Inspection Reports for
Mountain Manor
6101 Fair Oaks Blvd, Carmichael, CA 95608, United States, CA, 95608
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
168% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
48% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Deficiencies: 4
Date: Aug 26, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of practice related to intravenous (IV) therapy and treatment, specifically focusing on the care provided to Resident 1 regarding IV hydration and documentation.
Findings
The facility failed to ensure proper care and treatment in accordance with professional standards for Resident 1 by not clarifying the physician's IV bolus order, incomplete documentation of IV therapy details by licensed nurses, and lack of timely pharmacy follow-up for IV supplies. These deficiencies posed potential risks for fluid hydration treatment not being met and possible adverse events.
Deficiencies (4)
Failure to clarify the Physician's Order for IV bolus infusion duration.
Licensed nurses did not thoroughly document all aspects of IV therapy including date/time of insertion, catheter gauge, site assessment, and patient response.
Lack of documentation on the time the MD order was faxed to pharmacy and confirmation of receipt to ensure timely delivery of IV supplies.
Failure to document start and end times of IV bags administered including IV bolus administration.
Report Facts
IV hydration volume: 5
Date of Physician's Order: Feb 6, 2025
Date of Resident Admission Record: 202501
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed on 8/26/25 confirming deficiencies and expectations regarding IV therapy documentation and order clarification |
Inspection Report
Annual Inspection
Census: 16
Capacity: 33
Deficiencies: 0
Date: Aug 4, 2025
Visit Reason
The inspection was an unannounced required 1-year inspection conducted to evaluate compliance with licensing regulations.
Findings
The inspection found no deficiencies or violations. The facility met all required standards including safety equipment, food supplies, temperature controls, and record reviews, although personnel and resident records were noted as incomplete.
Report Facts
Personnel records reviewed: 5
Resident records reviewed: 5
Fire extinguisher last inspected: Feb 28, 2025
Hot water temperature: 107
Facility temperature: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrell Price | Administrator | Met with Licensing Program Analysts during inspection and involved in facility tour |
| Lavinia Muscan | Licensing Program Analyst | Conducted the inspection |
| Talwinder Bains | Licensing Program Analyst | Conducted the inspection |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 16
Capacity: 33
Deficiencies: 0
Date: Aug 4, 2025
Visit Reason
The visit was an unannounced case management inspection conducted regarding an incident report received by the department on 2025-07-15 involving two residents in the common area.
Complaint Details
The visit was triggered by an incident report received on 2025-07-15. The incident was investigated and found to have no deficiencies. The facility followed notification protocols.
Findings
The incident involved residents R1 and R2 after dinner on 2025-07-15. The facility notified the responsible parties and physician as required. No deficiencies were cited as a result of this incident.
Report Facts
Facility capacity: 33
Resident census: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrell Price | Administrator | Met with Licensing Program Analysts during the inspection and involved in incident management |
| Lavinia Muscan | Licensing Program Analyst | Conducted the case management visit |
| Talwinder Bains | Licensing Program Analyst | Conducted the case management visit |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 16
Capacity: 33
Deficiencies: 0
Date: Aug 4, 2025
Visit Reason
The inspection was an unannounced required 1 year inspection conducted by Licensing Program Analysts to evaluate compliance with care and safety regulations.
Findings
The inspection found no deficiencies or violations. The facility met all regulatory requirements including safety equipment, food supplies, temperature controls, and record reviews, although personnel and resident records were noted as incomplete.
Report Facts
Personnel records reviewed: 5
Resident records reviewed: 5
Food supply duration - non-perishable: 7
Food supply duration - perishable: 2
Hot water temperature: 107
Facility temperature: 74
Fire extinguisher last inspected: Feb 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrell Price | Administrator | Met with Licensing Program Analysts during inspection and involved in facility tour |
| Lavinia Muscan | Licensing Program Analyst | Conducted the inspection |
| Talwinder Bains | Licensing Program Analyst | Conducted the inspection and signed the report |
| Laura Munoz | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 16
Capacity: 33
Deficiencies: 0
Date: Aug 4, 2025
Visit Reason
The visit was an unannounced case management inspection conducted on August 4, 2025, regarding an incident report received by the department on July 15, 2025.
Complaint Details
The visit was triggered by an incident report received on 07/15/25. The incident was investigated and found to have no deficiencies.
