testing positive and opening the dining room during a Covid outbreak. The investigation included interviews with residents and staff, review of logs and health orders, and found the allegations unsubstantiated.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations occurred, resulting in the allegations being unsubstantiated. Interviews and record reviews showed the facility followed Covid-19 protocols including quarantine periods, clearance letters for staff, and dining room restrictions during outbreaks.
Report Facts
Facility capacity: 310
Census: 146
Resident interviews: 10
Staff interviews: 7
Covid logs reviewed: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Named in relation to allegations and interviews regarding Covid-19 protocols |
| Sanjay Vaid | Licensing Program Analyst | Conducted the complaint investigation |
| Mary Flores | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 1
Date: Nov 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility left a resident unsupervised in a facility vehicle and did not provide care to the resident during that time.
Complaint Details
The complaint was substantiated. The facility left resident R1 unsupervised in the facility vehicle for several hours. Staff confirmed the incident, and the resident was sent to the hospital for evaluation. The facility did not provide care during the time the resident was left unattended.
Findings
The investigation substantiated that a resident (R1) was left unattended in the facility shuttle from 3:00 pm to 8:45 pm due to staff error, resulting in no care being provided during that time. The staff member responsible was dismissed, and civil penalties were assessed.
Deficiencies (1)
Facility left resident unattended in facility van from 3:00 pm to 8:45 pm, posing immediate health, safety, or personal rights risk.
Report Facts
Capacity: 310
Census: 152
Deficiency Type A: 1
Time resident left unattended: 5.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Named in findings related to the incident of resident left unattended |
| Jewel Baptiste | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 1
Date: Nov 13, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation conducted to investigate allegations that the facility left a resident unsupervised in a facility vehicle and did not provide care to the resident during that time.
Complaint Details
The complaint was substantiated. The facility left resident R1 unsupervised in the facility vehicle for several hours. Staff confirmed the incident, and the resident was sent to the hospital. The facility did not provide care during this time. Civil penalties were assessed.
Findings
The investigation substantiated that a resident (R1) was left unattended in the facility shuttle from 3:00 pm to 8:45 pm, posing an immediate health and safety risk. Staff confirmed the incident, and the resident was sent to the hospital for evaluation. The facility did not provide care to the resident during the time left unattended. Civil penalties were assessed.
Deficiencies (1)
Failure to provide care, supervision, and services that meet individual needs by staff sufficient in numbers, qualifications, and competency, evidenced by leaving a resident unattended in the facility van from 3:00 pm to 8:45 pm.
Report Facts
Capacity: 310
Census: 152
Duration resident left unattended: 5.75
Plan of Correction Due Date: Due date for plan of correction is 11/14/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Confirmed the incident of resident left unattended and participated in exit interview |
| Jewel Baptiste | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 310
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff were not able to adequately care for a resident due to the resident needing a higher level of care, and that a resident assaulted other residents in care.
Complaint Details
The complaint involved allegations that staff could not adequately care for a resident due to aggressive behaviors and that the resident assaulted other residents. The resident was hospitalized following an incident involving aggression. Interviews and record reviews indicated behaviors consistent with the resident's diagnosis and sufficient staff response. The allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that although the resident exhibited aggressive behaviors consistent with their medical diagnosis, there was insufficient evidence to substantiate the allegations. Staff were able to provide care and there was sufficient staffing and supervision. The allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 310
Resident census: 150
Number of residents interviewed: 6
Number of staff interviewed: 6
Incident date: Oct 12, 2023
Previous incident date: Sep 20, 2023
Number of Reflections unit staff responding: 4
Number of residents confirming assault allegation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during investigation and exit interview |
| Noemi Galarza | Licensing Program Analyst | Conducted complaint investigation |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 310
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff were not able to adequately care for a resident needing a higher level of care and that a resident assaulted other residents in care.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate care due to resident needing higher level of care and resident assaulting others. Evidence showed resident behaviors were consistent with medical diagnosis and incidents were managed appropriately without lack of supervision or staffing.
Findings
The investigation found that although the resident exhibited aggressive behaviors consistent with their medical diagnosis, there was insufficient evidence to substantiate the allegations. Staff were able to provide care and there was sufficient staffing and supervision. The allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 310
Census: 150
Incident date: Oct 12, 2023
Incident date: Sep 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Facility representative met during investigation and exit interview |
| Noemi Galarza | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not prevent a resident from assaulting another resident and that staff handled a resident in a rough manner.
Complaint Details
The complaint involved allegations that staff failed to prevent a resident from assaulting another resident and that staff handled a resident roughly. The investigation found no conclusive evidence to substantiate these allegations, and the complaint was determined to be unsubstantiated.
Findings
The investigation included interviews with staff, residents, and a family member, review of records, and a tour of the memory care unit. The allegations were found to be unsubstantiated due to lack of preponderance of evidence, with staff stating they intervened appropriately and residents and family members reporting attentive and caring staff.
Report Facts
Capacity: 310
Census: 152
Staff interviewed: 7
Residents interviewed: 4
Family members interviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during the investigation and mentioned in findings |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff did not prevent a resident from assaulting another resident and that staff handled a resident in a rough manner.
Complaint Details
The complaint involved allegations that staff failed to prevent a resident from assaulting another and that staff handled a resident roughly. The allegations were unsubstantiated after interviews with staff, residents, a family member, and review of records.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff were observed to intervene appropriately, use redirection techniques, and handle residents carefully without force or causing injury. Residents and family members reported positive feedback about staff attentiveness and care.
Report Facts
Capacity: 310
Census: 152
Staff interviewed: 7
Residents interviewed: 4
Family members interviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during the investigation and mentioned in findings |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Rhonda Guzman | Wellness Director | Met with during the investigation |
| Tony Vasallo | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 0
Date: Sep 2, 2023
Visit Reason
An unannounced complaint investigation visit was conducted on 09/02/2023 regarding allegations that staff were not providing residents with paid services, admissions agreements, and were not responding to call buttons.
Complaint Details
The complaint involved allegations that staff were not providing residents with services paid for, not providing admissions agreements, and not responding to call buttons. After interviews with staff and residents and review of relevant documents and observations, the allegations were found to be unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents interviewed denied the allegations, and document reviews showed no discrepancies. Therefore, all allegations were unsubstantiated.
