Inspection Report Summary
Most inspections found deficiencies related to safety, maintenance, and resident care, with several substantiated complaints over the years. Key issues included unsecured toxins leading to a resident ingesting cleaning solution in July 2024, failure to maintain a compliant kitchen fire suppression system resulting in civil penalties in mid-2024, and medication management problems such as missed doses and improper insulin administration. The facility also had repeated problems with incident reporting and emergency communication systems, posing risks to resident safety. The most recent inspection on October 27, 2025, found no new deficiencies and confirmed that previous issues cited on October 10, 2025, including kitchen maintenance problems, had been corrected. While some older reports showed serious concerns, recent follow-ups indicate improvement in addressing prior deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Capacity: 160
Deficiencies: 1
Oct 27, 2025
Visit Reason
The visit was an unannounced plan of correction (POC) inspection to verify that previously cited deficiencies from a visit on 10/10/2025 had been corrected by the due date of 10/24/2025.
Findings
The deficiencies initially cited during the 10/10/2025 visit were cleared by this visit. The facility repaired or replaced the items as required and provided documentation to the department. An exit interview was conducted.
Deficiencies (1)
| Description |
|---|
| Deficiencies initially cited during a visit on 10/10/2025, Section Cited: 87555(b)(29) |
Report Facts
Capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the plan of correction visit |
| Gretchen Monares | Administrator | Met with Licensing Program Analyst during the POC visit |
| Lisa Rios | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 160
Deficiencies: 1
Oct 10, 2025
Visit Reason
The inspection was an unannounced case management visit based on incident reports submitted regarding a resident's fall and subsequent injuries.
Findings
The inspection found that a resident had an unwitnessed fall resulting in multiple rib fractures and a UTI, with follow-up care ordered. Additionally, multiple kitchen issues were discovered including broken thermostat, non-operational equipment, drainage problems causing puddling, unsecured mirror, and black smoke stains on dining area walls.
Complaint Details
The visit was triggered by a complaint regarding a resident (R1) who had an unwitnessed fall on 2025-09-30, refused EMS treatment, later diagnosed with UTI and multiple rib fractures after ER visit on 2025-10-03. Follow-up care was ordered by 2025-10-06.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Multiple issues in the kitchen including open seams in the sink, broken thermostat, equipment not operational, drainage issues resulting in puddling on the floor in front of the main oven, mirror not secured on the fireplace mantel, and black smoke stains on the walls in the dining area. | Type B |
Report Facts
Capacity: 160
Census: 53
Plan of Correction Due Date: Oct 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lisa Rios | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Gretchen Monares | Administrator | Facility administrator met during inspection |
Inspection Report
Capacity: 160
Deficiencies: 0
Sep 5, 2025
Visit Reason
Unannounced case management visit regarding an incident report detailing an unexpected death.
Findings
The Licensing Program Analyst met with staff and the Administrator to review the incident and the pre-assessment and support plan active when the resident was living. Multiple prior ER visits for the resident were noted.
Report Facts
Facility capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gretchen Monares | Administrator | Met with Licensing Program Analyst during visit |
| Albert Johnson | Licensing Program Analyst | Conducted the case management visit |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 160
Deficiencies: 0
Jul 14, 2025
Visit Reason
The visit was an unannounced case management inspection conducted based on two incident reports submitted to the department on 2025-07-08 involving residents experiencing medical emergencies.
Findings
The inspection found that two residents required emergency medical attention and were transported to the hospital. No deficiencies were cited during this visit.
Complaint Details
The visit was triggered by two incident reports: one resident experienced low blood pressure and was transported to the hospital for observation; another resident had labored breathing and was diagnosed with pneumothorax and taken to the hospital. The facility is following up on both residents' status.
Report Facts
Incident report date: Jul 8, 2025
Blood pressure reading: 70
Blood pressure reading: 45
Visit start time: 904
Visit end time: 1130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shanel Thitphaneth | LVN/RCD | Witnessed the incident involving resident R1 |
| Albert Johnson | Licensing Program Analyst | Conducted the case management visit |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on report |
| Gretchen Monares | Administrator | Facility Administrator met during inspection |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 160
Deficiencies: 0
Apr 23, 2025
Visit Reason
The visit was an unannounced case management incident investigation triggered by a report submitted on 2025-04-14 regarding a resident's fall on 2025-04-12.
Findings
The resident slipped and fell while trying to use his urinal, hitting his head but sustaining no noted injuries or bruising. Paramedics transported the resident to the hospital. The resident was discharged and has not returned; the facility plans to reassess before return. No deficiencies were cited during this visit.
Complaint Details
The complaint involved a resident fall incident reported on 2025-04-14. The resident fell on 2025-04-12, was transported to the hospital, and discharged. The complaint was investigated with no deficiencies found.
