Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. However, there were some substantiated issues primarily related to resident call bell response times, medication administration, wound reporting, personal rights violations involving theft by a staff member, and failure to meet mandated reporting requirements. The facility received civil penalties related to these findings, including ongoing fines for delayed correction of deficiencies. The most recent report from September 5, 2025, was clean with no deficiencies cited after addressing a complaint about resident behavior. Overall, the facility’s recent inspections show improvement compared to earlier reports that included more serious issues.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 152
Capacity: 214
Deficiencies: 0
Sep 5, 2025
Visit Reason
An unannounced case management visit was conducted to gather additional information and facility documentation related to a SOC 341 report concerning sexually inappropriate behavior by a resident.
Findings
The visit found that a safety plan was implemented to address the behavior of the resident involved, who has since moved out of the facility. No deficiencies were cited during the inspection.
Complaint Details
The complaint involved Resident 1 engaging in sexually inappropriate behavior with another resident, as observed by the resident's wife. The facility implemented a safety plan and coordinated with the resident's responsible party. Resident 1 has moved out of the facility.
Report Facts
Capacity: 214
Census: 152
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Executive Director | Met with Licensing Program Analyst during the visit and reported on safety plan implementation |
| Kelli Hendrix | Memory Care Director | Reported on safety plan implementation related to resident behavior |
| Pang Lee | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 214
Deficiencies: 0
Aug 22, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-07-28 regarding inadequate incontinent care, uncomfortable meal conditions, and lack of dignity and respect in resident care.
Findings
The investigation included interviews with staff, residents, family members, and direct observations. No evidence was found to substantiate the allegations. Residents' incontinent care needs were met, mealtimes were comfortable, and residents were treated with dignity and respect. No deficiencies were cited.
Complaint Details
The complaint allegations were found to be unsubstantiated after investigation. The preponderance of evidence standard was not met to prove the alleged violations occurred.
Report Facts
Facility census: 150
Facility capacity: 214
Family members interviewed: 6
Staff interviewed: 5
Residents interviewed: 5
Residents observed in dining room: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pang Lee | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kathleen Gilbey | Executive Director/Administrator | Facility administrator met during the investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 146
Capacity: 214
Deficiencies: 0
Apr 22, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements and ensure the health and safety of residents.
Findings
The facility was found to be clean, in good repair, and in compliance with Title 22 regulations. Observations included sufficient food supplies, proper medication storage, and safety measures such as smoke detectors and fire extinguishers. Resident and staff files were complete, and staff background checks were verified.
Report Facts
Facility staff count: 112
Resident files reviewed: 10
Resident medications reviewed: 5
Fire extinguisher last serviced: Apr 16, 2025
Hot water temperature: 109.1
Facility thermostat temperature: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Facility administrator present during inspection and exit interview |
| Pang Lee | Licensing Program Analyst | Conducted the inspection |
| Shakaricka Hughes | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 214
Deficiencies: 0
Jan 14, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not keep the facility free from bug infestation and did not ensure a resident had sufficient clothing.
Findings
The investigation found that the facility responded promptly to bed bug reports by hiring pest control companies and treating affected areas, and provided clothing and hygiene items to residents when necessary. Based on the evidence gathered, the allegations were found to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred regarding bug infestation and insufficient resident clothing.
Report Facts
Capacity: 214
Census: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kathleen Gilbey | Facility Designated Administrator | Met with Licensing Program Analyst during the investigation |
| Lisa Rios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 214
Deficiencies: 0
Jul 23, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-04-25 regarding allegations of inadequate resident care including assistance with showers, blood glucose testing equipment maintenance, and timely medication reordering.
Findings
The investigation found insufficient evidence to substantiate the allegations. Facility records, staff and resident interviews indicated that the resident in question was generally independent in personal care and medication management. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint involved three allegations: 1) staff not assisting a resident with showers, 2) staff not ensuring the resident's blood glucose testing equipment was working properly, and 3) staff not ensuring residents' medication was reordered timely causing missed medication. The findings were unsubstantiated as evidence did not prove the alleged violations occurred.