Findings
The incident involved two residents after dinner in the common area. The facility notified the responsible parties and physician as required. No deficiencies were cited as a result of the incident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrell Price | Administrator | Met with Licensing Program Analysts during the inspection and involved in the incident report discussion. |
| Lavinia Muscan | Licensing Program Analyst | Conducted the inspection and met with the facility administrator. |
| Talwinder Bains | Licensing Program Analyst | Conducted the inspection and met with the facility administrator. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Routine
Census: 61
Deficiencies: 3
Date: Jul 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection prevention, and safety protocols at Mountain Manor Senior Residence.
Findings
The facility was found deficient in ensuring proper monitoring of a resident's alarm bracelet for wandering risk, timely administration of insulin medication, and adherence to infection prevention protocols including proper sanitization of shared glucometers and use of personal protective equipment during resident care.
Deficiencies (3)
Failure to monitor Resident 3's alarm bracelet for placement and functionality as ordered, risking ineffective wandering management and potential elopement.
Resident 1 did not receive prescribed insulin in accordance with physician's order, risking hypoglycemia and other insulin side effects.
Failure to implement an effective infection prevention and control program, including improper sanitization of shared glucometer and failure to wear required PPE for Resident 4 on enhanced barrier precautions.
Report Facts
Resident census: 61
Brief Interview for Mental Status (BIMS) score: 3
Brief Interview for Mental Status (BIMS) score: 15
Blood sugar level: 167
Insulin units administered: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Confirmed early administration of insulin to Resident 1 |
| LN 2 | Licensed Nurse | Observed using and sanitizing shared glucometer improperly and not wearing gown for Resident 4 on EBP |
| LN 3 | Licensed Nurse | Observed delivering lunch to Resident 1 |
| LN 4 | Licensed Nurse | Confirmed lack of documentation for monitoring Resident 3's alarm bracelet |
| DSD | Director of Staff Development | Provided statements on risks related to alarm bracelet monitoring and insulin administration |
| IP | Infection Preventionist | Provided guidance on proper sanitization of glucometer and PPE use for EBP |
Inspection Report
Complaint Investigation
Census: 15
Capacity: 33
Deficiencies: 1
Date: May 22, 2025
Visit Reason
The visit was an unannounced case management inspection conducted to investigate an absent without leave incident involving a resident who left the facility unassisted contrary to physician's orders.
Complaint Details
The visit was triggered by a complaint regarding a resident who was absent without leave on 05/11/25. The complaint was substantiated by the finding that the resident left unassisted despite medical restrictions.
Findings
The investigation found that a resident left the facility unassisted despite a physician's report indicating the resident was unable to leave unassisted, posing an immediate health and safety risk. The facility increased safety checks following the incident and was cited for deficiencies related to insufficient staffing to meet resident needs.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary services, as evidenced by a resident leaving the facility unassisted contrary to physician's orders.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: May 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrel Price | Administrator | Met with Licensing Program Analyst during the inspection and discussed staffing and supervision |
| Talwinder Bains | Licensing Program Analyst | Conducted the inspection and authored the report |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 15
Capacity: 33
Deficiencies: 1
Date: May 22, 2025
Visit Reason
The visit was an unannounced case management inspection conducted due to an absent without leave incident involving resident R1 reported to the department on 05/13/2025.
Complaint Details
The visit was triggered by a complaint regarding an absent without leave incident involving resident R1. The complaint was substantiated as the resident left unassisted contrary to medical restrictions.
Findings
The investigation found that resident R1 left the facility unassisted on 05/11/2025 despite a physician's report indicating R1 was unable to leave unassisted, posing an immediate health and safety risk. The facility increased safety checks following the incident and was cited for deficiencies related to insufficient staffing to ensure resident care and supervision.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary services, resulting in resident R1 leaving the facility unassisted contrary to physician's report.
Report Facts
Capacity: 33
Census: 15
Plan of Correction Due Date: May 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrel Price | Administrator | Met with Licensing Program Analyst during inspection and discussed staffing and supervision issues |
| Talwinder Bains | Licensing Program Analyst | Conducted the inspection and authored the report |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Routine
Census: 45
Deficiencies: 15
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, infection control, food service, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a comfortable noise level for residents, inadequate bed hold notifications, incomplete care plans, medication administration errors, communication barriers, respiratory care inconsistencies, pharmaceutical service deficiencies, medication labeling and storage issues, food service personnel competency, menu adherence, food safety and sanitation, quality assurance committee composition, infection prevention and control practices, and antibiotic stewardship.
Deficiencies (15)
Failed to provide a comfortable noise level for four residents, affecting their comfort and sleep.
