Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on October 21, 2025, which was clean with no issues noted. However, several complaint investigations over the past few years substantiated deficiencies related primarily to care and supervision, medication management, and resident rights, including incidents of residents eloping unassisted and improper medication administration. Some investigations also found issues with food safety and failure to maintain proper records for outside care providers. Enforcement actions included civil penalties totaling at least $500 for elopement-related safety risks and a $250 fine for medication errors in 2023; no license suspensions or revocations were reported. While earlier reports showed multiple serious deficiencies, recent annual inspections have been free of citations, indicating some improvement in compliance.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
67% 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: 100
Capacity: 150
Deficiencies: 0
Date: Oct 21, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with Title 22 regulations and ensure there are no health and safety hazards.
Findings
The facility was found to be in compliance with health and safety regulations, including resident room conditions, kitchen food storage, common areas, outdoor spaces, record keeping, medication management, infection control, and emergency disaster planning. No deficiencies or concerns were noted during interviews or record reviews.
Report Facts
Resident records reviewed: 10
Staff records reviewed: 10
Staff interviewed: 5
Residents interviewed: 5
Fire extinguisher last serviced: Dec 23, 2024
Last fire safety inspection date: Aug 21, 2025
Last emergency disaster drill date: Sep 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Executive Director | Met with Licensing Program Analysts during inspection |
| Martha Arroyo | Licensing Program Analyst | Conducted the inspection |
| Brian Balisi | Licensing Program Analyst | Conducted the inspection |
| Desaree Perera | Licensing Program Manager | Named in report continuation and signature sections |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 150
Deficiencies: 1
Date: Oct 21, 2025
Visit Reason
The visit was conducted as a Case Management - Deficiencies inspection in conjunction with a complaint investigation (Complaint Control # 29-AS-20250822191726) to issue citations for deficiencies observed during the initial complaint investigation.
Complaint Details
The visit was complaint-related, triggered by Complaint Control # 29-AS-20250822191726. The complaint involved concerns about Resident #1's ostomy care being provided by an individual not affiliated with a Home Health Agency, with no verification of qualifications. The complaint was substantiated by the findings.
Findings
The facility failed to provide a current, written record of care for Resident #1's colostomy bag, including verification of the qualifications of the individual providing ostomy care, who was not affiliated with a Home Health Agency. This posed a potential health and safety risk to persons in care.
Deficiencies (1)
The licensee did not maintain a current, written record of care for Resident #1 that includes the names, address, and telephone number of vendors and all appropriately skilled professionals providing services. The facility stated that an outside person provides care for R1's colostomy bag but did not have contact information or verification that they are a skilled professional, posing a potential health and safety risk.
Report Facts
Capacity: 150
Census: 100
Plan of Correction Due Date: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the inspection and signed the report |
| Brian Balisi | Licensing Program Analyst | Conducted the inspection |
| Desaree Perera | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Bradlee Foerschner | Administrator/Director | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 150
Deficiencies: 0
Date: Aug 6, 2025
Visit Reason
The visit was conducted to follow up on a self-reported incident report and Suspected Dependent Adult/Elder Abuse report received on 2025-08-05 regarding possible sexual abuse of Resident #1 by unknown staff.
Complaint Details
The visit was complaint-related, triggered by a self-reported incident and Suspected Dependent Adult/Elder Abuse report concerning possible sexual abuse of a resident. Further investigation is pending.
Findings
During the unannounced visit, no immediate health and safety concerns were observed. A referral was made to the Community Care Licensing Division's Investigation Branch for further investigation, and an additional report may follow.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Executive Director | Met with Licensing Program Analyst during the inspection and involved in the physical plant tour. |
| Emily Peraldi | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit and interviews. |
| Bradlee Foerschner | Administrator/Director | Named as facility administrator/director in the report header. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 150
Deficiencies: 0
Date: Feb 19, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-07-19 alleging that facility staff spoke inappropriately to residents.
Complaint Details
The complaint alleged that facility staff bullied residents by intimidation, foul language, and threats, creating an unsafe environment. After interviews with residents and staff, there was insufficient evidence to substantiate the allegation.
Findings
Interviews with residents revealed that staff were friendly, pleasant, and respectful, with no evidence supporting the allegation of inappropriate speech. The complaint was deemed unsubstantiated.
Report Facts
Capacity: 150
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Jenay Turgeon | Business Office Director | Met with the Licensing Program Analyst during the inspection |
| Desaree Perera | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Bradlee Foerschner | Administrator | Facility Administrator named in the report |
Inspection Report
Annual Inspection
Census: 78
Capacity: 150
Deficiencies: 0
Date: Oct 11, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure health and safety standards.
