Inspection Reports for North Lake Villas
2851 Lake Ave, Altadena, CA 91001, United States, CA, 91001
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on August 18, 2024, which showed full compliance with health, safety, and infection control standards. A single substantiated deficiency occurred in November 2022 when a resident was made to wait in a cold basement before moving out, which was cited as a personal rights violation. Other complaint investigations were unsubstantiated, including allegations about eviction threats, admission agreement provision, and facility obstructions. Earlier inspections consistently found the facility in compliance with infection control and safety protocols, and no fines or enforcement actions were listed in the available reports. The overall record suggests the facility has maintained good standards with an isolated issue that does not appear to have recurred.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
0.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
93% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
83% occupied
Based on a August 2024 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 25
Capacity: 30
Deficiencies: 0
Aug 18, 2024
Visit Reason
An unannounced required one-year inspection was conducted to evaluate compliance with licensing and safety regulations at the facility.
Findings
The facility was found to be in compliance with health, safety, and infection control standards. No health and safety issues were observed during the visit, and the facility maintains proper documentation, adequate staffing clearances, and appropriate environmental conditions.
Report Facts
Bedrooms: 15
Bathrooms: 9
Hospice waiver residents: 10
Fire inspection date: Dec 29, 2023
Fire extinguisher inspection date: Nov 8, 2023
Disaster drill date: Jul 16, 2024
Perishable food supply days: 2
Non-perishable food supply days: 7
Hot water temperature range (°F): 105.1-116.5
First aid kits: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Braun | Assistant Administrator | Met during inspection and involved in visit |
| Maria Heredia | Staff who called the administrator and explained the reason for the visit | |
| Gary Tan | Licensing Program Analyst | Conducted the inspection |
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the inspection |
| Troy Agard | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 27
Capacity: 30
Deficiencies: 0
Jan 14, 2023
Visit Reason
An unannounced Required One (1) year Infection Control inspection was conducted to evaluate compliance with infection control and facility safety standards.
Findings
The facility was found to be in compliance with infection control protocols, including proper PPE stock, signage, and screening procedures. The physical plant was well maintained with no health or safety issues observed during the visit.
Report Facts
Bedrooms: 15
Bathrooms: 9
Fire clearance capacity: 30
Bedridden residents allowed: 23
Hospice waiver residents: 10
Food stock - perishable days: 2
Food stock - non-perishable days: 7
Hot water temperature range (°F): 108.3 to 118.2
First aid kits: 2
Fire extinguisher last inspection date: Nov 2, 2022
Facility temperature (°F): 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the inspection and authored the report |
| Nourit Braun | Administrator | Facility administrator designated for the inspection |
| Maria Heredia | Staff | Met with Licensing Program Analyst and designated to sign the report |
| Naira Margaryan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 30
Deficiencies: 1
Nov 9, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that facility staff made a resident wait in the cold basement before being moved out, did not allow a resident to be moved out without a 30-day notice, and did not inform the resident's DPOA prior to cutting the resident's hair.
Findings
The allegation that a resident was made to wait in a cold basement was substantiated, with a deficiency cited for not ensuring the resident's personal rights and comfortable accommodations. The allegations regarding the 30-day notice for moving out and informing the resident's DPOA prior to cutting hair were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff made a resident wait in a cold basement before being moved out. The other allegations regarding 30-day notice for moving out and informing the resident's DPOA prior to hair cutting were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The Licensee did not ensure that the personal rights of R1 were respected. R1 was not accorded comfortable accommodations while waiting to move out of the facility, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 30
Census: 23
Plan of Correction Due Date: Nov 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Adam Braun | Assistant Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 30
Deficiencies: 0
Jun 7, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including staff threatening a resident with eviction and resident's needs not being met.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. It was determined that the resident needed a higher level of care due to worsening pressure ulcers, and the facility offered adequate assistance with bathing and toileting, which the resident refused.
Complaint Details
The complaint involved allegations that staff threatened a resident with eviction and did not meet the resident's needs. Both allegations were deemed unsubstantiated after interviews and record reviews.
Report Facts
Facility capacity: 30
Census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 30
Deficiencies: 0
Jun 7, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that a resident was not provided a copy of their Admissions Agreement while in care and that the facility failed to keep premises free from obstructions.
Findings
Both allegations were investigated through interviews and observations. The facility was found to have provided the resident with the admission agreement and promptly removed obstructions from the resident's path. There was insufficient evidence to substantiate either allegation, and both were deemed unsubstantiated.
Complaint Details
The complaint involved two allegations: 1) Resident was not provided a copy of their Admissions Agreement while in care, and 2) Facility failed to keep premises free from obstructions. Both allegations were investigated and found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 30
Census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Cynthia Martinez | Met with Licensing Program Analyst during the visit | |
| Nourit Braun | Administrator | Facility administrator met with Licensing Program Analyst during the visit |
Inspection Report
Annual Inspection
Census: 23
Capacity: 30
Deficiencies: 0
Jul 29, 2021
Visit Reason
An unannounced Required One (1) year Infection Control inspection was conducted to assess compliance with infection control protocols and overall facility conditions.
Findings
The facility was found to be in compliance with infection control and safety standards, including proper signage, PPE stock, locked medication storage, and clean, well-maintained living areas. No deficiencies were cited during the inspection.
Report Facts
Bedrooms: 15
Bathrooms: 9
Hot water temperature: 111.2
Perishable food stock: 2
Non-perishable food stock: 7
Residents: 23
Capacity: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Braun | Director of Operations | Met with Licensing Program Analyst during inspection |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the inspection |
| Naira Margaryan | Licensing Program Manager | Named in report header |
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