Inspection Report
Annual Inspection
Capacity: 101
Deficiencies: 0
May 13, 2025
Visit Reason
The inspection was a Required-1 Year unannounced visit conducted to ensure compliance with Title 22 regulations for the care home.
Findings
The inspection found the facility to be properly maintained with no deficiencies cited. Areas observed included bedrooms, bathrooms, kitchen, medication storage, and outdoor areas, all meeting regulatory standards.
Report Facts
Food supply: 2
Food supply: 7
Bedrooms observed: 4
Bedrooms observed: 2
Hydro tub rooms observed: 2
Common area bathrooms observed: 7
Assisted living resident files reviewed: 3
Memory care resident files reviewed: 2
Staff files reviewed: 5
Hot water temperature: 116.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caroline Frangieh | Executive Director | Met with Licensing Program Analyst during inspection |
| Angela Hood | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in report |
Inspection Report
Follow-Up
Census: 87
Capacity: 101
Deficiencies: 0
Mar 27, 2025
Visit Reason
The visit was a follow-up on an incident report received by the department regarding an unwitnessed fall of a resident on 3/12/25.
Findings
During the visit, no deficiencies were cited. The resident involved in the incident returned to the facility and is now receiving hospice care services. The Licensing Program Analyst will return once all requested documentation is received to complete the follow-up.
Complaint Details
The visit was triggered by an incident report concerning an unwitnessed fall of Resident R1 on 3/12/25. The resident was hospitalized and later returned to the facility on 3/18/25.
Report Facts
Incident date: Mar 12, 2025
Resident return date: Mar 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caroline Frangieh | Executive Director | Met with Licensing Program Analyst during follow-up visit |
| Angela Hood | Licensing Program Analyst | Conducted follow-up visit and obtained documentation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 101
Deficiencies: 0
Jan 15, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2024-09-26 regarding staff care, environment, training, and food service at the facility.
Findings
The investigation found insufficient evidence to substantiate the allegations. Facility inspections, record reviews, and interviews indicated that care needs were met timely, environment and cleanliness standards were maintained, staff training met requirements, and food service was adequate.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not assisting residents timely, inappropriate staff communication, inadequate training, and poor food service. Investigations found no preponderance of evidence to prove violations occurred.
Report Facts
Capacity: 101
Census: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
| Caroline Frangieh | Executive Director | Met with Licensing Program Analyst during inspection |
| Luis Olivas | Administrator | Facility Administrator named in report |
Inspection Report
Annual Inspection
Census: 67
Capacity: 101
Deficiencies: 0
May 16, 2024
Visit Reason
The inspection was conducted as a Required-1 Year Inspection to ensure compliance with Title 22 regulations at the care home.
Findings
The facility was found to be in compliance with regulations, with properly maintained and sanitary living areas, adequate food supplies, and no safety hazards observed. No deficiencies were cited during this visit.
Report Facts
Bedrooms observed: 4
Bedrooms observed: 3
Hydro tub rooms observed: 2
Common area bathrooms observed: 7
Hot water temperature: 115
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Executive Director | Met with Licensing Program Analyst during inspection |
| Angela Hood | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Routine
Capacity: 101
Deficiencies: 0
May 10, 2024
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted by the Licensing Program Analyst Angela Hood to evaluate compliance with regulations.
Findings
During the visit, resident and staff files were reviewed and medication storage was checked. No deficiencies were cited according to California Code of Regulations, Title 22.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Executive Director | Met with Licensing Program Analyst during the inspection. |
| Angela Hood | Licensing Program Analyst | Conducted the Required-1 Year Inspection. |
Inspection Report
Complaint Investigation
Capacity: 101
Deficiencies: 1
Jan 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-09-27 regarding inadequate care and supervision, medication mishandling, staff behavior, and refund issues at the facility.
Findings
The investigation substantiated the allegation that staff were not providing adequate care and supervision to residents, based on prior citations from a separate complaint investigation. The allegation that staff mishandled a resident's medication and screamed at a resident were found unsubstantiated after interviews, medication counts, and record reviews. The allegation that staff did not issue a refund was found to be unfounded as the refund was issued and delivered.
Complaint Details
The complaint investigation was triggered by allegations received on 2023-09-27. The allegation of inadequate care and supervision was substantiated based on evidence and prior citations from a complaint investigation concluded on 2023-12-01. The allegations of medication mishandling and staff screaming were unsubstantiated. The allegation regarding refund issuance was unfounded.
Deficiencies (1)
| Description |
|---|
| Staff are not providing adequate care and supervision to residents |
Report Facts
Facility capacity: 101
Complaint received date: Sep 27, 2023
Inspection visit date: Jan 11, 2024
Refund amount: 500
Refund mailing date: Sep 28, 2023
Refund delivery date: Sep 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Luis Olivas | Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Kathleen Gilbey | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 101
Deficiencies: 2
Dec 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-09-18 regarding staff not properly maintaining records and not meeting residents' care needs.