Findings
The facility was found to be in compliance with regulations, with no health or safety hazards observed. Resident bedrooms, restrooms, medication storage, infection control policies, and emergency plans were all in order. No citations were issued during this visit.
Report Facts
Resident files reviewed: 8
Personnel files reviewed: 8
Staff interviewed: 5
Residents interviewed: 3
Resident bedrooms observed: 9
Resident restrooms observed: 9
Hot water temperature range: 110.4
Hot water temperature range: 114.6
Fire drill last conducted: Oct 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Cortes | Executive Director | Met with Licensing Program Analysts during inspection. |
| Martha Arroyo | Licensing Program Analyst | Conducted the inspection. |
| Brian Balisi | Licensing Program Analyst | Conducted the inspection. |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 150
Deficiencies: 1
Date: Jul 22, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by multiple allegations concerning resident care, supervision, medication assistance, food service, facility conditions, and reporting requirements at Oakmont of Camarillo.
Complaint Details
The complaint included multiple allegations such as resident sustaining multiple falls and injuries, inadequate supervision, improper medication assistance, failure to follow care plans and doctor's orders, improper food service, unsafe and unsanitary conditions, failure to safeguard belongings, and failure to follow proper reporting requirements. The complaint was received on 2023-07-12 and investigated with visits on 2023-07-20, 2024-05-22, and 2024-07-22. Most allegations were deemed unsubstantiated except for the refusal to accept a resident back to the facility, which was substantiated.
Findings
The investigation found insufficient evidence to substantiate most allegations including falls, supervision, medication assistance, care plan adherence, assessments, food service, facility sanitation, safeguarding belongings, and reporting. However, the allegation that staff refused to accept a resident back to the facility after hospitalization was substantiated, constituting a violation of resident rights.
Deficiencies (1)
Facility refused to accept resident back following hospital discharge, violating protections against involuntary transfers, discharges, and evictions.
Report Facts
Capacity: 150
Census: 77
Deficiency count: 1
Plan of Correction Due Date: Jul 29, 2024
Resident falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Mark Cortes | Executive Director | Met with Licensing Program Analyst during investigation and involved in findings |
| Kailey Vanderwall | Business Office Director | Participated in facility tour during investigation |
| Lena Gutierrez | Regional Memory Care Specialist | Interviewed and toured Memory Care unit with Licensing Program Analyst |
| Bradlee Foerschner | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 150
Deficiencies: 0
Date: Jun 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations including resident injury, untimely staff response to call buttons, delayed medical attention, facility disrepair, and inadequate staff training.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included resident injury due to lack of care, untimely staff response to call buttons, delayed medical attention, facility disrepair, and inadequate staff training. Each allegation was reviewed through interviews, record reviews, and observations, resulting in no violations found.
Findings
The investigation found insufficient evidence to support any of the allegations. All complaints were deemed unsubstantiated after interviews, observations, record reviews, and facility tours.
Report Facts
Capacity: 150
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
| Mark Cortes | Executive Director | Met with Licensing Program Analyst during inspection |
| Matt Ryan | Regional Operations Specialist | Met with Licensing Program Analyst during inspection |
| Lena Gutierrez | Regional Memory Care Specialist | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 150
Deficiencies: 1
Date: May 28, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2022-04-22 regarding medication administration and refill issues, as well as staff competency and conduct concerns at Oakmont of Camarillo.
Complaint Details
The complaint investigation was substantiated for allegations that medications were not administered as prescribed and not refilled timely. Other allegations including staff giving medications prescribed to other residents, inadequate staff training, staff sleeping during overnight shifts, and staff incompetency were unsubstantiated.
Findings
The investigation substantiated allegations that medications were not administered as prescribed and were not refilled timely, posing potential health risks to residents. Other allegations related to staff giving medications prescribed to other residents, staff training, sleeping during overnight shifts, and staff competency were found to be unsubstantiated.
Deficiencies (1)
The licensee did not comply with regulations requiring assistance with self-administered medications, as medications were not refilled timely and some were not documented as administered as prescribed, posing a potential health risk to residents.
Report Facts
Facility capacity: 150
Resident census: 83
Medication doses remaining: 1
Medication doses threshold: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 150
Deficiencies: 4
Date: May 28, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-06-16 regarding medication administration, medication refills, and response times to resident requests for assistance.
Complaint Details
The complaint investigation was substantiated for allegations related to medication administration, medication refills, and response times to resident calls. The allegation regarding improper assistance with transfers was unsubstantiated. Citations for substantiated allegations were previously issued under related complaint controls; no new citations were issued during this visit.