Report Facts
Report date: Apr 23, 2025
Incident date: Apr 12, 2025
Census: 53
Total capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Named as Licensing Program Analyst on report |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Plan of Correction
Census: 66
Capacity: 160
Deficiencies: 0
Dec 11, 2024
Visit Reason
An unannounced Plan of Correction (POC) visit was conducted to verify corrections from the annual inspection completed on 11/25/2024 and case management visits on 7/29/2024 and 6/07/2024.
Findings
The facility submitted the required corrections by the due dates, resulting in deficiencies being corrected and cleared.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced POC visit and mentioned in the narrative. |
Inspection Report
Annual Inspection
Census: 50
Capacity: 160
Deficiencies: 2
Nov 25, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing and safety regulations.
Findings
The inspection found broken ceiling panels, exposed wires, rat droppings, and an out-of-compliance fixed kitchen fire system requiring servicing. Medications were properly secured and staff files were in order. Deficiencies were cited and civil penalties assessed.
Deficiencies (2)
| Description |
|---|
| Observation of rat droppings and missing or broken ceiling panels posing potential health, safety or personal rights risk. |
| Fixed kitchen fire system is out of compliance and has not been serviced as required by the State fire marshal. |
Report Facts
Capacity: 160
Census: 50
Plan of Correction Due Date: Dec 13, 2024
Plan of Correction Due Date: Nov 26, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Gretchen Monares | LVN | Met with Licensing Program Analyst during inspection |
| Chantlle Hudson | Administrator/Director | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 160
Deficiencies: 1
Jul 29, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report received on 2024-07-26 involving a resident ingesting a cleaning solution.
Findings
The inspection found that a resident ingested a cleaning solution that was improperly stored and accessible in a bathroom cabinet, posing an immediate health and safety risk. Deficiencies were cited related to the failure to secure toxins.
Complaint Details
The visit was triggered by a complaint/incident report regarding a resident who ingested cleaning solution. Poison control was called and the resident was transported to the emergency room. The resident had a history of suicidal ideations and severe depression. The complaint was substantiated by the findings.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to secure toxins; a cabinet in a resident bathroom contained toxins which a resident ingested, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 160
Census: 48
Plan of Correction Due Date: Jul 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lisa Rios | Licensing Program Manager | Supervisor overseeing the inspection |
| Greg Awrey | Met with during the inspection visit | |
| Chantlle Hudson | Administrator/Director | Facility administrator mentioned in the report |
Inspection Report
Capacity: 160
Deficiencies: 1
Jun 13, 2024
Visit Reason
An unannounced visit was conducted on 06/13/2024 to perform a health and safety check during ongoing construction at the facility.
Findings
Exposed wires were observed uncovered in the main hallways of the construction area, posing an immediate health and safety risk. The construction company covered the wires during the visit, and the facility will continue to monitor construction areas to ensure safety. Medication counts were confirmed accurate, with an advisory given regarding taping medication back into bubble packs after pills were accidentally pushed out.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Exposed wires not covered in the main hallways of the construction area posing an immediate health and safety risk to persons in care. | Type A |
Report Facts
Facility capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced health and safety check and authored the report |
| Ignacio Lopez III | Executive Director | Met with Licensing Program Analyst during the inspection |
| Lisa Rios | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Follow-Up
Census: 48
Capacity: 160
Deficiencies: 1
Jun 7, 2024
Visit Reason
The visit was an unannounced health and safety check along with follow-up on incident reports and monitoring of ongoing construction issues at the facility.
Findings
The facility had issues with six rooms involving air conditioning which are being addressed. The kitchen's fixed fire suppression system was out of compliance due to overdue semi-annual servicing, resulting in a citation and civil penalty. The facility was reminded to maintain compliance with Title 22 regulations during construction to protect residents from health and safety hazards.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The fixed fire suppression system ('Ansul System') in the kitchen was not maintained in conformity with State Fire Marshal regulations and was overdue for semi-annual servicing since last serviced on 7/19/2023. | Type A |
Report Facts
Capacity: 160
Census: 48
Deficiencies cited: 1
Plan of Correction Due Date: Jun 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced visit and authored the report |
| Ignacio Lopez III | Administrator | Facility administrator met during inspection |
| Lisa Rios | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 160
Deficiencies: 0
Apr 26, 2024
Visit Reason
The visit was an unannounced case management inspection regarding an incident reported on 2023-02-16 involving unwelcome sexual advances by one resident toward another.
Findings
The investigation found that Resident 1 made unwelcome sexual advances toward Resident 2, with no visible injuries reported. A safety plan was verbally implemented for Resident 2, but lacked documented terms or timeframe. Technical assistance was recommended to document safety plans. A new LIC 602 assessment was requested to evaluate Resident 1's compatibility with the facility population.
