Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the missing cell phone of Resident 164, which raised concerns about the facility's failure to protect resident property.
Complaint Details
The complaint involved the missing cell phone of Resident 164. The Social Services Director confirmed the missing phone was not reported or investigated as required. Licensed Vocational Nurse 1 acknowledged not filing a Theft and Loss Report or notifying SSD. The complaint was substantiated with findings of failure to follow policy.
Findings
The facility failed to protect Resident 164's property when their cell phone went missing and staff did not report or investigate the loss as required by facility policy. This failure caused potential anxiety and stress for Resident 164 due to inability to contact family.
Deficiencies (1)
Failure to protect Resident 164's property when their cell phone went missing and failure to report or investigate the loss as required.
Report Facts
Residents sampled: 15
Residents affected: 1
Date of missing cell phone: Jun 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Acknowledged not filing Theft and Loss Report or notifying SSD about missing cell phone |
| Social Services Director | Social Services Director | Responsible for investigating theft and loss issues; confirmed missing phone was not reported |
| Director of Nursing | Director of Nursing | Stated importance of resolving missing cell phone issue for Resident 164 |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food storage and safety standards to ensure resident food was stored in a safe and sanitary manner.
Findings
The facility failed to ensure resident food was stored properly, with expired, unlabeled, and unsealed food items found in dry storage and freezer rooms, posing potential risks for infection and food borne illness. Facility staff were unaware of proper storage height and sealing requirements, and facility policies mandated proper labeling and storage to prevent contamination.
Deficiencies (7)
Expired prune juice cups stored on shelf.
Food items stored about 3.5 inches above floor, below required 6 inches.
Unsealed frozen dinner rolls with expired use by date.
Unsealed strawberry ice cream with ripped lid.
Unsealed frozen fish fillets and chicken.
Unsealed bacon with expired use by date.
Beef and chopped meat unlabeled and undated.
Report Facts
Expired prune juice cups: 16
Storage height: 3.5
Frozen dinner rolls: 1
Strawberry ice cream container: 3
Fish fillets weight: 15
Bacon slices: 300
Brown rice quantity: 17
White rice quantity: 9
Flour quantity: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food storage practices and knowledge | |
| Registered Dietician | Interviewed regarding proper food storage and labeling policies |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 15, 2022
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to make state inspection results accessible to residents, inaccurate PASARR assessments, failure to provide baseline care plan summaries, inadequate assistance with activities of daily living, improper oxygen administration, food safety violations, failure to implement infection control hand hygiene, and call light accessibility issues for residents.
Deficiencies (8)
Failed to ensure the results of past State Inspections were readily accessible to residents without having to ask staff.
Failed to accurately follow through the PASARR assessment process for two residents.
Failed to provide a written summary of baseline care plan to one resident.
Failed to provide care and assistance for activities of daily living; resident had long fingernails and missed showers/bed baths.
Failed to ensure residents received oxygen volume as ordered; two residents received more oxygen than prescribed.
Failed to follow food safety requirements including hand hygiene, dishwasher temperature, and unlabeled/undated food items.
Failed to ensure Activity Assistant performed hand hygiene between residents while preparing and serving coffee.
Failed to ensure call lights were within reach for four residents, potentially delaying care.
Report Facts
Dishwasher temperature: 110
Oxygen liters per minute: 3
BIMS score: 3
BIMS score: 0
BIMS score: 15
Residents affected: 3
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development/Infection Preventionist | DSD/IP | Interviewed regarding accessibility of state inspection results and hand hygiene expectations |
| Assistant Director of Nursing | ADON | Interviewed regarding PASARR assessments and baseline care plan summaries |
| Director of Nursing | DON | Interviewed regarding PASARR assessments, baseline care plan summaries, shower/bed bath care, oxygen administration, food safety, hand hygiene, and call light protocols |
| Certified Nursing Assistant 3 | CNA 3 | Observed and interviewed regarding Resident 254's long fingernails and shower schedule |
| Licensed Vocational Nurse 1 | LVN 1 | Interviewed regarding oxygen administration and call light placement |
| Dietary Manager | DM | Interviewed regarding hand hygiene and dishwasher temperature |
| Registered Dietician | RD | Interviewed regarding dishwasher temperature and food safety |
| Activity Assistant | AA | Observed and interviewed regarding failure to perform hand hygiene between residents |
| Director of Staff Development | DSD | Interviewed regarding shower schedules and care plans |
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