Findings
The investigation substantiated that staff did not properly document hourly checks for resident R1 and failed to respond timely to call button alerts, posing potential health and safety risks. Another allegation regarding the call signal system being in good repair was unsubstantiated. A third allegation about residents' rooms being kept unlocked was found to be unfounded.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not ensure records were properly maintained and did not meet care needs of resident R1, including failure to document hourly checks and delayed or absent responses to call button alerts. The allegation that the call signal system was not in good repair was unsubstantiated. The allegation that residents' rooms were not kept unlocked was unfounded.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not ensure R1’s records were maintained for hourly checks, posing potential health, safety, and personal rights risk. | Type B |
| Facility did not ensure R1 was receiving hourly checks or that residents’ call button alerts were responded to in a timely manner, posing potential health, safety, and personal rights risk. | Type B |
Report Facts
Capacity: 101
Census: 69
Call response delays: 19
Call alerts not responded: 16
Hourly checks required: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hood | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kathleen Gilbey | Executive Director | Facility representative interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 7
Capacity: 101
Deficiencies: 0
Apr 12, 2023
Visit Reason
The inspection was conducted to investigate a complaint alleging that a resident sustained injuries from a fall due to lack of supervision.
Findings
The investigation found that the resident's fall was accidental, with no evidence of lack of supervision. The resident was not requiring 1:1 staffing, and staff responded immediately after the fall. The complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that a resident sustained injuries from a fall while in care due to lack of supervision. The allegation was found to be unsubstantiated after investigation.
Report Facts
Facility capacity: 101
Resident census: 7
Staff interviewed: 5
Date of resident fall: Dec 18, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation |
| Kathleen Gilbey | Administrator | Met with investigator during inspection |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 72
Capacity: 101
Deficiencies: 1
Apr 7, 2023
Visit Reason
The inspection was an unannounced Continued Annual Inspection conducted by the Licensing Program Analyst to review resident files and ensure compliance with regulations.
Findings
The inspection found that three of six residents had physician's reports that were out of date, resulting in a substantiated allegation and citation for noncompliance with Title 22 regulations related to care of persons with dementia.
Complaint Details
The allegation was substantiated based on the evidence that physician's reports were out of date for three residents.
Severity Breakdown
B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Three of six residents had physician's reports out of date, posing a potential health, safety, or personal rights risk. | B |
Report Facts
Residents with out of date physician's reports: 3
Total residents reviewed: 6
Capacity: 101
Census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Maribeth Senty | Licensing Program Manager | Supervisor of the inspection |
| Kathleen Gilbey | Administrator | Facility administrator met during inspection |
Inspection Report
Annual Inspection
Census: 72
Capacity: 101
Deficiencies: 0
Apr 6, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to ensure health and safety compliance at the facility.
Findings
The inspection found no immediate health, safety, or personal rights violations. Resident care needs appeared to be met, and no deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Met with Licensing Program Analysts during the inspection. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the annual inspection and toured the facility. |
| Ivan Avila | Licensing Program Analyst | Arrived with Kevin Mknelly to conduct the annual inspection. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Follow-Up
Census: 74
Capacity: 101
Deficiencies: 2
Dec 8, 2022
Visit Reason
The inspection was an unannounced follow-up case management inspection related to a deficiency discovered during a prior complaint investigation #25-AS-20220519170123.
Findings
The inspection found that staff members (S1 and S2) had not completed the required initial medication shadowing training prior to administering medications, and staff (S3) had not completed the required continuing in-service medication training within the last 12 months, posing potential health and safety risks to residents.
Complaint Details
The follow-up inspection was conducted related to a prior complaint investigation #25-AS-20220519170123.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff (S1 and S2) had not completed the required initial medication shadowing training prior to assisting residents with self-administration of medications. | Type B |
| Staff (S3) had not completed the required ongoing medication training within the last 12 months. | Type B |
Report Facts
Hours of initial medication training required: 16
Hours of initial medication training completed: 8
Hours of continuing in-service medication training required: 8
Plan of Correction (POC) due date: Jan 16, 2023
Facility capacity: 101
Facility census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Met with Licensing Program Analyst during inspection. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the follow-up inspection. |
| Maribeth Senty | Licensing Program Manager | Named in report as supervisor. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 101
Deficiencies: 2
Oct 11, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 2022-05-19 regarding resident care issues including lack of shower chair, development of rash, and unmet hygiene needs.
Findings
The investigation substantiated that the resident did not receive a shower chair for several months and that the resident's hygiene needs were not consistently met, resulting in health and safety risks. The allegation that the resident developed a rash while in care was also substantiated. Other allegations regarding wound treatment and seeking medical attention were found unsubstantiated.