Complaint Details
The complaint involved Resident 1 entering Resident 2's room and making unwelcome sexual advances. The incident was self-reported and investigated with interviews and review of police and facility reports. Resident 1 denied assault, and Resident 2 reported feeling safe with staff care. The complaint was substantiated with recommendations for improved documentation and reassessment of Resident 1.
Report Facts
Incident date: Feb 16, 2023
Report date: Apr 26, 2024
Census: 46
Total capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the case management visit and investigation |
| Ignacio Lopez III | Executive Director | Interviewed regarding the incident and facility operations |
Inspection Report
Follow-Up
Census: 46
Capacity: 160
Deficiencies: 0
Apr 25, 2024
Visit Reason
Unannounced visit to conduct a health and safety check along with follow-up on incident reports, including a medication error and resident falls.
Findings
The facility was found to be in compliance with Title 22 regulations with no deficiencies cited. The medication error incident resulted in termination of one staff member and additional training for others. One resident remains hospitalized following a fall.
Report Facts
Facility capacity: 160
Resident census: 46
Incident date: Apr 12, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ignacio Lopez III | Administrator/Executive Director | New administrator introduced during the visit |
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced visit and inspection |
| Lisa Rios | Licensing Program Manager | Named in the report header and narrative |
| G. Monares | Met with during the inspection |
Inspection Report
Census: 50
Capacity: 160
Deficiencies: 0
Apr 2, 2024
Visit Reason
An unannounced health and safety check was conducted to assess overall safety of the facility including food supply, physical plant, and staffing.
Findings
No deficiencies were observed pursuant to Title 22 rules and regulations and Health and Safety Codes. The facility was found to be in compliance despite ongoing construction, with safety signs posted and controlled access to hazardous areas.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced health and safety check. |
| Lisa Rios | Licensing Program Manager | Named in the exit interview and report. |
Inspection Report
Follow-Up
Census: 50
Capacity: 160
Deficiencies: 2
Mar 19, 2024
Visit Reason
The visit was an unannounced follow-up to clear citations from a case management visit completed on 2024-02-01.
Findings
The deficiencies initially cited during the 02/01/2024 visit related to HVAC system repairs and updating resident service plans were confirmed cleared during this visit.
Deficiencies (2)
| Description |
|---|
| Failure to repair or replace the unit for air-conditioning and heating as required. |
| Failure to update service plans for residents being billed for services not identified in their pre-appraisal or current service plan. |
Report Facts
Residents with updated service plans reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced follow-up visit and confirmed clearance of deficiencies. |
| Gretchen Monares | Met with Licensing Program Analyst during the visit. | |
| Chantlle Hudson | Administrator | Named as facility administrator in relation to service plan deficiency. |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 160
Deficiencies: 0
Jan 19, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that the licensee evicted a resident without sufficient cause.
Findings
The investigation found that the facility did not report incidents involving resident altercations as required, but the allegation of wrongful eviction was unsubstantiated based on the preponderance of evidence. No deficiencies were cited.
Complaint Details
The complaint alleged that the licensee evicted a resident without sufficient cause. The investigation determined the allegation was unsubstantiated as the preponderance of evidence standard was not met. The facility was previously cited for not reporting incidents but no citations were issued for this complaint.
Report Facts
Facility capacity: 160
Resident census: 45
Citation date: Dec 4, 2023
Estimated days of completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Rios | Licensing Program Manager | Oversaw the complaint investigation |
| Nellie Gomez | Business Office Manager | Met with Licensing Program Analyst during investigation |
Inspection Report
Follow-Up
Census: 45
Capacity: 160
Deficiencies: 1
Dec 4, 2023
Visit Reason
The visit was an unannounced follow-up on 30 day notices submitted to two residents for various infractions, specifically to investigate whether the facility reported incidents as required.
Findings
The investigation found that the facility failed to report multiple incidents of resident altercations and assaults to the department and local authorities as mandated, including physical and verbal altercations involving residents R1, R2, R3, and R4. No incident reports or SOC 341 forms were submitted for these events.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit written incident reports to the licensing agency for specified events within seven days, posing an immediate health, safety, or personal rights risk to residents. | Type A |
Report Facts
Capacity: 160
Census: 45
Plan of Correction Due Date: Dec 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lisa Rios | Licensing Program Manager | Supervisor overseeing the inspection |
| Jennifer Whitely | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 45
Capacity: 160
Deficiencies: 3
Nov 13, 2023
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and regulations at the assisted living facility.