Report Facts
Capacity: 310
Census: 152
Staff interviewed: 3
Residents interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during investigation |
| Tony Vasallo | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 0
Date: Sep 2, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted on 09/02/2023 regarding allegations that staff were not providing residents with paid services, admissions agreements, and responding to call buttons.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not providing paid services, not providing admissions agreements, and not responding to call buttons. Interviews with staff and residents, document reviews, and observations did not support the allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents interviewed denied the allegations, and document reviews and observations showed no discrepancies. Therefore, all allegations were unsubstantiated.
Report Facts
Capacity: 310
Census: 152
Staff interviewed: 3
Residents interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kevin Taliaferro | Administrator | Facility administrator met during investigation and exit interview |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 152
Capacity: 310
Deficiencies: 0
Date: Sep 2, 2023
Visit Reason
An unannounced subsequent required 1-year annual inspection was conducted to evaluate compliance with licensing requirements.
Findings
No deficiencies were cited during the inspection. Staff and resident files were reviewed with no discrepancies found, and the facility's infection control plan and liability insurance were verified.
Report Facts
Staff files reviewed: 6
Staff interviewed: 9
Resident files reviewed: 10
Residents interviewed: 9
Liability insurance expiration date: Sep 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during the inspection and participated in exit interview |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the inspection and file reviews |
| Tony Vasallo | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 152
Capacity: 310
Deficiencies: 0
Date: Sep 2, 2023
Visit Reason
An unannounced subsequent required 1-year annual inspection was conducted to review staff and resident files, interview staff and residents, and verify compliance with licensing requirements.
Findings
No deficiencies were cited during the inspection. Reviews of staff personnel files, resident files, and facility infection control plan found no discrepancies. Liability insurance was current.
Report Facts
Staff files reviewed: 6
Staff interviewed: 9
Resident files reviewed: 10
Residents interviewed: 9
Liability insurance expiration date: Sep 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the inspection and file reviews |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 2
Date: Aug 31, 2023
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations that the facility was not providing reasonable accommodations to a resident in care and that the facility was in disrepair.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to provide reasonable accommodations to a resident and facility disrepair. Evidence from interviews, observations, and record review supported these findings.
Findings
The investigation substantiated that the facility failed to provide reasonable accommodation to a resident by temporarily placing them in a memory care unit that did not meet their individual needs. Additionally, the facility was found to be in disrepair due to flooding and plumbing issues in the resident's room.
Deficiencies (2)
Facility placed resident in memory care unit even though resident does not require memory care assistance or have a MCI diagnosis, violating reasonable accommodation rights.
Facility had flooding in resident's room caused by plumbing issues, violating maintenance and operation requirements.
Report Facts
Capacity: 310
Census: 152
Plan of Correction Due Date: Aug 5, 2023
Plan of Correction Due Date: Aug 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during investigation and named in findings |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 152
Capacity: 310
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
An unannounced Annual Required Visit was conducted to evaluate compliance with licensing requirements for the facility serving elderly residents over 60 years old.
Findings
The facility was observed to be clean, well-maintained, and compliant with safety and health standards. No deficiencies were cited during this visit. Observations included proper food handling, adequate supplies, safe water temperatures, locked medication carts, and functional safety equipment.
Report Facts
Hospice waiver residents: 30
Non-ambulatory residents capacity: 310
Bedridden residents capacity: 25
Water temperature range: 105-120
Walk-in refrigerator temperature: 37
Perishable food supply: 2
Non-perishable food supply: 7
Servers observed: 3
Resident rooms inspected: 8
Bathroom sinks tested: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst and participated in exit interview |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the unannounced annual required visit and observations |
| Tony Vasallo | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 152
Capacity: 310
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
An unannounced Annual Required Visit was conducted to evaluate compliance with licensing requirements for the facility serving elderly residents over 60 years old.
Findings
The facility was observed to be clean, well-maintained, and properly equipped with sufficient supplies and safety measures. No deficiencies were cited during this visit.
Report Facts
Residents allowed non-ambulatory: 310
Bedridden residents allowed: 25
Hospice waiver residents: 30
Census: 152
Resident rooms inspected: 8
Resident bathroom sinks tested: 8
Water temperature range: 105
Water temperature range: 120
Perishable food supply: 2
Non-perishable food supply: 7
Walk-in refrigerator temperature: 37
Servers observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst and led facility tour |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the unannounced annual required visit and observations |
| Tony Vasallo | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 310
Deficiencies: 2
Date: Aug 31, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was not providing reasonable accommodations to a resident in care and that the facility was in disrepair.
Complaint Details
The complaint was substantiated based on interviews, observations, and record review. The allegations included failure to provide reasonable accommodations and facility disrepair. The resident was temporarily relocated to a memory care unit that did not meet their needs, and the facility experienced flooding and plumbing issues in the resident's room.
Findings
The investigation substantiated both allegations: the facility placed a cognitively intact resident in a memory care unit that did not meet their individual service needs, and the facility experienced repeated flooding and plumbing issues causing unsafe conditions in the resident's room.
Deficiencies (2)
Facility placed resident in memory care unit even though resident does not require memory care assistance or have a MCI diagnosis, violating reasonable accommodation rights.
Facility had flooding in resident's room caused by plumbing issues, failing to maintain the facility in clean, safe, sanitary, and good repair condition.
Report Facts
Capacity: 310
Census: 152
Plan of Correction Due Date: 2023
Plan of Correction Due Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met during investigation and named in findings regarding facility disrepair and accommodations |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 310
Deficiencies: 2
Date: Aug 4, 2023
Visit Reason
The visit was a Case Management - Deficiencies visit conducted on 08/04/2023, stemming from an initial complaint investigation on the same date.
Complaint Details
The visit was triggered by an initial complaint investigation on 08/04/2023. Deficiencies were cited related to failure to report incidents timely, including resident relocation due to flooding and two resident deaths.
Findings
The facility failed to provide written incident reports within seven days for significant events including a flooding incident that required resident relocation and two resident deaths. These failures threaten the welfare, safety, or health of residents and resulted in cited deficiencies.
