Inspection Report Summary
Most inspections found no deficiencies, reflecting generally good facility conditions and compliance. Several complaint investigations were substantiated, primarily involving staffing shortages that affected medication administration and resident care, as well as a failure to maintain a comfortable dining room temperature. The most serious issues included staff neglect leading to a resident’s hospitalization for sepsis and operating beyond the licensed scope by retaining a resident with dementia. The most recent report from October 22, 2025, cited three deficiencies related to staff training, room assignments, and licensing conditions, indicating some ongoing areas needing attention. Overall, the facility showed improvement in staffing since mid-2024, but some care and operational issues persisted through the latest inspection.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
42% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 89
Capacity: 214
Deficiencies: 3
Date: Oct 22, 2025
Visit Reason
An unannounced, required annual inspection was conducted to evaluate compliance with licensing requirements and facility conditions.
Findings
The facility was found to be clean, sanitary, and in good repair with no immediate hazards. However, three Type B deficiencies were cited related to incomplete staff training, a bedridden resident residing in a non-bedridden approved room, and operating beyond the conditions of the license by retaining a resident with a Dementia diagnosis.
Deficiencies (3)
Care staff members S1 and S2 did not complete required training on postural supports, restricted conditions, or hospice care.
A bedridden resident (R1) was residing in a non-bedridden approved room, violating fire clearance requirements.
The facility retained a resident (R1) with a Dementia diagnosis, which is not approved by the facility's license.
Report Facts
Deficiencies cited: 3
Fire extinguisher service date: 2025
Last emergency drill date: Oct 3, 2025
Plan of Correction due date: Nov 19, 2025
Plan of Correction due date: Nov 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernest Lewis | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Perry Garrett | Maintenance Director | Met with Licensing Program Analyst during inspection. |
| Arian Golbakhsh | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Sabel Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 214
Deficiencies: 4
Date: Jul 30, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff neglect resulted in the hospitalization of a resident, that medical attention needs were not met, and that incontinence care was not provided.
Complaint Details
The complaint alleged staff neglect resulting in resident hospitalization, failure to seek medical attention, and failure to meet incontinence needs. The investigation substantiated these allegations based on interviews, record reviews, and observations.
Findings
The investigation substantiated the allegations, finding that staff neglect led to the resident's hospitalization due to sepsis from a UTI, medical needs were not appropriately addressed, and incontinence care was not provided. Staffing shortages and lack of documentation contributed to these deficiencies.
Deficiencies (4)
Failure to immediately bring significant changes in condition to the attention of licensed medical professionals.
Failure to regularly observe residents and document changes such as unusual weight loss or deterioration of condition.
Failure to seek medical attention to meet the resident's needs.
Failure to provide adequate incontinence care to the resident.
Report Facts
Resident weight loss: 12.3
Resident hospitalization duration: 14
Residents in care: 84
Plan of Correction due date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EJ Lewis | Executive Director | Named in relation to staffing shortages and plan of correction development. |
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Sabel Martinez | Licensing Program Manager | Oversaw the licensing program and signed the report. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 214
Deficiencies: 2
Date: Jul 30, 2025
Visit Reason
The inspection was conducted in response to a complaint received on May 29, 2024, alleging that staff failed to administer medication as ordered and that there was an insufficient number of staff to meet residents' needs.
Complaint Details
The complaint was substantiated based on observations and interviews. The allegations involved late medication administration due to staff shortages and insufficient staffing to meet resident needs. No adverse health outcomes were reported, but care services such as incontinence care, grooming, and housekeeping were often delayed or incomplete.
Findings
The investigation substantiated both allegations, finding that medication administration was often delayed due to staffing shortages and that residents' other care needs were not consistently met. The facility experienced ongoing staffing shortages between February and May 2024, with management acknowledging reliance on external staffing agencies. As of May 2025, new management has prioritized increasing staffing levels, and current staffing is adequate.
Deficiencies (2)
Failed to ensure medications were administered as ordered, posing a potential health risk to 69 residents.
Failed to maintain a sufficient number of staff to meet residents’ needs, posing a potential personal rights risk to 69 residents.