Findings
The inspection found several deficiencies including the absence of a certified administrator, missed medication doses for residents, and missing health screening documentation for a staff member. Advisory notices were given for the bus license number and elevator compliance.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility lacked a qualified and currently certified administrator. | Type A |
| Medications ordered for residents were not given as prescribed, posing an immediate health and safety risk. | Type A |
| Staff member S1 did not have a health screening and TB test results in file. | Type B |
Report Facts
Resident files reviewed: 15
Staff files reviewed: 5
Hot water temperature: 117
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lisa Rios | Licensing Program Manager | Supervisor of the inspection |
| Jennifer Whitely | Administrator | Facility administrator position was vacant during inspection |
| Gretchen Monares | LVN | Met with Licensing Program Analyst during inspection and assisted with medication review |
Inspection Report
Census: 51
Capacity: 160
Deficiencies: 0
Oct 16, 2023
Visit Reason
The visit was an unannounced Case Management visit triggered by an incident report dated 10/7/2023.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst reviewed records, toured the facility, and interviewed the Administrator regarding medication errors and a resident moving out. Advisories were given.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced Case Management visit and reviewed records. |
| Jennifer Whitely | Administrator | Interviewed about events related to medication errors and a resident moving out. |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 1
Aug 3, 2023
Visit Reason
The visit was an unannounced case management inspection related to an incident report concerning Resident 1's elevated blood sugar levels and medication management.
Findings
The investigation found that Resident 1 was administering his own insulin and monitoring his own glucose despite documentation stating he was not able to do so and required assistance from a licensed nurse. This posed an immediate risk to resident health and safety. A deficiency was cited for failure to provide skilled professional medication administration.
Complaint Details
The visit was triggered by incident reports indicating Resident 1 went to the emergency room multiple times for elevated blood sugar levels. The complaint was substantiated by findings that the resident self-administered insulin contrary to care plans.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that a resident with diabetes had medication administered by a skilled professional as required, posing an immediate risk to health and safety. | Type A |
Report Facts
Incident reports reviewed: 3
Facility capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and interviews |
| Gia Cocola | Executive Director | Met with Licensing Program Analyst and provided information about medication management |
| Liza King | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Census: 57
Capacity: 160
Deficiencies: 1
Jun 22, 2023
Visit Reason
The visit was an unannounced case management inspection conducted to address deficiencies related to incident reports received by the Department on 2023-06-05 concerning incidents occurring in May 2023.
Findings
The facility failed to submit six incident reports within the required seven-day timeframe, posing a potential risk to the health, safety, and personal rights of residents. Deficiencies were cited under California Code of Regulations, Title 22, Division 6.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit written incident reports to the licensing agency and responsible person within seven days of occurrence for incidents threatening resident welfare, safety, or health. | Type B |
Report Facts
Incident reports received: 6
Plan of Correction due date: Jun 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and cited deficiencies. |
| Gia Cocola | Executive Director | Met with Licensing Program Analysts during the inspection. |
| Liza King | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Census: 57
Capacity: 160
Deficiencies: 1
Apr 6, 2023
Visit Reason
The visit was an unannounced case management inspection related to the facility's renovation project and HVAC replacement, including follow-up on project delays and administrator certification status.
Findings
The HVAC replacement project was delayed due to supply chain and permit issues, with a new completion timeline of 4-6 months. The facility had a change in administrator approximately 3 weeks prior, with no current certified administrator of record, posing a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator Certification Requirements: The facility's former Administrator exited the position around 3/9/23 and there was no evidence of a new Administrator of record, posing a potential health, safety, and personal rights risk to residents. | Type B |
Report Facts
Capacity: 160
Census: 57
Plan of Correction Due Date: Apr 13, 2023
Project delay timeframe: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Liza King | Licensing Program Manager | Supervised the inspection |
| Gia Cocola | Executive Director | Met with Licensing Program Analyst during inspection and provided information about administrator change |
| Diane Wright | Administrator | Former Administrator who exited position around 3/9/23 |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 160
Deficiencies: 2
Feb 13, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that plans for the facility to be self-reliant for at least 72 hours following an emergency were not properly implemented by facility staff.
Findings
The investigation substantiated that the facility failed to notify families of residents during a prolonged power outage and did not timely report the outage to the licensing agency. The facility's emergency plan was reviewed and found lacking in implementation, including inadequate notification and lack of backup generator availability.
Complaint Details
The complaint investigation was substantiated based on evidence that the facility did not properly implement emergency self-reliance plans during power outages, including failure to notify families and failure to report the incidents to the licensing agency in a timely manner.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency within seven days of the power outage incident threatening resident welfare, safety, or health. | Type B |
| Failure to inform residents and their responsible parties of emergency communication processes during the power outage. | Type B |
Report Facts
Census: 51
Total Capacity: 160
Power Outage Duration: 54
Power Outage Duration: 24
Percentage of families not contacted: 25
Plan of Correction Due Date: Feb 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Diane Wright | Executive Director | Facility administrator interviewed during the investigation and named in findings. |
| Liza King | Licensing Program Manager | Oversaw the licensing program related to this investigation. |
Inspection Report
Annual Inspection
Census: 48
Capacity: 160
Deficiencies: 2
Dec 2, 2022
Visit Reason
The inspection was an unannounced one-year annual inspection conducted to evaluate compliance with regulatory requirements at the assisted living facility.