Report Facts
Facility capacity: 214
Census: 135
Complaint control number: 27-AS-20240425082151
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Facility Designated Administrator | Met with Licensing Program Analysts during complaint investigation |
| Arielle Pascua | Licensing Program Analyst | Conducted complaint investigation |
| Lisa Rios | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Follow-Up
Census: 135
Capacity: 214
Deficiencies: 2
Jul 23, 2024
Visit Reason
The visit was an unannounced case management follow-up on an incident report received by the department on 2024-06-29 regarding a resident's medication administration and wound care.
Findings
The facility failed to report a resident's unstageable wound within the required 7 days and did not administer prescribed medication to the resident for a total of 12 days, posing potential health, safety, and personal rights risks.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report resident's unstageable wound within 7 days of occurrence as required by regulations. | Type B |
| Failure to ensure resident received prescribed medication as ordered by physician from 06/03/2024 to 06/06/2024 and 06/12/2024 to 06/20/2024. | Type A |
Report Facts
Deficiency due date: Aug 23, 2024
Deficiency due date: Aug 24, 2024
Days medication not given: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Facility Designated Administrator | Met with during the inspection visit |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection |
| Lisa Rios | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 214
Deficiencies: 1
Jul 23, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that staff did not respond to residents' call pendants in a timely manner and did not ensure residents' oxygen care needs were met in a timely manner.
Findings
The investigation substantiated the allegation that staff did not respond to residents' call pendants in a timely manner, with 7 out of 8 SMART care log alerts not responded to within 15 minutes, posing potential health and safety risks. The allegation regarding oxygen care needs was unsubstantiated as evidence showed residents on oxygen received appropriate monitoring and assistance.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not respond to residents' call pendants in a timely manner. The allegation that staff did not ensure residents' oxygen care needs were met in a timely manner was unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Based on 7 out of 8 resident SMART care logs, residents' alert calls were not responded to timely, sometimes taking over 15 minutes, posing potential health, safety, or personal rights risks. |
Report Facts
Residents interviewed: 4
SMART care logs reviewed: 8
SMART care logs with unresponded alerts: 7
Residents on oxygen interviewed: 6
Facility staff interviewed: 5
Facility capacity: 214
Facility census: 135
Plan of Correction due date: Aug 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Met with during investigation and exit interview |
| Pang Lee | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Arielle Pascua | Licensing Program Analyst | Assisted in conducting complaint investigation |
| Terry Ervin | Vice President of Operation | Provided information on facility response times |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 214
Deficiencies: 0
Jul 23, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2024-04-19 regarding allegations that staff did not safeguard resident’s personal belongings, did not assist resident with feeding, and did not meet resident's needs.
Findings
The investigation found that the allegations were unsubstantiated due to lack of preponderance of evidence. It was noted that resident 1's glasses were broken and discarded by staff without informing the resident or Power of Attorney, but reimbursement was provided. Resident 1 was able to feed independently and did not require assistance as per the individualized service plan and physician's report.
Complaint Details
The complaint involved allegations that staff did not safeguard resident’s personal belongings, did not assist resident with feeding, and did not meet resident's needs. The investigation included interviews with staff and residents and review of records. The allegations were found to be unsubstantiated.
Report Facts
Reimbursement amount: 400
Census: 135
Total capacity: 214
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Administrator | Named in relation to findings about safeguarding resident's personal belongings and interviewed during complaint investigation |
| Pang Lee | Licensing Program Analyst | Conducted the complaint investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 214
Deficiencies: 0
Jul 23, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-05-08 alleging that the facility did not prevent a resident from making inappropriate comments to other residents.
Findings
The investigation included interviews with 9 residents and 5 staff members, all of whom denied witnessing or making inappropriate comments. The facility's staff house rules prohibit disruptive or abusive behavior. The allegations were found to be unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint alleged that the facility did not prevent a resident from making inappropriate comments to other residents. After investigation, the allegations were found to be unsubstantiated as there was not a preponderance of evidence to prove the violation occurred.
