Most inspections at this facility were clean, including the annual inspections on February 15, 2024, and March 14, 2025, which found no deficiencies. However, earlier reports revealed some serious issues, such as a Registered Sex Offender residing and working at the facility in late 2021, which led to a $500 fine and immediate health and safety concerns. Other deficiencies involved staff working without proper fingerprint clearance, expired training, unlocked hazardous chemicals, and lapses in emergency drills and documentation. The most recent inspection on August 8, 2025, found two deficiencies related to maintaining comfortable temperatures and adequate food supplies, but allegations of staff misconduct were unsubstantiated, and these issues were corrected afterward. Several complaint investigations were unsubstantiated, and the facility appears to have improved compliance over time.
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2025-02-20 regarding staff not maintaining comfortable temperature for residents and inadequate food services, as well as allegations of staff throwing items at residents, inappropriate speech, and soliciting monetary gifts.
Findings
The investigation substantiated the allegations that the facility did not maintain a comfortable temperature (observed at 64 degrees F) and did not have the required food supplies (2 days perishables and 7 days non-perishables). Allegations of staff throwing items, inappropriate speech, and soliciting gifts were unsubstantiated due to lack of evidence. The facility corrected the temperature and food supply deficiencies during subsequent visits.
Complaint Details
The complaint investigation was substantiated for allegations related to temperature and food supply deficiencies. Allegations regarding staff throwing items at residents, inappropriate speech, and soliciting monetary gifts were unsubstantiated due to insufficient evidence.
Severity Breakdown
Type B: 2
Deficiencies (2)
Description
Severity
Facility did not maintain a comfortable temperature at all times; observed temperature was 64 degrees F, below the required minimum of 68 degrees F.
Type B
Facility did not maintain required supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days.
The visit was an unannounced 1-Year Annual Required inspection conducted by Licensing Program Analyst A. Gomez to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. The inspection included a tour of the facility, review of resident and staff records, and verification of safety equipment and emergency preparedness.
Report Facts
Bedrooms: 8Residents' bedrooms occupied: 4Staff bedrooms occupied: 2Hot water temperature: 117.2Fire extinguisher purchase date: Jan 25, 2025Emergency Disaster Plan posted date: Nov 24, 2024Emergency disaster drill date: Mar 2, 2025Residents' records reviewed: 4Staff records reviewed: 3Staff with current first aid training: 3
Employees Mentioned
Name
Title
Context
Meeran Saxena
Administrator
Met with Licensing Program Analyst during inspection
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The facility was toured and inspected with no deficiencies cited. Safety features such as fire clearance, smoke detectors, and emergency plans were verified. Staff training records were reviewed and found mostly current.
Report Facts
Staff records reviewed: 3Staff with current first aid training: 2Staff with CPR training per shift: 1Fire extinguisher service date: Mar 17, 2023Emergency Disaster Plan last updated: Mar 23, 2023Fire drill last conducted: Dec 18, 2023
Employees Mentioned
Name
Title
Context
Meeran Saxena
Administrator
Met with Licensing Program Analyst during inspection
Unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing regulations and facility safety standards.
Findings
The inspection found multiple deficiencies including unlocked hazardous chemicals and medications accessible to residents, expired staff first aid training, incomplete resident records, lack of quarterly emergency drills, and an outdated fire extinguisher service date. All deficiencies were cited with plans of correction and some were cleared during the visit.
Deficiencies (7)
Description
Unlocked Clorox, drain cleaner, and oxy cleaner stored underneath bathroom sink cabinet posing immediate health and safety risk.
Unlocked Tylenol stored inside medication cabinet in resident R2's bathroom posing immediate health and safety risk.
R3's sliding screen door is off track and in disrepair.
Staff member S1's first aid training expired December 2020.
Quarterly emergency drills for each shift were not completed; last drill was in 2019.
Resident records are not maintained and available to Licensing Program Analysts.
Fire extinguisher was last serviced on 01/09/2022, posing potential safety risk.