Findings
The facility was generally sanitary, well-maintained, and compliant with infection control and safety measures. However, deficiencies were cited related to the inability to maintain comfortable temperatures in resident rooms due to portable heaters and issues with the call alert system where staff did not respond to alerts in a timely manner.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to maintain a comfortable temperature in resident rooms as portable heaters do not allow for accurate temperature setting, posing a risk to residents. | Type B |
| The call alert system in resident suites did not receive staff response within over ten minutes, posing an immediate health, safety, and personal rights risk to residents. | Type A |
Report Facts
Occupied units using portable heaters: 9
Water temperature: 116
Call alert response time: 20
Call alert response time: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and documented findings. |
| Diane Wright | Executive Director | Interviewed regarding portable heaters and facility operations. |
| Liza King | Licensing Program Manager | Supervisor of the inspection. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 160
Deficiencies: 1
Sep 29, 2022
Visit Reason
The visit was an unannounced case management inspection conducted due to deficiencies related to the theft of a resident's funds by a staff member.
Findings
The facility self-reported that a staff member used a resident's check to deposit funds into their own account, posing a potential health, safety, and personal rights risk to residents. The staff member was terminated, and the Administrator complied with all reporting requirements including notifying law enforcement, APS, and the Ombudsman.
Complaint Details
The complaint was substantiated as the facility self-reported the theft of a resident's funds by a staff member. The staff member was terminated, and the Administrator notified law enforcement, APS, and the Ombudsman.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to take appropriate measures to safeguard residents' cash resources, personal property, and valuables as evidenced by a staff member using a resident's check to deposit funds into their own account. | Type B |
Report Facts
Census: 49
Total Capacity: 160
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Diane Wright | Administrator | Named in relation to reporting the theft and compliance with reporting requirements |
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Trish Velez | Resident Care Coordinator | Met with Licensing Program Analyst during the inspection |
Inspection Report
Follow-Up
Census: 51
Capacity: 160
Deficiencies: 0
Sep 10, 2022
Visit Reason
The visit was conducted as a follow-up on concerns regarding a high temperature in the facility due to insufficient cooling by the A/C units.
Findings
The facility had purchased portable air conditioners for every resident and installed large fans throughout the building. Temperatures ranged between 78-83 degrees, and residents were observed to be comfortable. No deficiencies were cited during this visit.
Report Facts
Temperature range: 79
Temperature range: 83
Temperature range: 78
Temperature range: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Diane Wright | Facility Designated Administrator | Interviewed by Licensing Program Analyst regarding A/C unit backlog and follow-up plans |
| Shalini Peter | Medication Technician | Met with Licensing Program Analyst during the visit |
| Jennifer Armendariz | Medication Technician | Met with Licensing Program Analyst and received a copy of the report |
Inspection Report
Census: 52
Capacity: 160
Deficiencies: 1
Sep 9, 2022
Visit Reason
The visit was conducted unannounced due to a phone call reporting concerns about the temperature in the facility.
Findings
The inspection found that the temperature in the hallways and resident rooms on the upper level ranged between 87 and 97 degrees, exceeding the regulatory range of 68-85 degrees, posing an immediate safety, health, and personal rights risk to residents. A deficiency was cited accordingly.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to cool rooms to a comfortable range between 78 and 85 degrees Fahrenheit, with temperature readings above 85 degrees in the upstairs hallway and 3 resident rooms. | Type A |
Report Facts
Temperature readings: 87
Temperature readings: 97
Deficiency due date: Sep 10, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaenine Gaona | Resident Care Director | Met during inspection and received report and appeal rights |
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Liza King | Licensing Program Manager | Supervisor and Licensing Evaluator |
Inspection Report
Follow-Up
Census: 48
Capacity: 160
Deficiencies: 0
Aug 15, 2022
Visit Reason
The visit was an unannounced health and safety check and a follow-up to an informal meeting held on 7/18/22.
Findings
The facility was found to be free of debris and hazards in common areas, laundry, stairwells, and grounds. Portable and room air conditioning units were functioning, and residents confirmed comfortable room temperatures. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Diane Wright | Administrator | Met with Licensing Program Analyst during the visit. |
| Maja Jensen | Licensing Program Analyst | Conducted the health and safety check and follow-up visit. |
| Liza King | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 0
Jul 18, 2022
Visit Reason
The visit was an informal conference conducted to discuss the facility's compliance with Title 22 Regulations following deficiencies cited during complaint investigations and site visits on 1/24/22, 2/25/22, 3/30/22, and 4/15/22.
Findings
No deficiencies were cited as a result of the informal conference meeting. Issues discussed included COVID-19 prevention, storage of toxins and hazardous objects, sufficient staffing, pest infestation, building and grounds maintenance, and the alert notification system. Licensees committed to actions to maintain compliance.