Deficiencies (2)
Facility staff failed to provide written incident report within seven days of occurrence for flooding incident causing resident relocation.
Facility failed to provide written incident report within seven days of occurrence for deaths of two residents.
Report Facts
Resident deaths reported: 2
Deficiency type: 1
Plan of Correction due date: Aug 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the Case Management Visit-Deficiencies and authored the report |
| Kevin Taliaferro | Administrator | Facility administrator met during the visit |
| Tony Vasallo | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 310
Deficiencies: 2
Date: Aug 4, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was not providing reasonable accommodations to a resident in care and that the facility was in disrepair.
Complaint Details
The complaint investigation was substantiated. The allegations included failure to provide reasonable accommodations to a resident and facility disrepair. Both allegations were found substantiated based on interviews, observations, and record review.
Findings
The investigation substantiated both allegations: the facility temporarily placed a resident in a memory care unit that did not meet the resident's individual service needs, and the facility experienced plumbing issues causing flooding and A/C problems, indicating the facility was in disrepair.
Deficiencies (2)
Facility placed resident in memory care unit even though resident does not require memory care assistance or have a MCI diagnosis, violating reasonable accommodation rights.
Facility failed to maintain clean, safe, sanitary, and in good repair conditions due to plumbing issues and flooding.
Report Facts
Facility Capacity: 310
Census: 151
Deficiencies cited: 2
Plan of Correction Due Dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 310
Deficiencies: 2
Date: Aug 4, 2023
Visit Reason
The inspection was a Case Management Visit-Deficiencies conducted on 08/04/2023, stemming from an initial complaint investigation on the same date.
Complaint Details
The visit was triggered by a complaint investigation. The deficiencies cited relate to failure to submit timely incident reports regarding a flooding incident and resident deaths.
Findings
The facility failed to provide written incident reports within seven days for a flooding incident that required resident relocation and for two resident deaths. These failures threaten the welfare, safety, or health of residents and resulted in cited deficiencies.
Deficiencies (2)
Failure to provide written incident report within seven days for flooding incident causing resident relocation.
Failure to provide written incident report within seven days for two resident deaths.
Report Facts
Deficiencies cited: 1
Capacity: 310
Census: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the Case Management Visit-Deficiencies and authored the report |
| Kevin Taliaferro | Administrator | Facility administrator met during the inspection |
| Tony Vasallo | Supervisor | Supervisor named in relation to the inspection and deficiencies |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 310
Deficiencies: 2
Date: Aug 4, 2023
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that the facility is not providing reasonable accommodations to a resident in care and that the facility is in disrepair.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to provide reasonable accommodations to a resident and facility disrepair. Evidence included interviews, observations, and record reviews confirming the allegations.
Findings
The investigation substantiated both allegations: the facility temporarily placed a resident in a memory care unit that did not meet the resident's individual service needs, and the facility experienced plumbing issues causing flooding and disrepair, which affected the resident's room.
Deficiencies (2)
Facility placed resident in memory care unit even though resident does not require memory care assistance or have a MCI diagnosis.
Facility failed to maintain clean, safe, sanitary, and in good repair conditions; plumbing issues caused flooding in resident's room.
Report Facts
Capacity: 310
Census: 151
Plan of Correction Due Date: Aug 5, 2023
Plan of Correction Due Date: Aug 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during investigation and named in findings. |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation. |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 310
Deficiencies: 1
Date: Jun 23, 2023
Visit Reason
The visit was a Case Management Deficiencies inspection conducted on 06/23/2023 stemming from an initial complaint visit on the same date.
Complaint Details
The visit was triggered by a complaint and involved substantiation of failure to report a COVID-19 outbreak timely as required by Title 22 regulations.
Findings
The licensing agency found that the facility failed to submit required written reports within seven days regarding a COVID-19 epidemic outbreak that began on 06/03/2023, during which multiple residents and staff tested positive. Deficiencies were cited for failure to comply with reporting requirements.
Deficiencies (1)
Failure to submit written reports within seven days of a COVID-19 epidemic outbreak involving multiple residents and staff testing positive.
Report Facts
Residents tested positive for COVID-19: 22
Facility staff tested positive for COVID-19: 4
Additional residents tested positive for COVID-19: 13
Capacity: 310
Census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Facility administrator present during the inspection and recipient of the report |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the Case Management Deficiencies visit |
| Tony Vasallo | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 310
Deficiencies: 2
Date: Jun 23, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were not following proper COVID-19 mitigation guidance.
Complaint Details
The complaint alleged staff were not following proper COVID-19 mitigation guidance. The allegation was substantiated based on observations and interviews during the investigation.
Findings
The investigation substantiated that staff failed to adhere to the facility's COVID-19 mitigation plan, including lack of signage limiting visitors, open dining room during an outbreak, staff not wearing masks or gloves as required, and lack of hand sanitizer at COVID-19 positive resident carts.
Deficiencies (2)
Failure to develop and implement an Infection Control Plan including staff performing hand hygiene and demonstrating infection control knowledge and skills.
Licensee did not adhere to mitigation plan in regards to responding to outbreak of COVID-19.
Report Facts
Capacity: 310
Census: 143
Number of kitchen staff observed not wearing masks: 6
Number of COVID-19 positive resident carts without required hand sanitizer: 4
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met during investigation and exit interview |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 310
Deficiencies: 1
Date: Jun 23, 2023
Visit Reason
The visit was a Case Management Deficiencies inspection conducted on 06/23/2023 stemming from an initial complaint visit on the same date. The purpose was to investigate deficiencies related to reporting requirements following a COVID-19 outbreak at the facility.
Complaint Details
The visit was triggered by a complaint and focused on case management deficiencies related to failure to report a COVID-19 outbreak in a timely manner as required by Title 22 regulations.
Findings
The licensing evaluator found that the facility failed to submit required written reports within seven days regarding a COVID-19 epidemic outbreak that began on 06/03/2023. Specifically, 22 residents and 4 staff tested positive between 06/03 and 06/17, and an additional 13 residents tested positive between 06/17 and 06/23. The facility did not notify the licensing agency as required by regulations.