Findings
The investigation substantiated three allegations: facility staff not assisting with self-administration of medications as prescribed, medications not being refilled timely, and staff not responding timely to resident's requests for assistance. One allegation regarding improper assistance with resident transfers was unsubstantiated.
Deficiencies (4)
Facility staff are not assisting with self-administration of medications as prescribed, including improper documentation and medication delivery errors.
Medications are not being refilled timely, resulting in missed doses for Resident #1.
Facility staff did not respond timely to resident's request for assistance, with multiple calls exceeding acceptable response times.
Facility staff are not properly assisting resident with transfers.
Report Facts
Census: 83
Total Capacity: 150
Total calls for assistance: 144
Calls with response time >15 minutes: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during investigation |
| Martha Berard | Administrator | Facility administrator during initial complaint visit |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 150
Deficiencies: 2
Date: May 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including facility staff not meeting resident's basic care needs and illegal eviction.
Complaint Details
The complaint investigation was substantiated for allegations that facility staff were not meeting Resident #1's basic care needs and that an illegal eviction occurred. The resident eloped multiple times due to a door malfunction and was subsequently asked to leave without proper written notice. Other allegations including insufficient staffing, lack of supervision, and failure to engage the resident in activities were unsubstantiated.
Findings
The investigation substantiated that facility staff failed to meet Resident #1's basic care needs, as the resident eloped multiple times due to a faulty door strike that did not trigger alarms. The facility also illegally evicted the resident by requiring a private companion for return, which was not a viable option. Other allegations such as insufficient staffing, lack of supervision, and failure to engage the resident in activities were unsubstantiated.
Deficiencies (2)
Facility did not comply with CCR 87464(f)(c)(1) regarding care and supervision, allowing Resident #1 to leave unassisted multiple times, posing immediate risk to residents' safety.
Facility did not comply with CCR 87468.2(a)(20) regarding protection from involuntary transfers, discharges, and evictions; Resident #1 was asked to leave and not permitted to return without a 1:1 companion.
Report Facts
Resident elopement incidents: 4
Facility capacity: 150
Resident census: 71
Staff scheduled per shift: 3
Staff scheduled per shift: 2
Private companion cost: 40
Number of activities offered: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation. |
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during investigation and involved in findings. |
| Martha Berard | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 150
Deficiencies: 0
Date: May 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations that staff did not provide residents with adequate beverages and did not treat residents with dignity.
Complaint Details
The complaint alleged that beverages were withheld from Resident #1 and that staff were mean to residents. Interviews with Resident #1, other residents, and staff, as well as observations, did not substantiate these claims. No citations were issued.
Findings
The investigation found insufficient evidence to support the allegations. Observations and interviews indicated that beverages were adequately available throughout the facility and residents were treated with dignity. Both allegations were deemed unsubstantiated.
Report Facts
Capacity: 150
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Bradlee Foerschner | Administrator / Executive Director | Met with the Licensing Program Analyst during the investigation |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 150
Deficiencies: 0
Date: Mar 6, 2024
Visit Reason
The visit was an unannounced Case Management – Incident inspection to follow up on a self-reported incident that occurred on 2024-03-03 involving an altercation between two residents.
Complaint Details
The incident involved an altercation between Resident #1 and Resident #2, resulting in injury to Resident #2 who was sent to the hospital and subsequently moved out of the facility. The visit was to follow up on this self-reported incident.
Findings
The Licensing Program Analyst interviewed the Executive Director and toured the facility, finding no immediate health and safety hazards. The investigation is ongoing with no citations issued at this time.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during the incident follow-up visit and interviewed regarding the incident. |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit and investigation. |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 150
Deficiencies: 2
Date: Dec 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that the facility did not provide safe, comfortable accommodations, neglected a resident, and failed to respond timely to the resident's requests for assistance during an overnight shift incident on 03/21/2022 to 03/22/2022.
Complaint Details
The complaint involved an incident during the overnight shift from 03/21/2022 to 03/22/2022 where Resident #1 called for assistance multiple times using their pendant but staff did not respond timely. Resident called 9-1-1 for help. Staff member S1 responded initially but left resident unattended on commode. Resident's phone was found with batteries removed, and resident was found in a urine-soaked bed. Staff S1 was terminated. Allegations were substantiated.
Findings
The investigation substantiated the allegations that the resident was left in unsafe and uncomfortable conditions, including being left on a commode unattended, with wet bedding and no access to their phone, posing immediate health and safety risks. Staff failed to respond to multiple calls for assistance, resulting in termination of the involved staff member.