Complaint Details
The visit was related to complaint investigations with deficiencies cited on multiple prior dates (1/24/22, 2/25/22, 3/30/22, and 4/15/22). The informal conference was held to discuss these issues and compliance status.
Report Facts
Capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Diane Wright | Administrator | Facility administrator present during the informal conference |
| Chris Coulter | Licensee present during the informal conference | |
| Liza King | Licensing Program Manager | Licensing Program Manager present during the informal conference |
| Maja Jensen | Licensing Program Analyst | Licensing Program Analyst present during the informal conference |
Inspection Report
Original Licensing
Census: 47
Capacity: 160
Deficiencies: 3
Apr 15, 2022
Visit Reason
The inspection was a post licensing visit conducted unannounced to evaluate the facility's compliance with licensing requirements following initial licensing.
Findings
The facility was generally clean, sanitary, and well-maintained with adequate emergency supplies and safety equipment; however, multiple deficiencies were cited including expired first aid/CPR certification for a staff member, unlocked storage room containing toxins accessible to residents, and an unlocked sliding door providing unsafe access to the roof posing immediate safety risks.
Deficiencies (3)
| Description |
|---|
| Expired first aid/CPR certificate for staff member S2 as of 12/12/21. |
| Unlocked storage room on the second floor containing multiple toxins accessible to residents. |
| Unlocked sliding door on the second floor allowing access to an unstable roof with tripping hazards and fall risk. |
Report Facts
Residents on second floor: 16
Capacity: 160
Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Facility administrator named in report header |
| Andrea Eldridge | Resident Care Coordinator | Met during inspection and received exit interview |
| Maja Jensen | Licensing Program Analyst | Conducted inspection and authored report |
| Michael Bilger | Licensing Program Analyst | Conducted inspection |
| Liza King | Licensing Program Manager | Supervisor of licensing evaluation |
Inspection Report
Census: 47
Capacity: 160
Deficiencies: 0
Apr 15, 2022
Visit Reason
The visit was an unannounced case management visit conducted due to an incident reported on 2022-03-03 involving a resident who experienced shortness of breath and a fall.
Findings
The investigation determined that the resident was sent to the hospital and later returned to the facility under hospice care. Reporting requirements and emergency procedures were followed appropriately. No deficiencies were cited during the visit.
Report Facts
Incident date: Mar 2, 2022
Hospital admission date: Mar 3, 2022
Hospital discharge date: Mar 14, 2022
Resident death date: Mar 19, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Informed of Licensing Program Analysts visit and gave permission for sign-in |
| Michael Bilger | Licensing Program Analyst | Conducted case management visit and reviewed incident report |
| Maja Jensen | Licensing Program Analyst | Conducted case management visit |
| Andrea Eldridge | Resident Care Coordinator | Met with Licensing Program Analysts and signed in for Administrator |
| Liza King | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 0
Apr 14, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility had bed bugs.
Findings
The investigation found the allegation to be unsubstantiated. The facility had conducted renovations including replacing carpeting with laminate flooring and purchasing new furniture. The Resident Care Coordinator confirmed the facility was currently clear of bed bugs and was taking all necessary actions to control and eradicate pest infestation.
Complaint Details
The complaint was unsubstantiated based on observations, interviews, and records reviewed during the investigation.
Report Facts
Facility capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Michael Bilger | Licensing Program Analyst | Assisted in delivering complaint investigation findings |
| Andrea Eldridge | Resident Care Coordinator | Met with LPAs and provided information regarding pest control |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 160
Deficiencies: 1
Mar 30, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that positive COVID-19/symptomatic staff were required to work at the facility.
Findings
The investigation found that staff members documented experiencing COVID-19 symptoms and were allowed to work despite being symptomatic, which posed a threat to the health and safety of clients. The allegation was substantiated based on COVID screening logs and interviews.
Complaint Details
The complaint alleged that positive COVID-19/symptomatic staff were required to work at the facility. The allegation was substantiated based on evidence from COVID screening logs and interviews with staff and residents.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| COVID-19 Prevention: The employer failed to develop and implement a process for screening employees with COVID-19 symptoms and allowed symptomatic staff to work, posing a threat to the health and safety of clients. | Type A |
Report Facts
Capacity: 160
Census: 50
Dates of symptomatic staff working: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Met with Licensing Program Analysts during the investigation |
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Michael Bilger | Licensing Program Analyst | Assisted in the complaint investigation |
| Andrea Eldridge | Resident Care Coordinator | Met with Licensing Program Analysts during the investigation |
| Liza King | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 160
Deficiencies: 1
Mar 30, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including personal rights violations and insufficient staffing at CAMLU Assisted Living Facility.
Findings
The personal rights allegation was unsubstantiated based on interviews and observations. The insufficient staffing allegation was substantiated due to staff not scheduled or absent during critical times, posing an immediate health and safety risk.