Complaint Details
Complaint involved allegations that a resident did not receive a shower chair for a long period, developed a rash while in care, hygiene needs were not met, wounds were not properly treated, and staff did not seek medical attention. The investigation substantiated the lack of shower chair, rash development, and unmet hygiene needs, but found the wound treatment and medical attention allegations unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure that resident (R1) received scheduled showers, twice weekly, on a consistent basis from May 2022 to September 2022, posing an immediate health and safety risk. | Type A |
| Licensee did not ensure that resident (R1) had a shower chair to use for assistance during bathing from on/around April 2022 to September 2022, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 101
Census: 71
Deficiencies cited: 2
Plan of Correction Due Dates: Type A deficiency due 10/13/2022; Type B deficiency due 10/31/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Met with Licensing Program Analyst during investigation |
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation |
| Maribeth Senty | Licensing Program Manager | Oversaw complaint investigation and signed report |
| Ron Cheek | Memory Care Director | Provided additional documentation during investigation |
Inspection Report
Census: 74
Capacity: 101
Deficiencies: 0
Aug 30, 2022
Visit Reason
The inspection was conducted as a case management visit related to a prior complaint that was opened and closed under the facility's previous license. The purpose was to issue a related deficiency and document the inspection under the current license.
Findings
No deficiencies were issued during this inspection. However, a $500 penalty was issued for a violation from July 2018 that resulted in injury or illness to a resident.
Complaint Details
The visit was related to complaint #25-AS-20211027124047, which was opened and closed under the prior license. Complaint findings were issued on April 12, 2022.
Report Facts
Penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Met with Licensing Program Analyst during inspection. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection and issued the penalty. |
| Maribeth Senty | Licensing Program Manager | Named in report header. |
Inspection Report
Annual Inspection
Census: 74
Capacity: 101
Deficiencies: 0
May 2, 2022
Visit Reason
The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing regulations.
Findings
The facility was observed to be clean, in good repair, odor free, and well stocked with necessary supplies. No deficiencies were observed during the inspection.
Report Facts
Hospice residents: 3
Food storage duration: 2
Food storage duration: 7
Fire extinguisher last serviced: Aug 6, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator/Executive Director | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 101
Deficiencies: 0
Apr 12, 2022
Visit Reason
The inspection was conducted as a case management visit following the receipt of two incident reports involving residents.
Findings
The facility acted promptly in response to incidents involving two residents, with no deficiencies issued during this unannounced inspection.
Complaint Details
The visit was triggered by two incident reports: Resident 1 felt light-headed and was sent to the emergency room; Resident 2, diagnosed with dementia, was able to exit through a window but was found safely in the courtyard with minor skin tears. The administrator contacted the Licensing Program Analyst promptly after the incidents.
Report Facts
Incident Reports: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Met with Licensing Program Analyst during inspection and involved in incident response |
| Sabrina Calzada | Licensing Program Analyst | Conducted the case management inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 101
Deficiencies: 0
Mar 10, 2022
Visit Reason
The inspection visit was an unannounced case management investigation to continue the investigation into an open complaint at the facility.
Findings
No deficiencies were issued during this inspection. The inspection included discussion of the current COVID-19 situation and a recent resident death, with the facility agreeing to provide a copy of the county death certificate to the Department when received.
Complaint Details
The visit was triggered by an open complaint. The Licensing Program Analyst arrived unannounced to continue the investigation. No deficiencies were found during this visit.
Report Facts
Capacity: 101
Census: 67
Quarantine duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Met with Licensing Program Analyst during inspection and discussed findings |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced complaint investigation inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Follow-Up
Census: 66
Capacity: 101
Deficiencies: 0
Jan 5, 2022
Visit Reason
The inspection was an unannounced case management follow-up visit conducted to review three recent incident reports involving residents at the facility.
Findings
The facility took appropriate actions following each incident, including emergency services and physician notifications. No deficiencies were found, but more complete documentation on incident reports was discussed.
Report Facts
Incident reports followed up: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Met with Licensing Program Analyst during inspection and discussed incidents |
| Megan Leone | Memory Care Director | Provided additional information about incidents involving residents |
| Sabrina Calzada | Licensing Program Analyst | Conducted the case management inspection |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 64
Capacity: 101
Deficiencies: 0
May 19, 2021
Visit Reason
Licensing Program Analysts conducted an unannounced Annual/Random Inspection utilizing the infection control domain to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Met with Licensing Program Analysts during the inspection and toured the facility. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Original Licensing
Census: 66
Capacity: 101
Deficiencies: 0
Apr 22, 2021
Visit Reason
The inspection was a pre-licensing visit due to a change in ownership of the facility.
Findings
The facility was observed to be clean, in good repair, with sufficient furniture, lighting, food supplies, and safety equipment. No deficiencies were found during the inspection.
Report Facts
Fire clearance capacity: 89
Fire clearance capacity: 12
Food supply duration: 7
Food supply duration: 2
Hot water temperature: 118
Fire extinguisher service date: Aug 4, 2020
Egress door monitoring frequency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Condie | Executive Director | Met with Licensing Program Analyst during inspection |
| Kathleen Gilbey | Administrator Designee | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the scheduled tele-visit inspection |
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