Deficiencies (2)
Licensee did not provide safe, comfortable accommodations for resident in care as resident was left with wet bedding and no access to phone, posing immediate health and safety risk.
Facility staff neglected resident by leaving resident unattended on commode and not responding to calls for assistance.
Report Facts
Calls for assistance not responded to: 45
Deficiencies cited: 2
Plan of Correction Due Date: Dec 21, 2023
Plan of Correction Due Date: Dec 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Oversaw complaint investigation |
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during investigation |
| Martha Berard | Administrator | Interviewed during initial complaint visit |
| S1 | Staff member terminated due to neglect incident |
Inspection Report
Annual Inspection
Census: 77
Capacity: 150
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
An unannounced annual inspection was conducted to ensure the facility's compliance with Title 22 regulations and to evaluate health and safety conditions.
Findings
The facility was found to be in compliance with regulations, with no safety concerns noted. Common areas, kitchen, resident rooms, and emergency plans were all observed to be adequate and well maintained. No citations were issued during the inspection.
Report Facts
Rooms in Memory Care unit: 36
Units in Assisted Living: 54
Staff files reviewed: 5
Resident files reviewed: 5
Residents' medications reviewed: 3
Staff interviewed: 4
Residents interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analysts during inspection and participated in facility tour |
| Kelly Dulek | Licensing Program Analyst | Conducted record review and infection control/emergency disaster planning review |
| Teresa Camara | Licensing Program Analyst | Conducted facility tour, medication review, and interviews |
| Kristin Heffernan | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Follow-Up
Census: 77
Capacity: 150
Deficiencies: 1
Date: Oct 18, 2023
Visit Reason
The visit was an unannounced Case Management - Incident follow-up to investigate three self-reported incidents where residents left the facility unsupervised on 09/18/2023, 10/01/2023, and 10/11/2023.
Findings
The licensee failed to comply with care and supervision requirements as two residents with dementia left the facility unassisted multiple times, posing immediate health and safety risks. A deficiency was cited related to this failure.
Deficiencies (1)
Failure to provide adequate care and supervision as evidenced by residents leaving the facility unassisted, posing immediate health and safety risks.
Report Facts
Number of self-reported incidents: 3
Deficiency Plan of Correction due date: Oct 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Foerschner | Executive Director | Met with LPAs during the visit and involved in incident discussions |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection and authored the report |
| Teresa Camara | Licensing Program Analyst | Conducted the inspection |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 150
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address allegations including improper assistance with resident transfers resulting in a fall, understaffing, and failure to provide necessary hygiene items for residents.
Complaint Details
The complaint included allegations that facility staff did not properly assist a resident with transfers resulting in a fall, the facility was understaffed during certain shifts, and the licensee failed to provide necessary hygiene items. After investigation, all allegations were found unsubstantiated due to insufficient evidence.
Findings
All allegations were investigated through interviews, record reviews, and observations. Despite some concerns raised, there was insufficient evidence to substantiate any of the allegations, and all were deemed unsubstantiated at this time.
Report Facts
Capacity: 150
Census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during the inspection |
| Patricia Aguilera | Medication Technician | Assisted Licensing Program Analyst during facility tour |
| Martha Berard | Administrator | Facility Administrator interviewed during investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 150
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
The visit was an unannounced Case Management – Incident follow-up to investigate a self-reported incident on 2023-10-01 involving a resident found outside the facility unassisted.
Complaint Details
The investigation was triggered by a self-reported incident where Resident #1, diagnosed with dementia and unable to leave unassisted, was found about a block away from the facility. The facility reported the incident and is cooperating with the investigation.
Findings
The Licensing Program Analyst interviewed the Executive Director, toured the facility, tested delayed egress points, and reviewed documents. One delayed egress point had malfunctioned but was being monitored until repaired. No citations were issued during this visit.
Report Facts
Facility capacity: 150
Resident census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst and involved in incident investigation |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit |
| Kristin Heffernan | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 150
Deficiencies: 0
Date: Sep 22, 2023
Visit Reason
The visit was conducted as a case management incident follow-up to investigate a self-reported allegation of sexual abuse by a resident against a staff member that occurred on 05/08/2023.
Complaint Details
The complaint involved an allegation by Resident #1 that Staff #1 inappropriately touched them. The investigation included interviews with the resident, staff, and facility personnel, review of medical and police reports, and assessment of the resident's cognitive status. The allegation was found to be unsubstantiated due to lack of sufficient evidence.
Findings
The investigation included interviews with involved parties and review of medical and police reports. The evidence was insufficient to substantiate the allegation of sexual abuse, and the allegation was deemed unsubstantiated at this time.