Complaint Details
Complaint investigation was triggered by allegations of personal rights violations and insufficient staffing. Personal rights allegation was unsubstantiated. Insufficient staffing allegation was substantiated based on interviews and record reviews.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Requirements - General: Facility personnel were not sufficient in numbers and competent to meet resident needs on 1/11/22 and a staff member was absent for 2.5 hours on 3/12/22. | Type A |
Report Facts
Capacity: 160
Census: 50
Staff absence duration: 2.5
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Met with Licensing Program Analysts during complaint investigation and exit interviews |
| Maja Jensen | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Michael Bilger | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Liza King | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 160
Deficiencies: 0
Mar 30, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including questionable death, improper assistance with incontinence care, failure to follow residents' hospice care plans, facility malodor, and positive COVID-19/symptomatic staff required to work at the facility.
Findings
All allegations investigated were found to be unsubstantiated based on record reviews, interviews with staff, residents, and hospice workers, and physical assessments. The questionable death allegation requires further investigation and is to be replaced by a subsequent report dated 4/15/22.
Complaint Details
The complaint investigation was initiated based on allegations received on 01/21/2022. The allegations included questionable death, improper incontinence care, failure to follow hospice care plans, facility malodor, and positive COVID-19/symptomatic staff working. All allegations were found unsubstantiated except the questionable death allegation which needs further investigation and will be addressed in a later report.
Report Facts
Capacity: 160
Census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Met with Licensing Program Analysts during the complaint investigation |
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Bilger | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Eldridge | Resident Care Coordinator | Met with Licensing Program Analysts during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 160
Deficiencies: 1
Mar 30, 2022
Visit Reason
The visit was a case management visit relating to a complaint visit conducted for complaint #27-AS-20220118104227, specifically to investigate the functionality of a resident's emergency signal system.
Findings
The emergency signal system for resident R1 was found to be non-functional, with no staff response or monitoring system indication when activated, posing an immediate health, safety, and resident rights risk.
Complaint Details
The visit was triggered by a complaint (#27-AS-20220118104227) regarding the emergency signal system. The deficiency was substantiated based on observation and interview.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility's emergency signal system did not function as required, failing to operate from each resident's living unit and failing to summon staff or identify the specific resident living unit. | Type A |
Report Facts
Capacity: 160
Census: 50
Plan of Correction Due Date: Mar 31, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Facility administrator present during exit interview and named in report |
| Michael Bilger | Licensing Program Analyst | Conducted the inspection and signed the report |
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and observed the deficiency |
| Liza King | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Capacity: 160
Deficiencies: 0
Mar 16, 2022
Visit Reason
The visit was a case management health check conducted due to concerns over deliveries not being received at the facility.
Findings
No Title 22 deficiencies were observed during the visit, and the delivery issue was verified as resolved.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Met with Licensing Program Analysts during the visit. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 160
Deficiencies: 2
Feb 25, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding allegations of lack of care and supervision, presence of bedbugs, and unsafe and unsanitary buildings and grounds.
Findings
The investigation found multiple safety and sanitation issues including cigarette butts in non-designated areas, exposed wires, tripping hazards, broken electrical outlets, torn window screens, peeling paint, holes in drywall, water damage and mold, and bedbug infestations. Staff failed to follow proper COVID-19 screening and mask protocols. A resident experienced a delay of 28 minutes in receiving pain medication due to staff being occupied.
Complaint Details
The complaint investigation was substantiated. Allegations included lack of care and supervision, facility bedbugs, and unsafe and unsanitary buildings and grounds. Immediate civil penalty of $500 was issued for not ensuring personal rights to safe and healthful accommodations. A repeat violation from a prior report dated 1/24/22 resulted in a $1000 civil penalty.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Maintenance and Operation - The facility was not clean, safe, sanitary, and in good repair at all times, posing a potential health and safety risk to residents. | Type A |
| Conduct Inimical - Facility did not follow proper usage of face covering and did not implement COVID-19 pre-screening measures at entrance, posing immediate health and safety risk. | Type A |
Report Facts
Civil penalty: 500
Civil penalty: 1000
Deficiencies cited: 2
Delay in medication: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Facility Administrator who confirmed bedbug cases and discussed visit purpose. |
| Maja Jensen | Licensing Program Analyst | Conducted complaint investigation, observations, interviews, and authored report. |
| Avelina Martinez | Licensing Program Analyst | Conducted unannounced complaint investigation with Maja Jensen. |
Inspection Report
Follow-Up
Capacity: 160
Deficiencies: 3
Feb 25, 2022
Visit Reason
The visit was a case management follow-up to deficiencies found during a prior complaint investigation (27-AS-20220222163759).
Findings
Deficiencies were found including malfunctioning call buttons with transposed living room and bedroom buttons, a resident room converted to an office not reflected in the facility sketch, and missing hourly check log entries for three residents on multiple dates, indicating residents did not receive required care.