Report Facts
Residents interviewed: 9
Staff interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Gilbey | Facility Designated Administrator | Met with Licensing Program Analysts during the complaint investigation |
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 138
Capacity: 214
Deficiencies: 0
Apr 24, 2024
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate the health and safety compliance of the facility.
Findings
The facility was found to be clean, in good repair, and compliant with regulations including fire safety, medication storage, and resident care. No deficiencies were cited during the inspection.
Report Facts
Water temperature: 113.1
Residents pendant check: 5
Resident files reviewed: 6
Staff files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pang Lee | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kathleen Gilbey | Administrator | Facility administrator met during inspection |
| Janae Fernandez | Marketing Director | Assisted in inspection of physical plant and resident areas |
Inspection Report
Census: 136
Capacity: 214
Deficiencies: 0
Mar 20, 2024
Visit Reason
An unannounced case management inspection was conducted to address concerns discovered during an unrelated complaint investigation.
Findings
No deficiencies were cited per California Code of Regulations, TITLE 22. The case management inspection was not completed due to time constraints and will be continued at a later date.
Inspection Report
Complaint Investigation
Census: 136
Capacity: 214
Deficiencies: 3
Mar 20, 2024
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations including neglect/lack of supervision resulting in a resident fracture, disrepair of the facility call system, and failure to notify authorized persons of resident hospitalization.
Findings
The investigation substantiated the allegations of neglect/lack of supervision, failure to notify authorized representatives, and malfunctioning call system. Staff interviews revealed multiple falls of a resident without a fall prevention plan, unreliable alert pendants, and failure to notify authorized persons of the resident's hospitalization. Immediate civil penalties were issued due to resident injury.
Complaint Details
The complaint investigation was substantiated based on interviews and evidence showing neglect/lack of supervision causing resident injury, failure to notify authorized representatives of hospitalization, and malfunctioning call system. The investigation was triggered by a complaint received on 2023-09-21.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide a fall prevention plan for a resident at risk, resulting in falls and a fracture requiring hospitalization. | Type A |
| Failure to notify authorized representatives of incidents including resident's fall and hospitalization. | Type A |
| Facility call system did not operate properly, with staff not always notified of resident alerts. | Type A |
Report Facts
Capacity: 214
Census: 136
Deficiencies cited: 3
Plan of Correction Due Date: Mar 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation report |
| Kathleen Gilby | Facility representative met during investigation |
Inspection Report
Census: 147
Capacity: 214
Deficiencies: 1
Nov 16, 2023
Visit Reason
The visit was an unannounced case management inspection conducted in response to concerns brought to the department's attention on 10/30/2023 regarding the facility's failure to provide timely written responses to family council concerns.
Findings
The facility was found deficient for not providing written responses within 14 calendar days to family council concerns submitted on 09/09/2023 and 10/10/2023, with only a verbal response provided on 11/14/2023. Deficiencies were cited under California Code of Regulations, Title 22, and California Health and Safety Code.
Deficiencies (1)
| Description |
|---|
| Failure to respond in writing within 14 calendar days to family council written concerns or recommendations as required by §1569.158(f). |
Report Facts
Capacity: 214
Census: 147
Plan of Correction Due Date: Nov 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Administrator | Named in relation to failure to provide timely written responses to family council concerns |
| Pang Lee | Licensing Program Analyst | Conducted the inspection and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the inspection |
| Terry Ervin | Vice President of Operations | Mentioned as recipient of phone calls and emails regarding concerns |
Inspection Report
Plan of Correction
Census: 147
Capacity: 214
Deficiencies: 1
Nov 16, 2023
Visit Reason
The visit was an unannounced Plan of Correction (POC) follow-up to verify correction of prior deficiencies and plans of correction due on 11/07/2023 from a complaint investigation conducted on 10/24/2023.