Report Facts
Facility capacity: 150
Resident census: 82
Dates of interviews: Interviews conducted on 06/03/2023, 06/04/2023, and 07/05/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Foerschner | Executive Director | Interviewed during the investigation and reported the incident |
| Kelly Dulek | Licensing Program Analyst | Conducted the case management visit and investigation |
| Kailey Vanderwall | Business Office Director | Met with Licensing Program Analyst during the visit |
| Ryan Miles | Investigator | Conducted follow-up investigation interviews |
Inspection Report
Follow-Up
Census: 82
Capacity: 150
Deficiencies: 1
Date: Sep 22, 2023
Visit Reason
The visit was an unannounced Case Management – Incident follow-up to investigate a self-reported incident on 09/18/2023 where a resident with dementia left the facility unsupervised and was found a block away.
Findings
The Wanderguard system at the exit door next to Room 135 did not function properly during testing, as neither the auditory alarm nor the electronic alert activated, posing an immediate safety risk to residents.
Deficiencies (1)
Wanderguard system did not function properly; auditory alarm did not sound and electronic roam alert did not record when tested on the door by room 135, posing an immediate safety risk to residents.
Report Facts
Capacity: 150
Census: 82
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kailey Vanderwall | Business Office Director | Met with Licensing Program Analyst during the visit and authorized to sign licensing reports |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection visit and investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 150
Deficiencies: 0
Date: Sep 15, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the licensee did not provide a resident's records as requested.
Complaint Details
The complaint alleged that the licensee did not provide resident's records as requested. The allegation was investigated and found to be unsubstantiated based on interviews and document review.
Findings
The investigation found that the facility provided the requested resident's records in a timely manner, including prior provision to the resident's family and subsequent release to the requesting party. Therefore, the allegation was deemed unsubstantiated and no citations were issued.
Report Facts
Capacity: 150
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Bradlee Foerschner | Executive Director | Interviewed during the investigation and involved in document provision |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 150
Deficiencies: 0
Date: Sep 15, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to an allegation that the facility Administrator is not properly qualified.
Complaint Details
Complaint alleged that the facility Administrator is not properly qualified. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation included interviews with residents, staff, and review of the Administrator's qualifications and records. The Administrator was found to be positively regarded by staff and residents, with no evidence supporting the allegation. The complaint was deemed unsubstantiated and no citations were issued.
Report Facts
Capacity: 150
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 150
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff locked a resident in their facility bedroom.
Complaint Details
The complaint alleged that staff locked a resident in their facility bedroom. The allegation was investigated and found to be unsubstantiated based on observations and interviews.
Findings
The investigation found that the door to the resident's bedroom could be locked from the outside with a key, but residents could always exit their rooms safely by unlocking the door from the inside. There was insufficient evidence to support the allegation, and it was deemed unsubstantiated.
Report Facts
Capacity: 150
Census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during investigation and interviewed regarding the complaint |
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Kailey Vanderwall | Business Office Director | Toured the facility with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 150
Deficiencies: 0
Date: May 11, 2023
Visit Reason
The visit was an unannounced Case Management – Incident follow-up to a self-reported incident of alleged abuse by a resident against staff that occurred on 2023-05-08.
Complaint Details
The complaint involved an allegation of abuse by Resident #1 against Staff #1. Notifications were made to the resident's responsible party, primary care physician, local police, and Long Term Care Ombudsman. The complaint is under investigation by CCLD's Investigations Branch.
Findings
No immediate health and safety hazards were identified during the visit. The Licensing Program Analyst toured the facility, interviewed the Executive Director, and obtained pertinent documents. The incident was referred to the Investigations Branch for follow-up.
Report Facts
Capacity: 150
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Foerschner | Executive Director | Named in relation to the incident report and interview during the visit |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection visit |
| Kailey Vanderwall | Business Office Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Census: 77
Capacity: 150
Deficiencies: 1
Date: Mar 22, 2023
Visit Reason
The visit was a case management-deficiencies inspection conducted to review medication administration and compliance with licensing regulations.
Findings
The inspection found that medications for two residents contained inaccurate amounts of doses, posing an immediate health and safety risk. A repeat violation was cited and a civil penalty of $250 was issued.
Deficiencies (1)
Medications for 2 of 2 residents reviewed contained an inaccurate amount of doses, posing an immediate health and safety risk.
Report Facts
Civil penalty amount: 250
Residents reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during inspection and involved in medication review |
| Kelly Dulek | Licensing Program Analyst | Conducted the case management-deficiencies visit and medication review |
| Kristin Heffernan | Licensing Program Manager | Named as supervisor and licensing program manager |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 150
Deficiencies: 0
Date: Mar 2, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility overcharged a resident.