Failed to provide bed hold notification upon transfer to hospital for one resident.
Failed to develop a comprehensive person-centered care plan addressing insomnia and medication for one resident.
Failed to revise care plan after resident sustained a bruise.
Failed to clarify physician's order with multiple dosages prior to medication administration.
Failed to follow care plan communication interventions for one resident.
Failed to provide respiratory care consistent with physician's order for oxygen administration.
Failed to ensure accurate accountability and documentation of controlled substances and emergency kit medications.
Failed to ensure medications were properly labeled, dated, stored, and expired medications removed.
Food service personnel unable to correctly verbalize manual dishwashing process using two-compartment sinks.
Failed to follow therapeutic diet menus during lunch meals on multiple days.
Failed to ensure food was prepared, stored, served, or distributed in accordance with professional food safety standards including cleanliness of ice machine, equipment maintenance, food dating, packaging, thawing, and produce freshness.
Quality Assessment and Assurance committee did not include required members such as the Medical Director.
Failed to implement infection prevention and control practices including Enhanced Barrier Precautions for multiple residents and improper hand hygiene by staff.
Failed to follow Antibiotic Stewardship Program by prescribing antibiotic without adequate clinical and laboratory indication.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 17
Medication doses: 6
Missing signatures: 15
Residents affected: 45
Sanitizer concentration: 200
Temperature: 40
Antibiotic duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Reviewed care plans and medication administration |
| Licensed Nurse 2 | Licensed Nurse | Medication administration error and infection control observation |
| Licensed Nurse 3 | Licensed Nurse | Reviewed physician orders and infection control |
| Licensed Nurse 4 | Licensed Nurse | Interviewed about care plan revisions |
| Licensed Nurse 5 | Licensed Nurse | Reviewed residents' orders for infection control |
| Licensed Nurse 6 | Licensed Nurse | Confirmed lack of EBPs signage and PPE |
| Certified Nurse Assistant 5 | Certified Nurse Assistant | Observed not performing hand hygiene while passing lunch trays |
| Certified Dietary Manager | Certified Dietary Manager | Confirmed food service deficiencies and manual dishwashing knowledge |
| Dietary Aide 1 | Dietary Aide | Interviewed about manual dishwashing process |
| Dietary Aide 2 | Dietary Aide | Interviewed about manual dishwashing process |
| Director of Nursing | Director of Nursing | Provided statements on medication and infection control expectations |
| Infection Preventionist | Infection Preventionist | Reviewed infection control practices and antibiotic stewardship |
| Maintenance Supervisor | Maintenance Supervisor | Described ice machine cleaning procedures |
| Registered Dietitian | Registered Dietitian | Reviewed menu adherence and food safety issues |
Inspection Report
Complaint Investigation
Census: 15
Capacity: 33
Deficiencies: 0
Date: Jan 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-01-10 alleging that staff inappropriately spoke to a resident in care.
Complaint Details
The complaint alleged inappropriate staff communication with a resident. The investigation found the allegation to be unfounded, meaning it was false or without reasonable basis.
Findings
Based on interviews and records reviewed, the allegation that staff inappropriately spoke to residents in care did not occur in the assisted living section and was found to be unfounded.
Report Facts
Facility capacity: 33
Census: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrell Price | Executive Director | Met with investigators and named in the investigation |
| Cassandra Mikkelson | Licensed Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensed Program Manager | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 15
Capacity: 33
Deficiencies: 0
Date: Jan 17, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-01-10 alleging that staff inappropriately spoke to a resident in care.
Complaint Details
The complaint alleged that staff inappropriately spoke to a resident in care. The investigation found this allegation to be unfounded.
Findings
Based on interviews and records reviewed, the allegation that staff inappropriately spoke to residents in care was found to be unfounded, meaning the allegation was false or without reasonable basis.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrell Price | Executive Director | Met with investigators and involved in complaint investigation. |
| Cassandra Mikkelson | Licensed Program Analyst | Conducted complaint investigation. |
| Laura Munoz | Licensed Program Manager | Conducted complaint investigation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent elopement of a resident who left the facility unaccompanied by staff and subsequently sustained injuries.
Complaint Details
The complaint investigation found that Resident 1 eloped from the facility unattended, fell outside, and complained of neck and left knee pain. The resident was assessed and transferred to the ER. The facility's policy on elopement lacked preventive interventions. The Administrator confirmed the incident and noted no prior elopement attempts by the resident.