Deficiencies (1)
Failure to submit written reports to the licensing agency within seven days of the occurrence of a COVID-19 epidemic outbreak, including details of residents and staff testing positive.
Report Facts
Residents tested positive for COVID-19: 22
Facility staff tested positive for COVID-19: 4
Additional residents tested positive for COVID-19: 13
Facility capacity: 310
Facility census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Facility representative met during the inspection |
| Kimberly Ramirez | Licensing Program Analyst | Licensing evaluator who conducted the inspection |
| Tony Vasallo | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 310
Deficiencies: 2
Date: Jun 23, 2023
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that staff were not following proper COVID-19 mitigation guidance.
Complaint Details
The complaint was substantiated. The allegation was that staff were not following proper COVID-19 mitigation guidance, including failure to isolate symptomatic residents and staff, lack of visitor restrictions, and improper use of masks and gloves by staff.
Findings
The investigation substantiated that staff failed to follow proper COVID-19 mitigation protocols, including lack of signage limiting visitors, open dining room during an outbreak, staff not wearing masks or gloves appropriately, and lack of required hand sanitizer at COVID-19 positive resident carts.
Deficiencies (2)
Failure to develop and implement an Infection Control Plan including staff performing hand hygiene and demonstrating infection control knowledge and skills.
Licensee did not adhere to mitigation plan in regards to responding to outbreak of COVID-19.
Report Facts
Capacity: 310
Census: 143
Number of kitchen staff observed not wearing masks: 6
Number of COVID-19 positive resident carts without required hand sanitizer: 4
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met during inspection and exit interview |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 310
Deficiencies: 0
Date: Jun 16, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 12/17/2021 regarding resident care and facility conditions at Morningstar of Pasadena.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents sustaining injury, being left in soiled diapers, lack of proper meal and medication assistance, unsupervised resident leaving, unkempt and malodorous facility, and delayed response to pendant calls. Interviews with staff and residents, review of records, and observations did not support these allegations.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations, including resident injuries, improper meal and medication assistance, unsupervised resident leaving, facility cleanliness, malodor, and delayed response to pendant calls. All allegations were determined to be unsubstantiated.
Report Facts
Facility Capacity: 310
Census: 141
Staff interviewed: 6
Residents interviewed: 5
Incontinence care logging frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during investigation |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 310
Deficiencies: 0
Date: Jun 16, 2023
Visit Reason
This was an unannounced complaint investigation visit conducted in response to a complaint received on 2021-12-17 regarding multiple allegations including resident injuries, improper care, unsupervised resident leaving, medication assistance, facility cleanliness, and response to resident calls.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents sustaining injury, being left in soiled diapers, lack of proper meal and medication assistance, unsupervised resident leaving, unkempt and malodorous facility, and delayed response to pendant calls. All allegations were denied by staff and residents, and no supporting documentation was found.
Findings
All allegations were investigated through staff and resident interviews, record reviews, and observations. The investigation found no substantiated evidence to support any of the allegations, and all interviewed staff and residents denied the claims. The facility was observed to be clean and well-maintained, and care practices were found to be appropriate.
Report Facts
Capacity: 310
Census: 141
Staff interviewed: 6
Residents interviewed: 5
Incontinence care frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Kimberly Ramirez | Licensing Program Analyst | Conducted complaint investigation visit and authored report |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 310
Deficiencies: 0
Date: Jun 12, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging that staff financially abused a resident in care.
Complaint Details
The complaint alleged staff financially abused a resident. The investigation found no sufficient evidence to substantiate the allegation. Resident and POA stated the facility does not handle the resident's finances, and the suspected financial loss may have involved a private caregiver.
Findings
The investigation included interviews with the administrator, staff, resident, and resident's Power of Attorney, and a review of the resident's file. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, with indications that the financial issue may have involved a private caregiver and not the facility.
Report Facts
Capacity: 310
Census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kevin Taliaferro | Administrator | Facility administrator who assisted with the investigation |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 310
Deficiencies: 0
Date: Jun 12, 2023
Visit Reason
The visit was conducted in response to a complaint alleging that staff financially abused a resident in care.
Complaint Details
The complaint alleged staff financially abused a resident. The investigation revealed that the resident believed a private caregiver may have been involved, but there was no proof and the facility does not handle the resident's finances. The allegation was unsubstantiated.
Findings
The investigation included interviews with the administrator, staff, resident, and resident's Power of Attorney, and a review of the resident's file. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 310
Census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Assisted with the investigation and was interviewed regarding the allegation |
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lisa Hicks | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 310
Deficiencies: 1
Date: May 18, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that facility staff did not provide resident basic care and assistance, did not provide medication on time, and did not provide water with medication.
Complaint Details
The complaint investigation was triggered by allegations received on 05/08/2023 regarding failure to provide basic care, timely medication, and water with medication. The medication and water allegations were unsubstantiated. The allegation of insufficient staffing during the overnight shift was substantiated.
Findings
The investigation found the allegations regarding basic care, timely medication, and provision of water with medication to be unsubstantiated due to lack of preponderance of evidence. However, the allegation that the facility did not have sufficient staff to meet resident needs during the overnight shift was substantiated, citing a health and safety hazard when fire personnel could not access the facility due to no staff being present.
Deficiencies (1)
Failure to have sufficient staff on duty during overnight shift to respond to emergency personnel, resulting in fire department being unable to access facility.
Report Facts
Capacity: 310
Census: 131
Staff on overnight shift: 5
Deficiency count: 1
Plan of Correction due date: May 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during investigation and named in findings related to staffing and plan of correction |
| Alberto Lopez | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 310
Deficiencies: 0
Date: May 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-12-17 regarding multiple allegations about resident care and facility conditions at Morningstar of Pasadena.
Complaint Details
The complaint included allegations that residents sustained injuries while in care, were left in soiled diapers for extended periods, did not receive proper meal or medication assistance, were allowed to leave unsupervised, and that the facility was unkempt, malodorous, and slow to respond to pendant calls. All allegations were investigated and found unsubstantiated due to lack of evidence.