Complaint Details
The complaint alleged that the facility overcharged Resident #1 for care services. The allegation was investigated and found unsubstantiated due to insufficient evidence.
Findings
The investigation found that although the resident's care level increased due to a fall and hospitalization, the facility issued a credit to the resident's account reflecting a lower care level and backdated the credit. Based on interviews and record review, there was insufficient evidence to substantiate the allegation of overcharging, and the complaint was deemed unsubstantiated.
Report Facts
Capacity: 150
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Bradlee Foerschner | Executive Director | Interviewed during the investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 150
Deficiencies: 3
Date: Jan 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including incorrect medication administration resulting in hospitalization, lack of care and supervision causing resident injury, and understaffing at the facility.
Complaint Details
The complaint investigation was substantiated. Allegations included incorrect medication administration resulting in hospitalization, lack of care and supervision causing injury, and understaffing. The facility was found to have failed in medication administration, supervision during overnight shift, and staffing adequacy.
Findings
The investigation substantiated all allegations: a resident was given incorrect medication leading to hospitalization; a resident sustained an injury due to lack of care and supervision during an overnight shift; and the facility was understaffed during that shift. Deficiencies were cited related to medication administration, care and supervision, and staffing levels.
Deficiencies (3)
Facility staff gave another resident’s medications to Resident #1 and continued administering the former dosage after physician changed orders, posing immediate health risk.
Facility staff did not check on Resident #1 during the overnight shift despite known wandering behavior, resulting in injury of unknown origin.
Only one caregiver worked the overnight shift and did not check all residents in all care runs, posing immediate health and safety risk.
Report Facts
Civil penalty amount: 500
Residents in Memory Care unit requiring two person assist: 3
Residents in Memory Care unit during incident: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted complaint investigation and authored report. |
| Bradlee Foerschner | Executive Director | Facility administrator interviewed regarding findings. |
| Kailey Vanderwall | Business Office Director | Accompanied Licensing Program Analyst during facility tour. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 150
Deficiencies: 0
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that the facility was in financial distress due to staff not being paid for their total number of hours worked.
Complaint Details
The complaint alleged that the facility was in financial distress because staff had not been paid for all hours worked. The complaint was investigated and found to be unsubstantiated.
Findings
The investigation found that staff receive paychecks biweekly as scheduled, but some staff failed to submit missed punch sheets and paid time off requests timely, resulting in delayed payments. Corrective actions were taken with staff violating time card policies, and expedited checks are issued when errors are discovered. The allegation of financial distress was deemed unsubstantiated.
Report Facts
Capacity: 150
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during inspection and exit interview |
| Kailey Vanderwall | Business Office Director | Toured the facility with Licensing Program Analyst during inspection |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 150
Deficiencies: 0
Date: Dec 13, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of illegal eviction of a resident at the facility.
Complaint Details
The complaint alleged illegal eviction of Resident #1. The allegation was investigated and found unsubstantiated based on interviews, document review, and observation.
Findings
The investigation found that the facility served a proper '30-Day Notice to Pay or Quit' to the resident due to unpaid balance, with all required regulatory language and procedures followed. The resident was still present at the facility and had issued payment, so the allegation of illegal eviction was deemed unsubstantiated.
Report Facts
Capacity: 150
Census: 76
Complaint Control Number: 29-AS-20221206154636
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Bradlee Foerschner | Executive Director | Facility administrator involved in investigation and interviews |
| Kailey Vanderwall | Business Office Director | Interviewed during facility tour and investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report signature and oversight |
Inspection Report
Annual Inspection
Census: 76
Capacity: 150
Deficiencies: 0
Date: Oct 19, 2022
Visit Reason
The visit was an unannounced annual inspection with a specific emphasis on infection control practices and procedures.
Findings
The facility was found to be in compliance with Title 22 regulations, with no deficiencies cited. Infection control practices were adequate, including symptom screening, mask usage, PPE supply, and cleaning protocols. The facility had no health or safety hazards observed during the tour.
Report Facts
Rooms in Memory Care Unit: 36
Assisted Living Units: 54
Fire inspection date: Nov 12, 2021
Fire extinguisher last service date: Sep 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during inspection and exit interview. |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced annual inspection. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 150
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
The inspection visit was conducted as a case management - incident visit to address an incident involving alleged unauthorized entry to a resident's private room that occurred overnight on 08/30/2022-08/31/2022.
Complaint Details
The visit was complaint-related due to an alleged unauthorized entry to Resident #1's private room. The substantiation status is not stated.