Findings
The deficiency cited under Title 22 Regulation 87303(i)(1)(B) was cleared during this visit. Although the facility did not comply by the original POC due date, the administrator provided POC documents during the visit. Civil penalties were assessed for failure to correct by the due date, accruing $100 per day until correction.
Complaint Details
The visit followed a complaint investigation conducted on 10/24/2023. The POC was due on 11/07/2023. Civil penalties were assessed for failure to correct the cited deficiency by the due date.
Deficiencies (1)
| Description |
|---|
| Failure to correct deficiency under Title 22 Regulation 87303(i)(1)(B) by the POC due date. |
Report Facts
Civil penalty accrual rate: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Administrator | Met with Licensing Program Analyst during the POC visit and provided POC documents. |
| Pang Lee | Licensing Program Analyst | Conducted the unannounced Plan of Correction visit. |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 214
Deficiencies: 1
Oct 24, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to an allegation that staff do not respond to resident(s) call bells in a timely manner.
Findings
The investigation substantiated the allegation that staff did not respond to residents' call bells in a timely manner. Review of Personal Health Button Reports revealed that 3 out of 10 residents' calls were not responded to within 15 minutes, and 7 residents reported that calls were never responded to, posing a potential health, safety, or personal rights risk.
Complaint Details
The complaint was substantiated. The allegation was that staff do not respond to resident call bells in a timely manner. The investigation included interviews with staff, residents, and review of records. It was found that response times exceeded 15 minutes for some residents and some calls were never responded to.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have a signal system that transmits a visual and/or auditory signal to a central staffed location or produces an auditory signal at the living unit loud enough to summon staff, as required by CCR 87303(i)(1)(B). | Type B |
Report Facts
Residents with delayed response: 3
Residents with no response: 7
Facility capacity: 214
Facility census: 147
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Administrator | Met with Licensing Program Analyst and involved in investigation findings. |
| Terry Ervin | VP of Operations | Acknowledged facility response time and involved in investigation findings. |
| Pang Lee | Licensing Program Analyst | Conducted the complaint investigation. |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 214
Deficiencies: 1
Oct 19, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations regarding staff not providing a resident with a copy of financial statements and inadequately keeping records regarding a resident's expenses.
Findings
The investigation found the allegation that staff did not provide a resident with a copy of financial statements to be unsubstantiated, but substantiated that staff did not adequately keep records regarding a resident's expenses, specifically failing to provide a monthly itemized statement of charges. A deficiency was cited related to this issue with a plan of correction due.
Complaint Details
The complaint investigation was triggered by allegations that staff were not providing a resident with a copy of financial statements and were not adequately keeping records regarding a resident's expenses. The allegation regarding financial statements was unsubstantiated, while the allegation regarding record keeping was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator did not ensure that a resident is receiving a monthly statement itemizing all separate charges incurred by the resident on resident's invoice statement. | Type B |
Report Facts
Capacity: 214
Census: 147
Deficiencies cited: 1
Fine amount: 15
Plan of Correction Due Date: Oct 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Administrator | Met with Licensing Program Analyst during complaint investigation and provided information regarding resident invoice statements |
| Pang Lee | Licensing Program Analyst | Conducted the complaint investigation visit |
| Czarina A Camilon-Lee | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 214
Deficiencies: 2
Sep 22, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 07/28/2023 regarding staff stealing and fraudulently using residents' credit cards and failure to adhere to reporting requirements.
Findings
The investigation substantiated the allegations of personal rights violations involving four instances of credit card theft and unauthorized use by a staff member who was arrested. The facility failed to meet all mandated reporting requirements, specifically in submitting a suspected dependent adult/elder abuse report to the local ombudsperson within two working days. Another allegation regarding failure to follow theft/loss policy was found to be unfounded.