Findings
The investigation found no substantiated evidence to support the allegations. Staff and residents interviewed denied the allegations, and the Licensing Program Analyst observed no deficiencies or health and safety concerns during the visit. Therefore, all allegations were unsubstantiated.
Report Facts
Facility capacity: 310
Census: 140
Staff interviewed: 6
Residents interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during inspection |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 310
Deficiencies: 0
Date: May 9, 2023
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2021-12-17 regarding multiple allegations about resident care and facility conditions at Morningstar of Pasadena.
Complaint Details
The complaint included allegations such as residents sustaining injuries, being left in soiled diapers, improper meal and medication assistance, residents leaving unsupervised, facility being unkempt and malodorous, and pendant calls not answered timely. All allegations were denied by staff and residents, and no evidence was found to substantiate them.
Findings
The investigation found no substantiated evidence to support the allegations, as staff and residents denied the claims and no documentation or observations confirmed the complaints. The allegations were therefore deemed unsubstantiated.
Report Facts
Capacity: 310
Census: 140
Staff interviewed: 6
Residents interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during the visit |
| Tony Vasallo | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Census: 144
Capacity: 310
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
Licensing Program Analyst Galarza conducted an unannounced collateral visit to interview a resident regarding an unrelated complaint at another facility.
Findings
No deficiencies were observed during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during the visit and explained the purpose of the visit. |
| Graciela Aquino | Business Office Manager | Participated in the exit interview. |
Inspection Report
Monitoring
Census: 144
Capacity: 310
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
Licensing Program Analyst Galarza conducted an unannounced Collateral visit to interview a resident regarding an unrelated complaint at another facility.
Findings
No deficiencies were observed during the visit. An exit interview was conducted with the Business Office Manager and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during the visit and explained the purpose of the visit. |
| Graciela Aquino | Business Office Manager | Participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 310
Deficiencies: 0
Date: Mar 2, 2023
Visit Reason
The visit was an unannounced complaint investigation to determine if staff were properly sanitizing the facility following an allegation received on 12/06/2022.
Complaint Details
The complaint alleged that staff were not properly sanitizing the facility. The investigation included interviews with residents and staff, a tour of the facility, and review of documentation related to GI protocols. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Findings
Interviews with staff and residents, as well as observations of the dining room and kitchen, indicated that staff were following GI protocols and properly sanitizing the facility. However, there was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Report Facts
Residents affected: 4
Residents affected: 5
Capacity: 310
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during the investigation and named in interviews |
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 310
Deficiencies: 0
Date: Mar 2, 2023
Visit Reason
The visit was an unannounced complaint investigation to examine allegations that staff were not properly sanitizing the facility.
Complaint Details
The complaint alleged that staff were not properly sanitizing the facility. The investigation included interviews with residents and staff, a tour of the facility, and review of documentation. The allegation was found to be unsubstantiated.
Findings
Interviews with staff and residents, as well as observations of the dining room and kitchen, found that staff were following GI protocols and properly sanitizing the facility. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents affected: 4
Residents affected: 5
Capacity: 310
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Met with during the investigation and involved in interviews |
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 310
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding improper supervision of residents resulting in falls, improper food storage causing food poisoning, untimely assistance to residents, and untimely meal provision.
Complaint Details
The complaint investigation was triggered by allegations of inadequate supervision leading to falls, improper food storage causing food poisoning, delays in assisting residents, and delays in meal delivery. After thorough investigation including interviews and documentation review, all allegations were determined to be unsubstantiated.
Findings
The investigation included interviews with staff and residents, review of documentation, and facility tour. All allegations were found to be unsubstantiated due to lack of preponderance of evidence, with staff and resident interviews and documentation not corroborating the complaints.
Report Facts
Staff interviews: 8
Resident interviews: 11
Physical therapists available: 3
Staff to resident ratio: 5
Rounds frequency: 2
Food supply duration: 2
Food supply duration: 7
Servers per shift: 4
Wait time for assistance: 5
Wait time for assistance: 30
Meal delivery time: 30
Meal delivery time: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analyst during investigation and named in report |
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation visit |
| David Sicairos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 310
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including improper supervision of residents resulting in falls, improper food storage causing food poisoning, untimely assistance to residents, and untimely meal provision.
Complaint Details
The complaint investigation was triggered by allegations of inadequate supervision leading to falls, improper food storage causing food poisoning, delays in assisting residents, and delays in meal provision. After thorough investigation including interviews with 8 staff and 11 residents, review of records, and observations, all allegations were determined to be unsubstantiated.
Findings
The investigation included interviews with staff and residents, review of documentation, and facility tour. All allegations were found to be unsubstantiated due to lack of preponderance of evidence. Staff supervision, food handling, resident assistance, and meal delivery were found to be adequate based on interviews and observations.
Report Facts
Staff interviews: 8
Resident interviews: 11
Staff to resident ratio: 5
Physical therapists available: 3
Rounds frequency: 2
Food supply duration: 2
Food supply duration: 7
Servers per shift: 4
Food delivery time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during investigation and named in report |
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation |
| David Sicairos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 310
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
An informal virtual meeting was held to discuss the facility's compliance with Pasadena Public Health Department (PPHD) COVID-19 reporting requirements and guidelines, ensuring agreement among CCLD, PPHD, and the facility.
Findings
The facility was reminded of timely COVID-19 case reporting requirements, testing protocols for staff, and submission of daily and weekly reports. The facility agreed to improve reporting and requested testing kits from PPHD.
Report Facts
Capacity: 310
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Facility representative attending the meeting and involved in compliance discussion |
| Rhonda Guzman | Wellness Director | Facility representative attending the meeting and involved in compliance discussion |
| Bennette Pena | Licensing Program Analyst | Attended the meeting representing licensing agency |
| David Sicairos | Licensing Program Manager | Attended the meeting representing licensing agency |
Inspection Report
Capacity: 310
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
An informal virtual meeting was held to discuss the facility's compliance with Pasadena Public Health Department (PPHD) COVID-19 reporting requirements and guidelines, ensuring agreement among CCLD, PPHD, and the facility.
Findings
The facility was reminded to submit COVID-19 positive case contact line lists within 24-48 hours and to report all COVID-19 cases and testing results timely. PPHD clarified testing requirements and reporting schedules, and the facility agreed to improve reporting compliance and requested testing kits.