Findings
The facility failed to prevent elopement for one resident who wandered outside the facility and fell, resulting in neck and knee pain. The resident had a history of falls and cognitive impairment. The facility's elopement policy did not include interventions to prevent such incidents.
Deficiencies (1)
Failure to prevent elopement of a resident resulting in a fall and injury.
Report Facts
Resident BIMS score: 3
Wandering Risk Assessment: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed on 10/30/24 regarding the elopement incident and facility monitoring |
Inspection Report
Complaint Investigation
Census: 11
Capacity: 33
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to a SOC 341 report received by the Department regarding an incident involving a resident's unwitnessed fall and subsequent allegation of sexual assault.
Complaint Details
The complaint involved an unwitnessed fall on 10/7/2024 and an allegation of sexual assault by the resident at the emergency room. A police report was filed. The facility was not notified until discharge paperwork was reviewed. The resident has a history of confusion related to UTIs and a tendency to talk about sexual assault when confused. There are no male caregivers at the facility. The incident remains under review.
Findings
The inspection focused on reviewing the incident involving Resident 1's unwitnessed fall and allegation of sexual assault, including discussions about the resident's medical history, confusion related to urinary tract infections, and facility staffing. The incident remains under review by the Department.
Report Facts
Facility capacity: 33
Current census: 11
Incident date: Oct 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the case management visit and inspection |
| Anthony Perez | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Darrell Price | Administrator/Director | Facility Administrator/Director mentioned in report header |
| Kim Jackson | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 11
Capacity: 33
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to a SOC 341 report received by the Department regarding an incident involving a resident's unwitnessed fall and subsequent allegation of sexual assault.
Complaint Details
The visit was triggered by a complaint involving an unwitnessed fall and an allegation of sexual assault by a resident. The incident remains under review by the Department and no substantiation status is provided.
Findings
The Licensing Program Analyst met with the Resident Care Director to discuss the incident involving Resident 1, who had an unwitnessed fall and alleged sexual assault at the hospital. The facility was not notified until discharge paperwork was reviewed. The Resident Care Director noted the resident's history of confusion related to urinary tract infections and stated there are no male caregivers at the facility. The incident remains under review by the Department.
Report Facts
Facility capacity: 33
Current census: 11
Incident date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the case management visit and inspection |
| Darrell Price | Administrator/Director | Facility administrator mentioned in the report |
| Kim Jackson | Met with the Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 6, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide advance notice and obtain consent before moving a resident (Resident 3) to another room.
Complaint Details
The complaint investigation found that Resident 3 was moved without advance notice or consent, violating his rights. The Social Service Director confirmed no consent form was used and no documentation of notice or explanation was present. The room change was discussed only during the morning IDT meeting on the day of the move.
Findings
The facility failed to ensure Resident 3's rights were exercised when he was moved to another room without advance notice or consent, resulting in confusion for the resident. Documentation showed no evidence of written or verbal notice, explanation for the move, or consent from Resident 3.
Deficiencies (1)
Failure to provide advance notice and obtain consent before moving Resident 3 to another room.
Report Facts
Residents affected: 3
IDT meeting start time: 930
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Social Service Director | Provided information about facility policy and confirmed lack of consent documentation |
| Administrator | Administrator | Discussed the room change and acknowledged the failure to obtain consent |
Inspection Report
Annual Inspection
Census: 11
Capacity: 33
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
The visit was an unannounced required annual inspection to evaluate the facility's compliance using the full care tool.
Findings
The inspection found no deficiencies. The Licensing Program Analyst conducted a tour, medication count, and file reviews, and observed compliance with health and safety requirements.
Report Facts
Non-ambulatory residents: 1
Ambulatory residents: 10
Hospice waiver: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the inspection and met with facility staff |
| Darrell Price | Administrator/Director | Facility Administrator named in report header |
Inspection Report
Annual Inspection
Census: 11
Capacity: 33
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance with health and safety regulations using the full care tool.
Findings
The Licensing Program Analyst conducted a tour and file review, observed medication management and safety measures, and found no deficiencies during the inspection. The facility was compliant with required documentation and safety protocols.
Report Facts
Non-ambulatory residents licensed: 1
Ambulatory residents licensed: 32
Hospice waiver: 1
Residents present: 1
Residents present: 10
Residents present: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the inspection and evaluation |
| Darrell Price | Administrator/Director | Facility Administrator/Director |
Inspection Report
Routine
Census: 38
Deficiencies: 14
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, dietary services, and facility operations at Mountain Manor Senior Residence.