Complaint Details
The complaint was substantiated for allegations of personal rights violations involving theft and fraudulent use of residents' credit cards by a staff member, and failure to adhere to mandated reporting requirements. The staff member was arrested and charged with 12 felony counts. The allegation regarding failure to follow theft/loss policy was unfounded.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Additional Personal Rights of Residents in Privately Operated Facilities: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by four instances of theft of a resident's credit card and unauthorized use by a staff member who was arrested. | Type B |
| Administrator - Qualifications and Duties: The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). This requirement was not met as evidenced by the facility did not meet all reporting requirements for mandated reporting of financial abuse as a suspected dependent adult/elder abuse report was not submitted within two working days for one incident. | Type B |
Report Facts
Identified victims: 4
Felony counts: 12
Deficiencies cited: 2
Plan of Correction due date: Oct 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Luis Olivas | Administrator | Facility administrator met during investigation and discussed findings |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 214
Deficiencies: 0
Sep 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging that the licensee does not ensure the facility is in good repair.
Findings
The investigation found that one of the facility's elevators was out of service from August 1, 2023, and was repaired on August 11, 2023, after a delayed replacement part shipment. The facility implemented meal tray service and transportation assistance during the elevator outage. Due to lack of preponderance of evidence, the allegation was unsubstantiated.
Complaint Details
The complaint was unsubstantiated as the facility addressed the elevator issue in a timely manner and there was insufficient evidence to prove the alleged violation occurred.
Report Facts
Facility capacity: 214
Census: 146
Complaint receipt date: Aug 4, 2023
Elevator out of service date: Aug 1, 2023
Elevator repair date: Aug 11, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Luis Olivas | Administrator | Facility administrator met with Licensing Program Analyst during the visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 214
Deficiencies: 0
Jul 25, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations including suspicious death and failure to call 911 during a medical emergency at Oakmont of East Sacramento.
Findings
The investigation found that the allegations could not be substantiated. The resident had a seizure-like episode and expired at the facility with a do not resuscitate order. Staff contacted Alpha One for medical transport, which is certified to provide emergency services, rather than 911. No deficiencies were cited.
Complaint Details
The complaint involved allegations of suspicious death and failure to call 911 during a medical emergency. The allegations were determined to be unsubstantiated/unfounded based on interviews, record reviews, and evidence gathered during the investigation.
Report Facts
Capacity: 214
Census: 147
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Luis Olivas | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 214
Deficiencies: 1
May 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that facility staff were not ensuring resident receives showers, not cleaning resident's room, and not providing food following dietary restrictions, as well as a separate allegation regarding improper billing of a resident.
Findings
The investigation found the first set of allegations regarding showering assistance, room cleanliness, and dietary restrictions unsubstantiated based on resident statements and records. However, the allegation of improper billing related to a pet fee was substantiated, with the facility crediting the resident for the erroneous charge. No other deficiencies were noted.
Complaint Details
The complaint investigation was triggered by allegations received on 2023-01-26 regarding failure to provide showers, room cleaning, and dietary compliance. These were unsubstantiated. A separate allegation of improper billing was substantiated, involving a pet fee charged inappropriately to a resident.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Payment provisions, including a comprehensive description of billing and payment procedures, were not met as evidenced by facility disclosure of reimbursement to resident for pet service fee intended for dog care, not cats, posing potential health, safety, and personal rights risk. | Type B |
Report Facts
Capacity: 214
Census: 146
Deficiencies cited: 1
Plan of Correction Due Date: May 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Luis Olivas | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 142
Capacity: 214
Deficiencies: 0
Feb 23, 2023
Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was found to be clean, odor-free, and in good repair with all required safety equipment and supplies in place. No deficiencies were cited during the inspection.
Report Facts
Resident files reviewed: 6
Staff files reviewed: 4
Water temperature: 115
Food supplies: 7
Food supplies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Administrator | Met with Licensing Program Analyst during inspection |
| Kevin Gould | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 214
Deficiencies: 0
Jan 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2023-01-06 regarding staff not meeting with responsible party for reappraisal meeting, not showering a resident, and not meeting a resident's dietary needs.