Report Facts
Capacity: 310
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Facility representative attending the meeting and involved in compliance discussion |
Inspection Report
Annual Inspection
Census: 133
Capacity: 310
Deficiencies: 0
Date: Oct 7, 2022
Visit Reason
The visit was an annual continuation case management inspection conducted to evaluate compliance with Title 22 regulations and assess various facility components including physical plant, safety equipment, infection control, and resident records.
Findings
The inspection found no deficiencies during both the initial and continuation visits. Various areas including hot water temperatures, medication records, staff and resident files were reviewed and found compliant.
Report Facts
Hot water temperature readings: 114.8
Hot water temperature readings: 113.5
Hot water temperature readings: 114
Hot water temperature readings: 107.5
Hot water temperature readings: 115.6
Hot water temperature readings: 115.4
Hot water temperature readings: 116.2
Hot water temperature readings: 110.1
Medication records reviewed: 8
Staff records reviewed: 8
Resident records reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Business Director | Assisted with the visit and was present during exit interview |
| Bennette Pena | Licensing Program Analyst | Conducted initial and continuation visits |
| Ashley Calderon | Licensing Program Analyst | Conducted continuation visit |
| Rhonda Guzman | Wellness Director | Joined the LPAs during the visit |
| David Sicairos | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 133
Capacity: 310
Deficiencies: 0
Date: Oct 7, 2022
Visit Reason
The inspection was an annual continuation visit conducted to evaluate compliance with Title 22 Regulations, including a review of the physical plant, resident rooms, infection control protocols, and records.
Findings
The annual required visit was completed with no deficiencies observed during both the initial and continuation visits. Various facility areas and records were inspected and found compliant.
Report Facts
Hot water temperature readings: 114.8
Hot water temperature readings: 113.5
Hot water temperature readings: 114
Hot water temperature readings: 107.5
Hot water temperature readings: 115.6
Hot water temperature readings: 115.4
Hot water temperature readings: 116.2
Hot water temperature readings: 110.1
Medication records reviewed: 8
Staff records reviewed: 8
Resident records reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Business Director | Assisted with the visit and received the report copy |
| Bennette Pena | Licensing Program Analyst | Conducted the initial annual visit and continuation visit |
| Ashley Calderon | Licensing Program Analyst | Conducted the continuation visit |
| Rhonda Guzman | Wellness Director | Joined the LPAs during the visit |
| David Sicairos | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 160
Capacity: 310
Deficiencies: 0
Date: Sep 19, 2022
Visit Reason
An unannounced required 1-year visit focusing on the Infection Control Domain was conducted to evaluate compliance with licensing requirements and infection control protocols.
Findings
No deficiencies were observed during the visit. The facility was found to be operating within compliance, with adequate infection control measures, sufficient food supplies, clean and secure laundry and kitchen areas, and operational fire safety equipment.
Report Facts
Resident rooms: 144
Memory Care residents: 12
Hospice residents: 9
Assisted Living residents: 110
Fire extinguishers per floor: 12
Fire extinguisher last inspection date: May 3, 2022
PPE supply duration: 30
Perishable food supply duration: 2
Non-perishable food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Administrator involved in exit interview and facility oversight |
| Graciela Aquino | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Bennette Pena | Licensing Program Analyst | Conducted the inspection visit |
| David Sicairos | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 160
Capacity: 310
Deficiencies: 0
Date: Sep 19, 2022
Visit Reason
Licensing Program Analyst Bennette Pena conducted an unannounced Required 1-year visit focusing on the Infection Control Domain as part of the annual inspection process.
Findings
The facility was inspected for infection control and general compliance. No deficiencies were observed during the visit, and the facility was found to be operating within compliance. Due to time constraints, the annual inspection was not completed and will be continued at a later date.
Report Facts
Licensed capacity: 310
Current census: 160
Memory Care residents: 12
Hospice residents: 9
Assisted Living residents: 110
Suites: 144
Fire extinguishers per floor: 12
PPE supply duration: 30
Resident rooms on 2nd floor: 43
Memory Care rooms on 2nd floor: 28
Dining room capacity on 2nd floor: 28
Resident rooms on 3rd floor: 39
Resident rooms on 4th floor: 36
Perishable food supply: 2
Non-perishable food supply: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Administrator present during exit interview and involved in facility walkthrough |
| Graciela Aquino | Business Office Manager | Met with Licensing Program Analyst at start of inspection |
| Bennette Pena | Licensing Program Analyst | Conducted the inspection visit |
| David Sicairos | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 117
Capacity: 310
Deficiencies: 0
Date: Jun 10, 2022
Visit Reason
The visit was a follow-up to check the corrections made in the memory care unit after an initial inspection on 2022-05-27.
Findings
The hot water temperature was within the required range, bathroom wall tiles in apartment #206 were repaired, and the smaller outdoor patio was temporarily closed while the larger patio remained available. The newly constructed Memory Care unit meets Title 22 regulations and is ready to serve residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during the visit and stated he will inform LPA when the smaller patio reopens. |
| Cynthia Chan | Licensing Program Analyst | Conducted the follow-up visit and initial inspection of the Memory Care unit. |
Inspection Report
Follow-Up
Census: 117
Capacity: 310
Deficiencies: 0
Date: Jun 10, 2022
Visit Reason
Licensing Program Analyst Cynthia Chan conducted a follow-up visit to check the items to be corrected from the memory care unit after the initial inspection on 2022-05-27.
Findings
The hot water temperature was within the required range, bathroom wall tiles in apartment #206 were repaired, and the smaller outdoor patio was temporarily closed while the larger patio remained available. The newly constructed Memory Care unit meets Title 22 regulations and is ready to serve residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with during the follow-up visit and stated he will inform LPA when the smaller patio reopens. |
| Cynthia Chan | Licensing Program Analyst | Conducted the follow-up visit and initial inspection of the Memory Care unit. |
Inspection Report
Census: 117
Capacity: 310
Deficiencies: 3
Date: May 27, 2022
Visit Reason
The visit was a case management inspection for the purpose of adding a memory care unit to the facility's plan of operation.