Findings
The facility was found deficient in multiple areas including delayed completion of admission assessments, incomplete care plans, medication errors, improper medication storage, failure to follow dietary menus, inadequate infection control practices, and food safety violations. Most deficiencies were assessed as minimal harm or potential for actual harm.
Deficiencies (14)
Failed to complete Minimum Data Set admission assessments within 14 calendar days for two residents.
Failed to develop a comprehensive care plan addressing dialysis for one resident.
Allowed use of a leg/knee immobilizer without a physician's order for one resident.
Failed to maintain nail care for one resident with long, dirty fingernails.
Failed to implement physician order to float heels for one resident, risking skin breakdown.
Failed to assist one resident in obtaining prescription eyeglasses.
Failed to post nurse staffing information daily at the beginning of each shift.
Failed to replace two opened emergency drug kits in medication room timely.
Failed to ensure two residents were free from unnecessary medications due to lack of stop dates and prolonged antibiotic use.
Medication error rate exceeded 5% due to incorrect dosing and missing medication for two residents.
Failed to ensure medications and biologicals were properly labeled, stored, and expired medications removed.
Failed to follow therapeutic diet menus for multiple residents during lunch service.
Failed to ensure food was prepared, stored, served, and distributed in accordance with professional food safety standards, including unclean ice machine, spoiled produce, wet and dirty pans, staff belongings in food storage, and unclean juice dispenser.
Failed to follow infection control practices by not using face shield while caring for COVID-19 positive resident.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 38
Medication error rate: 5.41
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Tomatoes spoiled: 11
Medication carts with issues: 1
Expired insulin vials: 2
Expired glucometer control solutions: 2
Loose pills: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Named in medication error findings and medication storage issues | |
| Assistant Director of Nursing | Acknowledged multiple deficiencies including medication errors, care plan issues, and infection control | |
| Certified Dietary Manager | Acknowledged dietary menu and food safety deficiencies | |
| Registered Dietitian | Provided expert statements on dietary and food safety deficiencies | |
| Licensed Nurse 4 | Acknowledged failure to implement heel float order | |
| Licensed Nurse 6 | Verified missing physician order for immobilizer | |
| Licensed Nurse 5 | Confirmed PPE requirements in COVID-19 unit | |
| Certified Nursing Assistant 3 | Failed to wear face shield in COVID-19 unit | |
| Licensed Nurse 2 | Noted expired insulin vials | |
| Licensed Nurse 4 | Observed failure to float heels for Resident 2 | |
| Licensed Nurse 3 | Not specifically named but implied in medication administration | |
| Physical Therapist | Stated immobilizer should be worn with physician order | |
| Social Worker | Acknowledged failure to provide eyeglasses | |
| Infection Preventionist | Confirmed PPE requirements and infection control deficiencies | |
| Registered Pharmacist | Explained medication packaging error causing missing medication |
Inspection Report
Complaint Investigation
Census: 12
Capacity: 33
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The visit was conducted as a case management investigation regarding an absent without leave incident report received by the department on 2024-05-06.
Complaint Details
The visit was complaint-related due to an absent without leave incident involving resident R1. The complaint was substantiated by findings that R1 left the facility unassisted against medical advice.
Findings
The investigation found that resident R1 was observed leaving the facility unassisted despite a physician's report indicating R1 was unable to leave unassisted, posing an immediate health and safety risk. Deficiencies were cited related to insufficient staffing to ensure resident supervision.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary services, as evidenced by R1 leaving the facility unassisted contrary to physician's report.
Report Facts
Capacity: 33
Census: 12
Deficiencies cited: 1
Plan of Correction Due Date: May 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the case management visit and evaluation |
| Anthony Perez | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
| Darrell Price | Administrator | Facility Administrator mentioned as unavailable during visit |
| Celeste Giuliano-Laui | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 12
Capacity: 33
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The visit was an unannounced case management inspection conducted due to an absent without leave incident report received by the department regarding a resident leaving the facility unassisted.
Complaint Details
The visit was triggered by a complaint regarding a resident who was absent without leave. The resident was found impaired outside the facility, violating the physician's report that the resident could not leave unassisted.
Findings
The inspection found that the facility failed to have sufficient personnel to ensure resident supervision, as a resident was observed leaving the facility unassisted despite a physician's report stating the resident could not leave unassisted. Deficiencies were cited related to personnel requirements.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary services, as evidenced by a resident leaving the facility unassisted contrary to physician's orders.