Findings
The investigation found the allegations that staff did not meet with the responsible party for a reappraisal meeting and did not shower the resident to be unfounded. The allegation that staff did not meet the resident's dietary needs was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was based on three allegations: staff did not meet with responsible party for reappraisal meeting, staff do not shower resident, and staff do not meet resident's dietary needs. The first two allegations were found to be unfounded, and the third was unsubstantiated.
Report Facts
Capacity: 214
Census: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Executive Director | Met with Licensing Program Analyst during the complaint investigation and exit interview |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 214
Deficiencies: 0
Dec 29, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff did not provide adequate food service for residents.
Findings
Based on interviews and record review, it was determined that the resident received insulin and meals at appropriate times and the facility provided three snacks throughout the day. The allegations were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged inadequate food service for residents. The investigation found no sufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Report Facts
Capacity: 214
Census: 151
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 214
Deficiencies: 0
Dec 29, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not seek medical attention for a resident in care.
Findings
The investigation found that staff were never made aware of the resident having chest pain; chart notes indicated only shoulder pain treated with PRN medication. There was insufficient evidence to substantiate the allegation, so it was deemed unsubstantiated.
Complaint Details
The complaint allegation was that staff did not seek medical attention for a resident in care. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 214
Census: 151
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Executive Director | Met with Licensing Program Analyst during the complaint investigation and exit interview |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 214
Deficiencies: 1
Dec 9, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-11-07 regarding resident safety, staffing adequacy, hazard accessibility, dietary needs, and staff behavior.
Findings
The investigation found that most allegations were unsubstantiated, including concerns about elopement prevention, staffing adequacy, hazard accessibility, and dietary needs. However, the allegation that staff spoke inappropriately to residents was substantiated, with corrective actions initiated.
Complaint Details
The complaint investigation was triggered by allegations including failure to prevent elopement of memory care residents, inadequate staffing, accessible hazards, unmet dietary needs, and inappropriate staff speech. The allegation of inappropriate speech by Staff 1 was substantiated; others were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure residents were accorded dignity by Staff 1 (S1), posing a potential health and safety risk to residents in care. | Type B |
Report Facts
Capacity: 214
Census: 151
Deficiencies cited: 1
Plan of Correction Due Date: Dec 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Executive Director | Met during inspection and involved in addressing findings |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
| Staff 1 | Named in substantiated finding for speaking inappropriately to residents |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 214
Deficiencies: 0
Nov 29, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-11-02 regarding a non-functioning call system and staff not following up with a resident's physician after emergency treatment.
Findings
The investigation found that the call system was functioning properly with staff responding timely to calls, and staff were regularly checking on the resident despite the resident's request to reduce checks. The allegations were determined to be unfounded.
Complaint Details
The complaint investigation was conducted for two allegations: 1) Facility has a non-functioning call system, and 2) Staff did not follow-up with resident’s physician following emergency treatment. Both allegations were found to be unfounded.
Report Facts
Capacity: 214
Census: 146
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | Executive Director | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 214
Deficiencies: 0
Jul 26, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff allowed residents to perform tasks such as giving medications, opening mail, bathing, catheter changes, and dressing other residents.
Findings
The investigation found all allegations to be unfounded, determining that the residents were either independent in these activities or the allegations were false and without reasonable basis.
Complaint Details
The complaint investigation was triggered by multiple allegations regarding improper resident care activities being performed by other residents. The findings concluded the allegations were unfounded.
Report Facts
Facility capacity: 214
Census: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
| Luis Olivas | Executive Director | Met with Licensing Program Analyst during investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Original Licensing
Census: 137
Capacity: 214
Deficiencies: 0
Mar 29, 2022
Visit Reason
The inspection was an unannounced Pre-Licensing inspection due to Change of Ownership.
Findings
The facility was found to be clean, odor-free, and in good repair with all required safety and health measures in place. No deficiencies were observed during the inspection.
Report Facts
Water temperature: 110
Water temperature: 107
Capacity: 214
Census: 137
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Clymo | Assistant Executive Director | Met with Licensing Program Analyst during inspection and exit interview |
| Christopher Hopkins | Licensing Program Analyst | Conducted the inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report header |
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