Report Facts
Residents at risk: 69
Facility capacity: 214
Plan of Correction due date: Sep 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EJ Lewis | Executive Director | Named in findings related to acting as medication technician due to staff shortages and involved in Plan of Correction development |
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sabel Martinez | Licensing Program Manager | Oversaw the licensing program related to this investigation |
Inspection Report
Follow-Up
Census: 84
Capacity: 214
Deficiencies: 0
Date: May 30, 2025
Visit Reason
The visit was an unannounced Case Management follow-up on an incident reported to Community Care Licensing involving a resident found unresponsive and pronounced deceased.
Findings
During the visit, the Licensing Program Analyst conducted a file review and consultation with the Executive Director. No deficiencies were cited during the visit.
Report Facts
Capacity: 214
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernest Lewis | Executive Director | Met with Licensing Program Analyst during the visit and involved in consultation |
| Arian Golbakhsh | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 214
Deficiencies: 1
Date: Jan 24, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 12/26/2024 alleging that staff did not maintain the dining room at a comfortable temperature.
Complaint Details
The complaint was substantiated. It was confirmed that staff did not maintain the dining room at a comfortable temperature, posing a potential health, safety, and personal rights risk to residents.
Findings
The investigation substantiated that the dining room was often colder in the mornings, staff including the Executive Director and Maintenance Director were aware of the issue for several months but did not address it. The thermostat was locked and only accessible by maintenance staff, who sometimes delayed adjusting it, causing discomfort to residents.
Deficiencies (1)
87303 Maintenance and Operation (b) - A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidenced by the dining room being maintained at an uncomfortable temperature.
Report Facts
Capacity: 214
Census: 86
Thermostat temperature: 68
Thermostat temperature: 73
Plan of Correction due date: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Emily DeLaBarre | Executive Director | Interviewed during investigation and involved in plan of correction |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 82
Capacity: 214
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
The visit was an unannounced Case Management inspection triggered by an incident report regarding a resident's fall and subsequent injury.
Findings
The report details that Resident #1 sustained a fall on 12/05/2024, initially showed no fractures, but later was diagnosed with a pelvic fracture after a second hospital visit. Additional visits and review of pending records are necessary.
Report Facts
Facility capacity: 214
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily DeLaBarre | Executive Director | Met during inspection and involved in incident report discussion |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 214
Deficiencies: 0
Date: Nov 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not provide resident medication as prescribed.
Complaint Details
The complaint alleged that staff did not provide resident medication as prescribed. The allegation was found to be unsubstantiated.
Findings
The investigation found that Resident #1 did not require assistance with medication management and managed their own medication. The allegation that staff did not provide medication as prescribed was unsubstantiated based on evidence including care plans and interviews.
Report Facts
Capacity: 214
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation visit and delivered complaint findings |
| Emily De La Barre | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Annual Inspection
Census: 85
Capacity: 214
Deficiencies: 0
Date: Nov 19, 2024
Visit Reason
The inspection was an unannounced Required Continuation Annual Inspection conducted to evaluate compliance with licensing requirements for the facility.
Findings
The Licensing Program Analyst conducted a thorough inspection including resident bedrooms, bathrooms, water temperature, and facility signal system, finding all within required operational ranges. No deficiencies were cited during this visit.
Report Facts
Hospice waiver residents approved: 15
Residents bedridden capacity: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the inspection and provided technical advice |
| Emily De La Barre | Executive Director | Met with the Licensing Program Analyst during the inspection and exit interview |
Inspection Report
Census: 85
Capacity: 214
Deficiencies: 0
Date: Oct 25, 2024
Visit Reason
The visit was an unannounced Case Management visit conducted in response to an Unusual Incident Report regarding a resident who eloped from the facility and was returned by police.
Findings
The investigation found that the resident had mild cognitive impairment and had previously attempted to leave the facility but this was the first time the resident left unassisted. The facility notified the family and transported the resident to the hospital. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation. |
| Emily De La Barre | Executive Director | Met with the Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Annual Inspection
Census: 85
Capacity: 214
Deficiencies: 0
Date: Oct 23, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. All inspected areas, including bedrooms and equipment, were in proper working order and safely maintained.