Report Facts
Deficiencies cited: 1
Plan of Correction due date: May 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrell Price | Administrator/Director | Facility Administrator/Director mentioned as unavailable during visit |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection visit |
| Anthony Perez | Supervisor | Supervisor overseeing the inspection |
| Celeste Giuliano-Laui | Met with Licensing Program Analyst during the visit |
Inspection Report
Annual Inspection
Census: 10
Capacity: 33
Deficiencies: 0
Date: Aug 16, 2023
Visit Reason
The inspection was an unannounced required one-year inspection conducted to evaluate compliance with licensing regulations using the CARE inspection tool.
Findings
No deficiencies were observed during the inspection. The facility was found to be in compliance with health, safety, and personal rights standards. The Administrator Certificate was noted as expired, and a backlog in renewal was discussed.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Non-ambulatory residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrell Price | Administrator | Met during inspection and discussed Administrator Certificate renewal backlog |
| Kim Jackson | Director | Met during inspection and toured facility with Licensing Program Analyst |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 10
Capacity: 33
Deficiencies: 0
Date: Aug 16, 2023
Visit Reason
The inspection was an unannounced Required Year Inspection conducted to evaluate compliance with licensing requirements using the CARE inspection tool.
Findings
No deficiencies were observed during the inspection. The facility was found to be in compliance with health, safety, and personal rights standards. The Administrator Certificate was noted to be expired, and an incident report for an AWOL resident will be submitted.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Licensed capacity: 33
Current census: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrell Price | Administrator | Facility Administrator present during inspection and discussed Administrator Certificate renewal |
| Kim Jackson | Director | Facility Director present during inspection and toured facility with Licensing Program Analyst |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection |
| Anthony Perez | Supervisor | Supervisor named in the report |
Inspection Report
Deficiencies: 1
Date: May 11, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding resident rights and medication education, specifically focusing on whether residents were fully informed about changes in their treatment.
Findings
The facility failed to ensure that one of three sampled residents (Resident 39) was informed about a new medication (a diuretic) added to their treatment without proper education. This failure potentially deprived the resident of the right to make informed decisions regarding their care.
Deficiencies (1)
Failure to ensure Resident 39 was informed of changes in their treatment when a new medication was added without education.
Report Facts
Residents affected: 3
Medication administration duration: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Stated resident was not educated about the new medication and explained resident rights regarding medication education and refusal |
| Nurse Practitioner | Nurse Practitioner | Provided information on the use of diuretics and treatment of lymphedema |
| Director of Nursing | Director of Nursing | Stated expectation that Resident 39 should receive education and have the right to decline medication if informed |
Inspection Report
Routine
Deficiencies: 16
Date: May 11, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meal assistance, inadequate resident education on medication changes, incomplete and inaccurate resident assessments and care plans, improper medication administration practices, failure to complete annual performance reviews for nursing assistants, medication storage and accountability issues, infection control lapses, and food preparation and storage deficiencies.
Deficiencies (16)
Failure to maintain resident dignity when staff stood in front of resident while assisting with meals.
Failure to ensure resident was informed of changes in treatment when new medication was added without education.
Failure to ensure Physician Orders for Life-Sustaining Treatment (POLST) was valid in the electronic health record.
Failure to comprehensively reassess resident after skin tear deteriorated to pressure injury within required timeframe.
Failure to accurately assess residents leading to inaccurate reporting of diagnoses and functional status.
Failure to ensure baseline care plan was accurately developed and signed within 48 hours of admission.
Failure to develop and complete comprehensive person-centered care plans for residents.
Failure to revise comprehensive care plan quarterly and evaluate effectiveness of restorative nursing program.
Failure to follow professional standards for insulin administration and medication administration per pharmacy auxiliary label.
Failure to complete annual performance reviews for certified nursing assistants.
Failure to ensure accurate accountability and secure storage of controlled medications, availability and replacement of emergency kits, and hazardous drug handling precautions.
Failure to ensure opened biologicals and multi-dose inhalers were dated, expired and discontinued medications removed, medication carts locked and medications not left unattended, and temperature monitoring of medication storage room and refrigerator.
Failure to ensure menus were followed for pureed rice preparation according to recipe.
Failure to ensure dry bulk goods were stored safely; older flour was stored inside new flour bag and mislabeled.
Failure to implement infection prevention and control practices including hand hygiene and proper sanitization of glucometers between resident use.
Failure to ensure psychotropic medications were prescribed and monitored appropriately including stop dates, signed consents, correct indications, and behavior and side effect monitoring.