Findings
The inspection found that the memory care unit is located on the 2nd floor with 28 resident bedrooms, but residents' rooms are currently unfurnished. Several issues were identified that must be corrected before licensing, including adjusting hot water temperatures in multiple rooms, repairing bathroom tiles in room #260, and securing side gaps in the outdoor patio.
Deficiencies (3)
Hot water temperature must be adjusted to read between 105 – 120 degrees Fahrenheit in specified rooms.
Room #260 bathroom tiles by the sink must be repaired.
The side gaps next to the walls in the outdoor patio must be secured.
Report Facts
Resident bedrooms in memory care unit: 28
Hot water temperature below 105 degrees: 6
Hot water temperature above 120 degrees: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analysts during case management visit |
| Cynthia D Chan | Licensing Evaluator | Conducted the facility evaluation and signed the report |
| Lisa Hicks | Supervisor | Supervised the licensing evaluation |
Inspection Report
Census: 117
Capacity: 310
Deficiencies: 3
Date: May 27, 2022
Visit Reason
The visit was a case management inspection conducted for the purpose of adding a memory care unit to the facility's plan of operation.
Findings
The inspection found that the memory care unit is located on the 2nd floor with 28 resident bedrooms, but residents' rooms are currently unfurnished. Several safety and maintenance issues were identified that must be corrected before licensing, including hot water temperature adjustments, bathroom tile repairs in room #260, and securing side gaps next to walls in the outdoor patio.
Deficiencies (3)
Hot water temperature must be adjusted to read between 105 – 120 degrees Fahrenheit in multiple rooms.
Room #260 bathroom tiles by the sink must be repaired.
The side gaps next to the walls in the outdoor patio must be secured.
Report Facts
Resident bedrooms in memory care unit: 28
Facility capacity: 310
Resident census: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with Licensing Program Analysts during the case management visit |
| Cynthia Chan | Licensing Evaluator | Conducted the inspection and authored the report |
| Bennette Pena | Licensing Program Analyst | Conducted the case management visit |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 310
Deficiencies: 0
Date: Apr 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2021-12-29 alleging that staff are not properly trained to provide care to residents.
Complaint Details
The complaint alleged that staff were not properly trained to provide care to residents. The allegation was investigated through interviews with the administrator, 7 staff members, and 11 residents, as well as review of training documentation. The allegation was found to be unsubstantiated.
Findings
The investigation found that staff are fully trained and have more than the required annual hours of training. Interviews with staff and residents confirmed that staff receive ongoing training and are adequately trained to perform their duties. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 310
Census: 114
Training hours: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Interviewed during the complaint investigation regarding staff training |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 310
Deficiencies: 0
Date: Apr 21, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff are not properly trained to provide care to residents.
Complaint Details
The complaint alleged that staff were not properly trained to provide care to residents. The allegation was investigated through interviews with the Executive Director, 7 staff members, and 11 residents, as well as review of training documentation. The allegation was determined to be unsubstantiated.
Findings
The investigation found that staff are fully trained and have more than the required annual hours of training. Interviews with staff and residents confirmed that staff are adequately trained and provide respectful and helpful care. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 310
Census: 114
Training hours: 4
Staff interviewed: 7
Residents interviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Interviewed regarding staff training and facility operations |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 310
Deficiencies: 1
Date: Jan 19, 2022
Visit Reason
An unannounced case management visit was conducted as part of an initial 10-day complaint investigation to assess compliance with health and safety regulations.
Complaint Details
The visit was complaint-related, conducted as an initial 10-day complaint investigation. The deficiency was substantiated as the facility failed to screen for COVID-19 upon entry.
Findings
The Licensing Program Analyst observed that upon entering the facility, staff and visitors were not screened for COVID-19, posing an immediate health and safety risk to persons in care. This was found to be a violation of California Code of Regulations, Title 22, Division 6.
Deficiencies (1)
Failure to screen staff and visitors for COVID-19 upon entering the facility, posing an immediate health and safety risk to persons in care.
Report Facts
Census: 106
Total Capacity: 310
Deficiencies cited: 1
Plan of Correction Due Date: Jan 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Named in relation to the exit interview and receipt of the report |
| Rhonda Guzman | Wellness Director | Present during the inspection visit |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 310
Deficiencies: 1
Date: Jan 19, 2022
Visit Reason
An unannounced case management visit was conducted as part of an initial 10-day complaint investigation regarding COVID screening procedures upon entering the facility.
Complaint Details
The visit was complaint-related, triggered by concerns about COVID screening. The deficiency was substantiated as the Licensing Program Analyst was not screened for COVID upon entry.
Findings
The facility was found to be in violation of California Code of Regulations Title 22, Division 6, due to failure to screen visitors for COVID upon entry, posing an immediate health and safety risk to persons in care.
Deficiencies (1)
Failure to screen visitors for COVID upon entering the facility, posing an immediate health and safety risk.
Report Facts
Capacity: 310
Census: 106
Plan of Correction Due Date: Jan 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Named in relation to the exit interview and receipt of the report |
| Nune Margaryan | Licensing Program Analyst | Conducted the unannounced case management visit and documented findings |
| Rhonda Guzman | Wellness Director | Met with during the visit |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 310
Deficiencies: 1
Date: Dec 10, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not complying with local public health department's COVID-19 requirements, specifically failing to submit required documentation on a weekly basis.
Complaint Details
The complaint was substantiated. The facility failed to submit required weekly COVID-19 testing documentation for unvaccinated employees and residents as mandated by the Pasadena Public Health Department from September to November 2021.
Findings
The investigation found that the facility failed to submit completed lab reports for twice weekly testing of unvaccinated employees and weekly testing of unvaccinated residents for several weeks between September and November 2021. The Executive Director acknowledged the failure and has delegated staff to ensure timely submission going forward. The allegation was substantiated.
Deficiencies (1)
Failure to submit required weekly lab reports for unvaccinated staff and residents to the Pasadena Public Health Department, posing potential health and safety risks.
Report Facts
Capacity: 310
Census: 104
Plan of Correction Due Date: Dec 17, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Acknowledged failure to submit COVID-19 testing reports and delegated staff to ensure compliance |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 310
Deficiencies: 1
Date: Dec 10, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not complying with local public health department's COVID-19 requirements, specifically failing to submit required weekly documentation.