Report Facts
Hospice waiver residents approved: 15
Bedridden residents capacity: 8
Perishable food supply: 2
Non-perishable food supply: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced required annual inspection |
| Emily De La Barre | Executive Director | Met with Licensing Program Analyst during inspection and assisted with the visit |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 214
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
The visit was conducted in response to an Unusual Incident Report submitted on August 28, 2024, regarding Resident #1 who had left the facility and was considered AWOL.
Complaint Details
The complaint involved Resident #1 leaving the facility and being considered AWOL. The investigation substantiated that the facility followed proper procedures.
Findings
Review of records and interviews confirmed the facility followed its elopement procedures. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation. |
| Emily De La Barre | Executive Director | Assisted the Licensing Program Analyst during the visit and participated in the exit interview. |
| Mercedes Heredia | Business Office Manager | Was informed of the visit purpose and assisted during the investigation. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 214
Deficiencies: 0
Date: Aug 9, 2024
Visit Reason
The visit was conducted in response to an Unusual Incident Report (LIC 624) received by the Department on 08/09/2024 regarding a resident who had a fall and sustained a fracture.
Complaint Details
The complaint involved Resident #1 who had a fall resulting in a fracture. The investigation found no immediate health or safety concerns during the visit.
Findings
During the unannounced Case Management visit, pertinent records were secured and a facility tour was conducted. No immediate health or safety concerns were observed at the time of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily De La Barre | Executive Director | Met with during the inspection and involved in the exit interview. |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 214
Deficiencies: 1
Date: Mar 6, 2024
Visit Reason
An unannounced complaint investigation was conducted following an allegation that the licensee did not provide a refund within the required timeframe after a resident's belongings were removed from the facility.
Complaint Details
The complaint was substantiated. It was alleged and confirmed that the licensee did not provide a refund within the required 15-day period after a resident's belongings were removed from the facility.
Findings
The investigation substantiated that the facility did not refund fees within 15 days as required by California Code of Regulations, Title 22, posing a potential health, safety, and personal rights risk to one resident. Documentation confirmed the refund was eventually provided and the Plan of Correction was cleared during the visit.
Deficiencies (1)
Failure to refund fees within 15 days after resident's personal property was removed, violating HSC 1569.652(c).
Report Facts
Estimated Days of Completion: 90
Census: 74
Total Capacity: 214
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Emily De La Barre | Executive Director | Interviewed during investigation and exit interview |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 214
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations that the facility did not provide an adequate amount of food to a resident and overcharged a resident.
Complaint Details
The complaint alleged inadequate food provision and overcharging of a resident. The investigation concluded the allegations were unfounded, meaning they were false, could not have happened, or lacked reasonable basis.
Findings
The investigation found no evidence to support the allegations. Records and interviews confirmed that the resident involved was not residing at the facility during the alleged violations. The complaint was determined to be unfounded.
Report Facts
Facility capacity: 214
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation |
| Emily DeLaBarre | Executive Director | Met with Licensing Program Analyst during the investigation and received investigative findings |
| Simon Jacob | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 214
Deficiencies: 0
Date: Jan 3, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff threatened a resident and that a resident was locked out of the facility.
Complaint Details
The complaint involved allegations that staff threatened Resident #1 and locked them out of the facility. The investigation revealed conflicting statements and no preponderance of evidence to support the allegations. Staff interviews indicated that Resident #1 usually threatens staff. The complaint was unsubstantiated.
Findings
The investigation found inconsistent statements and insufficient evidence to substantiate the allegations. Interviews and record reviews indicated that the facility did not lock the resident out nor did staff threaten the resident. The allegations were deemed unsubstantiated.
Report Facts
Complaint Control Number: 08-AS-20231227160957
Capacity: 214
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation visit |
| Emily DeLaBarre | Executive Director | Interviewed during the investigation |
| Candi Laird | Administrator | Facility administrator named in the report |
Inspection Report
Census: 71
Capacity: 214
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
An unannounced Case Management visit was conducted to discuss eviction procedures and collect pertinent records.