Complaint Details
The visit was a follow-up to deficiencies found during complaint investigation 27-AS-20220222163759.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Hourly check logs for three residents did not reflect hourly checks, resulting in residents not receiving required care. | Type B |
| Facility sketch did not reflect that a resident room was converted to an office. | Type B |
| Call button page alert displayed misinformation due to transposed living room and bedroom call buttons, posing a potential threat to residents' health and safety. | Type B |
Report Facts
Deficiencies cited: 3
Plan of Correction Due Date: Mar 11, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted case management visit and cited deficiencies. |
| Avelina Martinez | Licensing Program Analyst | Conducted case management visit and tested call button system. |
| Alma Whitted | Administrator | Facility administrator met during visit. |
| Liza King | Licensing Program Manager | Supervisor and named in report. |
Inspection Report
Census: 57
Capacity: 160
Deficiencies: 2
Jan 24, 2022
Visit Reason
Licensing Program Analysts conducted an unannounced Case Management, Health and Safety visit to assess the facility's compliance with health and safety regulations.
Findings
The facility was found to have unlocked tools and chemicals accessible to residents, posing an immediate health and safety risk, and debris and cobwebs throughout the facility, which is a potential health and safety risk. Deficiencies were cited under California Code of Regulations, Title 22.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Unlocked tools and chemicals accessible to residents posing an immediate health and safety risk. | Type A |
| Debris and cobwebs throughout the facility posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 160
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Treana White | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Liza King | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Original Licensing
Census: 56
Capacity: 160
Deficiencies: 0
Dec 16, 2021
Visit Reason
An unannounced pre-licensing visit was conducted to evaluate the facility for licensing as a Residential Care Facility for the Elderly (RCFE) to serve up to 160 residents.
Findings
The facility was found to be in compliance with no deficiencies observed. All areas including dining, common areas, resident rooms, medication storage, and safety equipment were toured and found to meet regulatory requirements.
Report Facts
Residents on hospice: 8
Medication count: 3
Staff charts reviewed: 4
Hot water temperature: 109.4
Signal system response time: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Michael Bilger | Licensing Program Analyst | Conducted the unannounced pre-licensing visit and authored the report |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Original Licensing
Census: 56
Capacity: 160
Deficiencies: 0
Oct 15, 2021
Visit Reason
The inspection was an unannounced prelicensing inspection conducted for a Change of Ownership Application at the assisted living facility.
Findings
The inspection found multiple facility maintenance and safety issues including non-working carbon monoxide detectors, damaged walls and ceiling tiles, unsecured hazardous materials, and incomplete resident and staff files. No deficiencies were cited per California Code of Regulations, Title 22, but several repairs and updates are required before licensure approval.
Report Facts
Hospice residents: 6
Staff observed with criminal record clearance: 4
Staff with Serve Safe certification: 1
Medications counted: 3
Resident files reviewed: 3
Time for second floor repair completion: 60
Inspection start time: 1310
Inspection end time: 1820
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Met with Licensing Program Analyst during inspection and gave verbal designation for Designee Staff. |
| Ashley Boothe | Licensing Program Analyst | Conducted the prelicensing inspection and authored the report. |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Original Licensing
Census: 60
Capacity: 160
Deficiencies: 1
Jun 23, 2021
Visit Reason
The inspection was an unannounced Prelicensing Change of Ownership inspection conducted to evaluate the facility prior to licensure.
Findings
The central air conditioning system was observed not to be in working order and requires full replacement. Portable units are currently in use in all resident rooms and common areas. Building permits have been submitted and contractor bids are under review.
Deficiencies (1)
| Description |
|---|
| Central air conditioning system not in working order and requires repair or replacement. |
Report Facts
Capacity: 160
Census: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Met with Licensing Program Analyst during inspection |
| Ashley Boothe | Licensing Program Analyst | Conducted the Prelicensing Change of Ownership inspection |
| Liza King | Licensing Program Manager | Named in report header |
Inspection Report
Census: 60
Capacity: 160
Deficiencies: 0
Jun 23, 2021
Visit Reason
The document was created as a Case Management - Legal/Non-compliance visit report, but the narrative states that no Legal/Non-compliance visit was conducted at the facility on this date.
Findings
No inspection or visit was conducted; the report was created in error by the Licensing Program Analyst.
Inspection Report
Census: 61
Capacity: 96
Deficiencies: 0
Apr 26, 2021
Visit Reason
The visit was conducted as an office evaluation related to a Change of Ownership application for the assisted living facility.
Findings
The applicant and administrator participated in a telephone call to complete Component II of the licensing process, confirming understanding of Title 22. The component was successfully completed and the applicant was advised to submit required documentation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Administrator participating in the licensing evaluation and telephone call. |
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