Findings
The Licensing Program Analyst was made aware of the incident during an unrelated visit and observed law enforcement arriving to take a report. At the time of the visit, no written report of the incident had been received, and the investigation was to be continued at a later date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Foerschner | Executive Director | Met with Licensing Program Analyst during the incident visit and participated in entrance and exit interviews. |
| Kelly Dulek | Licensing Program Analyst | Conducted the case management - incident visit and investigation. |
| Kristin Heffernan | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 150
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility failed to safeguard a resident's personal belongings following a report of missing items from a former resident's room.
Complaint Details
The complaint was unsubstantiated. The allegation was that the facility failed to safeguard a resident's belongings after items were reported missing from a former resident's room between 08/02/2022 and 08/07/2022. The facility reported the incident to law enforcement and Community Care Licensing. The resident's admission agreement stated the facility was not responsible for loss unless caused by negligence. No documented inventory of the missing items existed. The investigation concluded insufficient evidence to support the allegation.
Findings
The investigation found that although the allegation may be valid, there was insufficient evidence to support that a violation occurred. The resident had left belongings in an unlocked desk drawer, and the facility had followed proper procedures including reporting to law enforcement and Community Care Licensing. The allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 150
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Bradlee Foershner | Executive Director | Met with Licensing Program Analyst during investigation |
| Kailey Vanderwall | Business Office Director | Participated in exit interview |
| Kristin Heffernan | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 150
Deficiencies: 1
Date: Sep 1, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that the facility was not serving good quality food to residents and did not have enough food to serve residents.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility was not serving good quality food to residents. The allegation that the facility did not have enough food to serve residents was unsubstantiated.
Findings
The investigation substantiated that the facility was serving expired and improperly labeled food items, posing a potential health risk to residents. However, the allegation that the facility did not have enough food to serve residents was unsubstantiated based on observations and interviews.
Deficiencies (1)
Numerous food items in the kitchen refrigerator and freezer were expired and/or beyond the best by date, including Horseradish, Buffalo Sandwich Sauce, and Blood Orange concentrate, posing a potential health risk to residents.
Report Facts
Facility capacity: 150
Census: 80
Plan of Correction due date: Sep 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Bradlee Foershner | Executive Director | Met with Licensing Program Analyst during investigation and facility tour |
| Kailey Vanderwall | Business Office Director | Participated in exit interview and received report |
| Martha Berard | Administrator | Facility administrator listed in report |
| Kristin Heffernan | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Follow-Up
Census: 71
Capacity: 150
Deficiencies: 1
Date: Jul 8, 2022
Visit Reason
The visit was an unannounced Case Management – Incident follow-up conducted to investigate a self-reported incident on 06/29/2022 where a resident eloped from the facility’s secure memory care unit.
Findings
The facility was found to have deficiencies related to care and supervision as Resident #1 left the facility unassisted, posing an immediate health and safety risk. Civil penalties of $250 were assessed. The facility had taken corrective actions including changing door codes, providing a Wanderguard bracelet, testing exit points, and adjusting care plans and schedules.
Deficiencies (1)
Failure to provide adequate care and supervision as Resident #1 left the facility unassisted, posing an immediate health and safety risk.
Report Facts
Civil penalty amount: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Martha Berard | Executive Director | Met with Licensing Program Analyst during the visit and involved in incident reporting. |
Inspection Report
Plan of Correction
Census: 80
Capacity: 150
Deficiencies: 0
Date: Jun 23, 2022
Visit Reason
An unannounced Plan of Correction (POC) visit was conducted to follow up on deficiencies cited during a Case Management visit on 2022-06-14.
Findings
The delayed egress in the Memory Care unit was tested and found functional. The Plan of Correction was cleared during this visit. A copy of Resident #1's reappraisal was received.
Report Facts
Capacity: 150
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Berard | Administrator | Met with Licensing Program Analyst during the inspection and involved in the Plan of Correction visit |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Plan of Correction visit |
Inspection Report
Follow-Up
Census: 80
Capacity: 150
Deficiencies: 2
Date: Jun 14, 2022
Visit Reason
Unannounced Case Management – Incident visit to follow up on two self-reported incident reports involving Resident #1 eloping from the facility's secure Memory Care unit on 06/05/2022 and 06/07/2022.
Findings
The inspection found that all interior delayed egress alarms were functional, but one exterior gate with delayed egress was bolted shut due to prior malfunction, posing an immediate safety risk. Resident #1, known to be an elopement risk, left the facility unassisted twice, indicating noncompliance with care and supervision requirements.