Report Facts
Residents present: 6Staff present: 4Facility capacity: 6Deficiency due date: Mar 16, 2023Deficiency due date: Mar 20, 2023Deficiency due date: Mar 24, 2023Deficiency due date: Mar 31, 2023
Employees Mentioned
Name
Title
Context
Meeran Saxena
Administrator
Met with Licensing Program Analysts during inspection and responsible for corrective actions
Lizette Francisco
Licensing Program Analyst
Conducted inspection and authored report
Harpreet Humpal
Licensing Program Manager
Supervisor overseeing the inspection
S1
Staff member with expired first aid training cited in deficiency
The visit was an unannounced Case Management inspection conducted as part of an investigation for complaint #15-AS-20211222084738 regarding fingerprint clearance of staff.
Findings
A deficiency was found where staff member S1 was working at the facility without fingerprint clearance since November 2021, posing an immediate health and safety risk. A $500 civil penalty was assessed.
Complaint Details
Investigation for complaint #15-AS-20211222084738 found staff member S1 not fingerprint cleared and working at the facility, with conflicting employment dates noted. The deficiency was substantiated.
Deficiencies (1)
Description
Staff member S1 employed and working without fingerprint clearance since November 2021.
Report Facts
Civil penalty amount: 500
Employees Mentioned
Name
Title
Context
Meeran Saxena
Administrator
Administrator present during inspection and authorized Care Staff to sign report.
Irene Joseph
Care Staff
Greeted Licensing Program Analyst and signed report.
Unannounced annual infection control inspection conducted to assess compliance with health and safety regulations, including COVID-19 protocols.
Findings
The facility generally maintained infection control measures such as screening, hand washing stations, and PPE supplies. However, a deficiency was found regarding a staff member (S1) lacking a COVID-19 vaccination exemption and not undergoing required weekly COVID-19 testing.
Deficiencies (1)
Description
Staff member S1 employed since March 2022 does not have a COVID-19 vaccination exemption on file and is not undergoing weekly COVID-19 testing as required by Public Health Orders.
Report Facts
Capacity: 6Census: 6Plan of Correction Due Date: Jul 8, 2022
Employees Mentioned
Name
Title
Context
Meeran Saxena
Administrator
Facility administrator present during inspection
Irene Joseph
Care Staff
Care staff who greeted Licensing Program Analyst and authorized to sign report
The inspection was conducted as a result of the Department receiving a Priority 1 complaint (#15-AS-20211222084738) to perform a Health and Safety Inspection.
Findings
The Licensing Program Analyst toured the facility and observed compliance with food supply, smoke detectors, carbon monoxide detectors, fire extinguishers, and staffing. However, a deficiency was found where an individual (S1) was fingerprint cleared but not associated with the facility, posing a potential health and safety risk.
Complaint Details
The visit was triggered by a Priority 1 complaint (#15-AS-20211222084738).
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
S1 is fingerprint cleared but not associated with the facility, violating criminal record clearance requirements.
Type B
Report Facts
Capacity: 6Census: 6Plan of Correction Due Date: Dec 29, 2021
Employees Mentioned
Name
Title
Context
Meeran Saxena
Administrator
Met with Licensing Program Analyst during inspection
Unannounced complaint investigation visit conducted due to allegation that a Registered Sex Offender (RSO) was allegedly associated or present at the facility.
Findings
The investigation substantiated that a Registered Sex Offender was residing and employed at the facility, posing an immediate health and safety risk. The RSO had been present since November 2021 but left the facility prior to the inspection visit. An immediate $500 civil penalty was assessed.
Complaint Details
The complaint alleged that a Registered Sex Offender was associated or present at the facility. The allegation was substantiated based on interviews, document review, and observation. The RSO was confirmed to have been residing and employed at the facility since November 2021. The RSO left the facility before the inspection visit. The substantiation was based on the preponderance of evidence standard.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
1569.17(c)(3) Fingerprints and criminal records: Failure to act immediately to terminate employment and remove a person convicted of a sex offense against a minor from the residential care facility for the elderly.
Type A
Report Facts
Civil penalty amount: 500Capacity: 6Census: 6
Employees Mentioned
Name
Title
Context
Meeran Saxena
Administrator
Interviewed during investigation and named in findings related to knowledge of RSO presence.
Lizette Francisco
Licensing Program Analyst
Conducted the complaint investigation visit and authored the report.
Harpreet Humpal
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation.
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