Report Facts
Residents sampled: 12
Certified Nursing Assistants: 8
Missing signatures: 33
Expired medications: 20
Medication administration dates missing documentation: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Occupational Therapy Assistant 1 | COTA | Observed standing in front of resident during meal assistance |
| Director of Nursing | DON | Provided multiple interviews confirming expectations and deficiencies |
| Licensed Nurse 1 | LN 1 | Interviewed regarding medication administration and controlled drug documentation |
| Licensed Nurse 3 | LN 3 | Observed administering insulin incorrectly and medication cart practices |
| Certified Dietary Manager | CDM | Interviewed regarding food preparation and storage deficiencies |
| Consultant Pharmacist | CP | Interviewed regarding medication regimen reviews and hazardous drug handling |
| Assistant Director of Nursing | ADON | Interviewed regarding medication storage and temperature monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding physical abuse between two residents, Resident 3 and Resident 4, at Mountain Manor Senior Residence.
Complaint Details
The complaint investigation found that Resident 3 physically abused Resident 4, causing injuries that required hospital treatment. The local Sheriff's Department took Resident 3 into custody for felony elderly abuse. The facility acknowledged it was not equipped to care for residents with aggressive behaviors and failed to document Resident 3's agitation episodes properly.
Findings
The facility failed to protect two residents from physical abuse when Resident 3 struck Resident 4, resulting in Resident 4's transfer to the Emergency Department for facial injuries and Resident 3 being taken into police custody. The facility also failed to provide adequate care for Resident 3's combative behaviors and did not properly monitor his agitation as required by policy.
Deficiencies (3)
Failure to protect residents from physical abuse, resulting in actual harm.
Inadequate care for Resident 3's history of combative behaviors.
Failure to follow policy to accurately monitor Resident 3 for behaviors of agitation.
Report Facts
Residents affected: 2
Date of incident: Mar 7, 2023
Episodes of agitation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator (ADM) | Stated the facility is not able to care for residents with aggressive behaviors and confirmed admission policies |
| Director of Nursing | Director of Nursing (DON) | Confirmed monitoring and documentation failures related to Resident 3's agitation and aggressive behaviors |
| Medical Doctor | Medical Doctor (MD) | Stated he was not made aware of Resident 3's agitation episodes and relies on nursing notes for referrals |
| Pharmacist | Pharmacist (PD) | Stated nursing charting was incomplete, preventing medication recommendations |
Inspection Report
Complaint Investigation
Capacity: 33
Deficiencies: 0
Date: Mar 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident caused injuries to another resident in care.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis.
Findings
The complaint was found to be unfounded after investigation, as the incident occurred in a skilled nursing facility not regulated by this department, and public health was informed. The allegation was determined to be false or without reasonable basis.
Report Facts
Facility capacity: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darrell Price | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 33
Deficiencies: 0
Date: Mar 17, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a resident caused injuries to another resident in care.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis.
Findings
The Licensing Program Analyst found the complaint to be unfounded after investigation, determining that the incident occurred at a skilled nursing facility not regulated by this department, and that public health authorities were informed and involved.
Report Facts
Facility capacity: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Darrell Price | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 10
Capacity: 33
Deficiencies: 0
Date: Aug 9, 2022
Visit Reason
The inspection was an unannounced Case Management Inspection conducted to assess compliance and facility conditions, including COVID-19 protocols and facility risk assessment.
Findings
No immediate health, safety, or personal rights violations were observed during the inspection. The facility plans to discontinue building modifications to increase non-ambulatory capacity due to costs, and will continue fire watches until only one non-ambulatory resident remains. No deficiencies were cited.
Report Facts
Non-ambulatory residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the Case Management Inspection |
| Darrell Price | Executive Director | Met with Licensing Program Analyst during inspection and discussed facility plans |
| James Jordan | Administrator | Facility Administrator named in report header |
Inspection Report
Census: 10
Capacity: 33
Deficiencies: 0
Date: Aug 9, 2022
Visit Reason
Licensing Program Analyst Kevin Mknelly arrived unannounced to conduct a Case Management Inspection, including COVID-19 protocols and a facility risk assessment.
Findings
No immediate health, safety, or personal rights violations were observed during the inspection. The facility plans to discontinue building modifications to increase non-ambulatory capacity due to costs, and will continue fire watches until only one non-ambulatory resident remains. No deficiencies were cited.