Deficiencies (2)
An outdoor gate with delayed egress was non-functional and was subsequently bolted shut, posing an immediate safety risk to residents.
Resident #1 left the facility unassisted twice, posing an immediate health and safety risk to persons in care.
Report Facts
Civil penalties assessed: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit and authored the report. |
| Martha Berard | Administrator | Facility Administrator mentioned as unavailable during the visit. |
| Kailey Vanderwall | Business Office Director | Met with Licensing Program Analyst during the visit and provided information. |
Inspection Report
Census: 77
Capacity: 150
Deficiencies: 0
Date: Apr 6, 2022
Visit Reason
The visit was an unannounced Case Management – Incident inspection conducted to follow up on a self-reported incident involving two facility residents that occurred on 2022-03-31, which was verbally reported on 2022-04-01 and followed by a written report on 2022-04-05.
Findings
During the visit, no immediate health and safety concerns were observed. The Licensing Program Analyst determined that further investigation is needed and will return at a later date to continue the investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Berard | Administrator | Reported the incident and participated in the entrance and exit interviews. |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit and interviews. |
| Kailey Vanderwall | Business Office Director | Accompanied the Licensing Program Analyst during the facility tour. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 150
Deficiencies: 1
Date: Mar 18, 2022
Visit Reason
The visit was a case management-deficiencies inspection conducted due to deficiencies related to reporting COVID positive cases late.
Complaint Details
The visit was complaint-related due to late submission of COVID positive incident reports. The deficiency was substantiated as the facility submitted 5 incident reports past the 24-hour required timeframe.
Findings
The facility failed to submit five incident reports of COVID positive cases within the required 24-hour timeframe, posing an immediate health and safety risk to residents.
Deficiencies (1)
Failure to report epidemic outbreaks such as COVID positive cases within 24 hours to the licensing agency and local health officer as required by Title 22 CA Code of Regulations 87211(a).
Report Facts
Incident reports late: 5
Capacity: 150
Census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the case management-deficiencies visit and authored the report. |
| Kailey Vanderwall | Business Office Director | Met with the Licensing Program Analyst and DOJ agents during the inspection. |
| Martha Berard | Administrator | Facility administrator who was reminded about COVID reporting requirements. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 150
Deficiencies: 0
Date: Nov 15, 2021
Visit Reason
The visit was a Case Management - Incident investigation triggered by two elopement incidents involving Resident #1, a Memory Care resident, who left the facility unsupervised on two occasions.
Complaint Details
The complaint involved two elopement incidents by Resident #1 on 10/28/2021 and 11/02/2021. The facility took corrective actions including door repair, delayed egress testing, Wander Guard implementation, 1:1 caregiver assignment, staff retraining, and window security improvements. Further follow-up is needed.
Findings
The facility identified and repaired a faulty door latch after the first elopement and implemented delayed egress and Wander Guard for the resident. After the second elopement through a window, the facility initiated a 1:1 private caregiver, retrained staff on elopement procedures, and enhanced window security and surveillance.
Report Facts
Capacity: 150
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Berard | Executive Director | Met with Licensing Program Analyst during the visit and reported incidents |
| Kelly Dulek | Licensing Program Analyst | Conducted the Case Management - Incident visit |
Inspection Report
Original Licensing
Census: 69
Capacity: 150
Deficiencies: 3
Date: Sep 14, 2021
Visit Reason
The inspection was an announced pre-licensing visit for a change of ownership application, with the facility name remaining the same. The visit included inspection of fire safety, personal accommodations and services, medication procedures, and food service.
Findings
The facility was found to be generally clean and in good condition with no obstructions or tripping hazards. Fire safety systems were operational, though fire extinguishers last serviced in 12/2019 require servicing or replacement. Water temperature testing revealed temperatures outside the required range. Some faucets require repair or replacement. The facility has an approved Hospice Waiver and is limited to eight bedridden residents.
Deficiencies (3)
Hot water temperature in all rooms must be within the required range of 105 to 120 degrees Fahrenheit
Fire extinguishers last serviced in 12/2019 must be serviced or replaced
Faucets in room 134 and 135 must be replaced or repaired
Report Facts
Facility capacity: 150
Census: 69
Hospice Waiver capacity: 15
Bedridden resident limit: 8
Memory Care rooms: 36
Memory Care double occupancy rooms: 4
Assisted Living units: 54
Water temperature range: 110-123
Fire extinguisher last service date: 201912
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Berard | Executive Director/Administrator | Met with Licensing Program Analyst during inspection and remains as Executive Director/Administrator for new facility |
| Kelly Dulek | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Kristin Heffernan | Licensing Program Manager | Named in report header and narrative |
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