Complaint Details
The complaint was substantiated based on evidence that the facility did not submit required weekly COVID-19 testing reports for unvaccinated employees and residents as mandated by the Pasadena Public Health Department from September to November 2021.
Findings
The investigation confirmed that the facility failed to submit completed lab reports for twice weekly testing of unvaccinated employees and weekly testing of unvaccinated residents for several weeks between September and November 2021. The Executive Director acknowledged the failure and has delegated staff to ensure timely submission going forward. The allegation was substantiated.
Deficiencies (1)
Failure to submit required weekly lab reports for unvaccinated staff and residents to the Pasadena Public Health Department, posing potential health and safety risks.
Report Facts
Capacity: 310
Census: 104
Plan of Correction Due Date: Dec 17, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Acknowledged failure to submit COVID-19 testing reports and delegated staff to ensure compliance |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Census: 104
Capacity: 310
Deficiencies: 0
Date: Dec 7, 2021
Visit Reason
An informal conference was held to discuss the facility's noncompliance with Pasadena Public Health Department guidelines regarding unvaccinated individuals at the facility.
Findings
The facility was not compliant with the requirement to submit weekly reports of unvaccinated employees to the Pasadena Public Health Department and to test unvaccinated staff twice weekly and residents once weekly. No deficiencies were issued during the meeting.
Report Facts
Capacity: 310
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Named in relation to ensuring compliance with weekly reporting and testing requirements |
Inspection Report
Census: 104
Capacity: 310
Deficiencies: 0
Date: Dec 7, 2021
Visit Reason
An informal conference was held to discuss the facility's noncompliance with Pasadena Public Health Department guidelines regarding unvaccinated individuals at the facility.
Findings
The facility was found not compliant with the requirement to submit weekly reports on unvaccinated staff and residents and to conduct required testing. No deficiencies were issued during the meeting, and the facility committed to corrective actions to achieve compliance.
Report Facts
Capacity: 310
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Administrator | Named in relation to compliance with Pasadena Public Health Department guidelines and corrective actions |
Inspection Report
Original Licensing
Census: 102
Capacity: 310
Deficiencies: 0
Date: Sep 15, 2021
Visit Reason
The visit was a pre-licensing inspection to evaluate the facility for initial licensing and ensure compliance with regulations.
Findings
The facility was found to be in substantial compliance with no deficiencies at the time of the pre-licensing visit. Previous deficiencies related to hot water temperature and freezer/refrigerator temperatures were corrected.
Report Facts
Residents' medication logs reviewed: 12
Hospice waiver capacity: 30
Non-ambulatory capacity: 285
Bedridden capacity: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliferro | Executive Director | Met during the pre-licensing visit and exit interview. |
| Rhonda Guzman | Wellness Director | Present during the pre-licensing visit. |
| Cynthia D Chan | Licensing Program Analyst | Conducted the pre-licensing inspection and Component III visit. |
| Lisa Hicks | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Original Licensing
Census: 102
Capacity: 310
Deficiencies: 0
Date: Sep 15, 2021
Visit Reason
The visit was a pre-licensing inspection to evaluate the facility's readiness for licensing and to ensure compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with no deficiencies at the time of the pre-licensing visit. Previous deficiencies related to hot water temperature and freezer/refrigerator temperatures were corrected.
Report Facts
Residents' medication logs reviewed: 12
Approved capacity: 310
Current census: 102
Hospice waiver capacity: 30
Non-ambulatory capacity: 285
Bedridden capacity: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met during inspection and named in report |
| Rhonda Guzman | Wellness Director | Met during inspection and named in report |
| Cynthia D Chan | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Original Licensing
Census: 102
Capacity: 310
Deficiencies: 3
Date: Sep 9, 2021
Visit Reason
The visit was conducted as a prelicensing evaluation following an application for Change of Ownership for a Residential Care Facility for the Elderly.
Findings
The facility was inspected and observed to be a 4-story building with adequate resident rooms and amenities. Some corrective actions were required related to freezer and refrigerator temperatures and hot water temperature.
Deficiencies (3)
The freezer should be maintained at 0 degrees F.
The refrigerator should be maintained at 40 degrees F.
The hot water temperature is measured between 105-120 degrees F.
Report Facts
Capacity: 310
Census: 102
Resident rooms: 151
Non-ambulatory residents allowed: 285
Bedridden residents allowed: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with LPAs during inspection and received copy of report |
| Rhonda Guzman | Wellness Director | Provided assistance with the tour of the physical plant |
Inspection Report
Original Licensing
Census: 102
Capacity: 310
Deficiencies: 3
Date: Sep 9, 2021
Visit Reason
The visit was an announced prelicensing evaluation conducted for a Change of Ownership application for a Residential Care Facility for the Elderly for ages 60 years and older.
Findings
The facility was inspected and observed to be a 4-story building with adequate resident rooms and amenities. Some corrective actions were required related to maintaining proper freezer and refrigerator temperatures and hot water temperature. The fire clearance was approved for a capacity of 310 residents.
Deficiencies (3)
The freezer should be maintained at 0 degrees F.
The Refrigerator should be maintained at 40 degrees F.
The hot water temperature is measured between 105-120 degree F.
Report Facts
Capacity: 310
Census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Taliaferro | Executive Director | Met with LPAs during the prelicensing evaluation and received a copy of the report |
Inspection Report
Original Licensing
Census: 92
Capacity: 310
Deficiencies: 0
Date: Mar 11, 2021
Visit Reason
The visit was conducted as a Component II telephone call with the applicant and administrator to verify identity and confirm understanding of Title 22 regulations as part of the licensing process.
Findings
The applicant and administrator successfully completed Component II, demonstrating understanding of facility operation, staff qualifications, program policies, and application document requirements. They were advised to submit required signed documents and photo ID to the Community Care Licensing analyst.
Report Facts
Capacity: 310
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rhonda Guzman | Administrator | Facility administrator participating in the licensing process |
| Kevin Taliaferro | Met with during the visit |
Viewing
Loading inspection reports...