Report Facts
Non-ambulatory residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the Case Management Inspection |
| Darrell Price | Executive Director | Met with Licensing Program Analyst and discussed facility plans |
| James Jordan | Administrator | Facility Administrator |
Inspection Report
Annual Inspection
Census: 13
Capacity: 33
Deficiencies: 0
Date: Jun 16, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to evaluate the health and safety compliance of the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during this inspection.
Report Facts
Fire extinguishers inspected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Jackson | Director | Met with Licensing Program Analyst during inspection |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 13
Capacity: 33
Deficiencies: 0
Date: Jun 16, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to evaluate the health and safety compliance of the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Report Facts
Fire extinguishers inspected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Jackson | Director | Met with Licensing Program Analyst during the inspection. |
| Cassie Yang | Licensing Program Analyst | Conducted the Required-1 Year Inspection. |
| James Jordan | Administrator | Named as facility administrator. |
Inspection Report
Annual Inspection
Census: 15
Capacity: 33
Deficiencies: 0
Date: Aug 17, 2021
Visit Reason
The inspection was an unannounced required annual inspection conducted to ensure compliance with health, safety, and infection control standards at the assisted living facility.
Findings
No deficiencies or violations were found during the inspection. The facility was found to be in compliance with infection control protocols and no immediate health, safety, or personal rights violations were observed.
Report Facts
Capacity: 33
Census: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Wallace | Resident Care Director | Met with Licensing Program Analyst during inspection |
| Darrell Price | Executive Director | Met with Licensing Program Analyst during inspection and provided updates on pending fire safety upgrades |
Inspection Report
Annual Inspection
Census: 15
Capacity: 33
Deficiencies: 0
Date: Aug 17, 2021
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the health and safety compliance of the Mountain Manor Senior Residence facility.
Findings
No immediate health, safety, or personal rights violations were observed during the inspection. The facility was found to be in compliance with infection control requirements, and no deficiencies were cited.
Report Facts
Facility Capacity: 33
Census: 15
Temperature: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Wallace | Resident Care Director | Met with Licensing Program Analyst during inspection and toured facility |
| Darrell Price | Executive Director | Met with Licensing Program Analyst during inspection and provided updates on fire safety upgrades |
| Sabrina Calzada | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Complaint Investigation
Census: 16
Capacity: 33
Deficiencies: 1
Date: Nov 13, 2020
Visit Reason
The inspection visit was an unannounced complaint investigation conducted to address multiple allegations received on 03/11/2020 regarding inadequate record keeping, medication administration, safeguarding of personal belongings, admission agreement compliance, overcharging for services, and telephone responsiveness at Mountain Manor Senior Residence.
Complaint Details
The complaint investigation was substantiated for inadequate record keeping after evidence showed mix-ups in resident mail and billing errors. Other allegations including medication errors, safeguarding personal belongings, admission agreement violations, overcharging, and telephone responsiveness were found unsubstantiated.
Findings
The investigation substantiated the allegation of inadequate record keeping related to resident mail and billing errors. All other allegations, including inappropriate medication administration, failure to safeguard personal belongings, non-compliance with admission agreement, overcharging for unauthorized services, and telephone issues, were found to be unsubstantiated.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have the right to send and receive unopened correspondence in a prompt manner. The licensee did not provide residents with their correct mail, posing a potential risk.
Report Facts
Facility capacity: 33
Census: 16
Deficiency count: 1
Hair care service charge: 18
Plan of Correction due date: Nov 20, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melana Llopis | Licensing Program Analyst | Conducted the complaint investigation and communicated findings |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation |
| Darrell Price | Administrator | Facility administrator interviewed during investigation |
| James Jordan | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 16
Capacity: 33
Deficiencies: 1
Date: Nov 13, 2020
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2020-07-10 regarding an improper rent increase at Mountain Manor Senior Residence.
Complaint Details
The complaint investigation was substantiated based on evidence that the facility failed to provide the required 60 days' written notice prior to increasing resident rent, violating California Code of Regulations, Title 22, Division 6.
Findings
The investigation substantiated the allegation that the facility increased resident rent without providing the required 60 days' written notice to residents or their responsible parties, posing a potential health risk to residents in care.
Deficiencies (1)
Increase in fee rates for elderly residents without providing 60 days’ written notice stating amount and reasons for increase as required by HSC 1569.655.
Report Facts
Census: 16
Total Capacity: 33
Deficiency Type Count: 1
Rent Increase Amount: 11
Notice Period: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melana Llopis | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation |
| Darrell Price | Administrator | Facility administrator interviewed during investigation |
Viewing
Loading inspection reports...