Findings
The Licensing Program Analyst conducted the visit with assistance from facility staff and discussed eviction procedures. Relevant records were collected and an exit interview was conducted.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Sam Elizondo | Business Office Manager | Met with the Licensing Program Analyst and participated in the exit interview. |
| Elaine Nunes | Resident Care Director | Assisted the Licensing Program Analyst during the visit. |
| Emily Delbarre | Executive Director | Joined the visit via telephone. |
Inspection Report
Census: 72
Capacity: 214
Deficiencies: 0
Date: Oct 31, 2023
Visit Reason
An unannounced Case Management visit was conducted by Licensing Program Analyst Sabel Martinez to secure report signatures and deliver an amended report.
Findings
The Licensing Program Analyst identified himself, explained the purpose of the visit, secured report signatures, delivered an amended report, and conducted an exit interview with the Business Office Manager.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit and secured report signatures. |
| Sam Elizondo | Business Office Manager | Met with the Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 214
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint alleging the facility charged a resident for services not received.
Complaint Details
The complaint alleged the facility charged a resident for services not received. The allegation was unsubstantiated after review of records and interviews.
Findings
The investigation found that the invoices in question were from the previous facility and not the currently licensed facility. No invoices for November 2023 had been sent out. Based on the evidence, the alleged violation was unsubstantiated.
Report Facts
Capacity: 214
Census: 78
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Candi Laird | Executive Director | Facility representative met during investigation |
| Lizzette Tellez | Licensing Program Manager | Named in report header |
Inspection Report
Census: 78
Capacity: 214
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
An unannounced Case Management visit was conducted by Licensing Program Analyst Sabel Martinez to secure report signatures and deliver an amended report.
Findings
The Licensing Program Analyst identified himself, explained the purpose of the visit, secured report signatures, delivered an amended report, and conducted an exit interview with the Executive Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit and delivered the amended report. |
| Candi Laird | Executive Director | Met with the Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Census: 78
Capacity: 214
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
Licensing Program Analyst Sabel Martinez conducted an unannounced collateral visit to obtain records and conduct interviews with a resident and staff.
Findings
No immediate health or safety concerns were observed and no deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candi Laird | Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced collateral visit. |
| Lizzette Tellez | Licensing Program Manager | Named in the report header. |
Inspection Report
Original Licensing
Census: 78
Capacity: 214
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
An unannounced pre-licensing visit was conducted to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code.
Findings
The facility was found clean, sanitary, and in good repair with compliant ambient and hot water temperatures. Safety equipment and fire extinguishers were operational and serviced. The facility passed the pre-licensing inspection with no deficiencies noted.
Report Facts
Hot water temperature: 115.7
Hot water temperature: 115.7
Hot water temperature: 118.2
Hot water temperature: 105.1
Hot water temperature: 117.1
Hot water temperature: 118.2
Hot water temperature: 120
Hot water temperature: 115.7
Kitchen Walk-In Refrigerator temperature: 35
Kitchen Walk-In Freezer temperature: -3
Facility capacity: 214
Facility census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced pre-licensing visit and inspection |
| Candi Laird | Executive Director | Applicant's representative met during the inspection |
Inspection Report
Original Licensing
Census: 79
Capacity: 214
Deficiencies: 0
Date: Sep 15, 2023
Visit Reason
The visit was conducted as a Component II evaluation for a Change in Ownership (CHOW) application for the Residential Care Facility for the Elderly (RCFE).
Findings
The Component II evaluation was completed successfully, confirming the Applicant and Administrator's understanding of licensing laws, facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candi Laird | Administrator | Participant in Component II evaluation and interview. |
| Larry John | Applicant | Participant in Component II evaluation and interview. |
| Darla Neeley | Licensing Program Manager | Named in report as Licensing Program Manager. |
| Celia Phomphachanh | Licensing Program Analyst | Named in report as Licensing Program Analyst. |
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