Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated or unfounded, indicating generally good compliance. The most recent report from October 22, 2025, had no deficiencies and focused on reviewing updated fall protocols. Past substantiated issues included inadequate supervision and fall prevention leading to a resident injury in April 2025, and earlier concerns about medication management and safeguarding resident property, some of which were resolved with refunds or corrective actions. There were no fines listed in the most recent reports, though a civil penalty was issued in 2021 for a late plan of correction submission. Overall, the facility’s record shows improvement over time, with recent inspections consistently clean and complaint allegations mostly unsubstantiated.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 92
Capacity: 129
Deficiencies: 0
Oct 22, 2025
Visit Reason
The visit was an informal office meeting held on 10/22/2025 to discuss complaint history, including a complaint dated 09/25/2024, and to review updated fall protocols for residents identified as fall risks.
Findings
No deficiencies were cited during the visit. The facility representatives discussed their fall mitigation program, current fall risk assessments, resident-centered interventions, and policies for residents who suffer multiple falls.
Complaint Details
The visit included discussion of a complaint dated 09/25/2024. No deficiencies were cited, indicating no substantiated violations.
Report Facts
Capacity: 129
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Rogers | Administrator | Met with during the inspection and discussed facility protocols |
| Laura Munoz | Licensing Program Manager | Present for the inspection and meeting |
| Lavinia Muscan | Licensing Program Analyst | Present for the inspection and meeting |
| Terry Ervin | Regional VP of Operations | Participated in the meeting via Teams |
| Jennifer Sato | Senior VP of Health Services | Participated in the meeting via Teams |
| Kevin Wrigley | Senior Regulatory Director | Participated in the meeting via Teams |
| Jimmy Duong | Nurse | Participated in the meeting via Teams |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 129
Deficiencies: 0
Aug 26, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was malodorous.
Findings
The investigation found the facility to be clean, sanitary, and free from odor during multiple tours and staff interviews. The allegation of the facility being malodorous was determined to be unfounded.
Complaint Details
The complaint alleged that the facility was malodorous. After investigation including interviews and observations, the allegation was found to be unfounded.
Report Facts
Complaint Control Number: 59
Investigation Duration: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Chad Rogers | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 129
Deficiencies: 0
Aug 26, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-08-06 regarding medication administration, staffing levels, facility cleanliness, laundry machine condition, and call pendant functionality.
Findings
The investigation found the medication administration allegation unsubstantiated with no evidence of errors. Allegations of understaffing, non-working call pendants, unsanitary conditions, and laundry machine disrepair were found to be unfounded based on staff and resident interviews and observations, confirming the facility was adequately staffed, clean, and equipment functional.
Complaint Details
The complaint investigation was unsubstantiated for medication errors and unfounded for understaffing, call pendant issues, cleanliness, and laundry machine disrepair. The findings were based on interviews with ten staff and five residents, document reviews, and observations.
Report Facts
Staff interviews: 10
Resident interviews: 5
Facility capacity: 129
Facility census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Chad Rogers | Administrator | Facility administrator met during the investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 4
Jun 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-05-02 regarding staff response to call buttons, resident movement, hot water delivery, and mail delivery.
Findings
The investigation found the allegation that staff were not responding to call buttons timely to be unsubstantiated, with typical response times ranging from 5 to 15 minutes. Other allegations regarding restricting resident movement, hot water delivery, and mail interference were found to be unfounded based on interviews, observations, and record reviews.
Complaint Details
The complaint investigation was unsubstantiated for the call button response allegation and unfounded for the allegations regarding resident movement, hot water delivery, and mail interference. The report states that there was insufficient evidence to support these allegations.
Deficiencies (4)
| Description |
|---|
| Facility staff are not responding to call buttons in a timely manner |
| Facility staff are not allowing resident to move freely around the facility |
| Facility staff do not ensure that residents are delivered hot water throughout the facility |
| Facility staff interfere with resident receiving mail in a timely manner |
Report Facts
Capacity: 129
Census: 89
Call button response time (minutes): 5
Call button response time (minutes): 12
Call button response time (minutes): 10
Call button response time (minutes): 15
Number of staff interviewed: 4
Number of residents interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Talwinder Bains | Licensing Program Analyst | Assisted in delivering complaint findings |
| Christina Del Rosario | Health Services Director | Met with investigators during the complaint investigation |
| Chad Rogers | Administrator | Facility administrator named in the report |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Jun 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-05-27 regarding staff not ensuring the facility door is properly operating.
Findings
The investigation found that the activation button for wheelchair accessible residents did not always catch, but the door still opened automatically when pushed. Residents were not locked outside, and other doors were functioning properly. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint was unsubstantiated, meaning there was not sufficient evidence to prove the alleged violation occurred.
Report Facts
Complaint Control Number: 59
Complaint Received Date: May 27, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Talwinder Bains | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Christina Del Rosario | Health Services Director | Met with investigators during the complaint investigation |
| Chad Rogers | Administrator | Facility administrator involved in discussion about door activation button |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Jun 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff were not following universal precautions to prevent the spread of scabies.
Findings
The investigation found that the facility was following universal precautions, including placing PPE outside the resident room at the first sign of a rash, notifying staff, and conducting in-service training on handwashing and precautions. The allegation was determined to be unfounded.
Complaint Details
The complaint alleged that staff were not following universal precautions to ensure staff do not spread scabies. The allegation was found to be unfounded based on observation, record review, and statements.
Report Facts
Facility capacity: 129
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina Del Rosario | Health Services Director | Met with investigators during complaint investigation |
| Lavinia Muscan | Licensing Program Analyst | Conducted complaint investigation |
| Talwinder Bains | Licensing Program Analyst | Conducted complaint investigation |
| Laura Munoz | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 89
Capacity: 129
Deficiencies: 0
Jun 17, 2025
Visit Reason
The inspection was conducted as a required annual unannounced visit to evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, well organized, and compliant with all health and safety regulations. No health or safety violations were observed during the tour of the facility and review of resident and staff files.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Perishable food supply days: 2
Non-perishable food supply days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Rogers | Administrator | Administrator toured the facility with Licensing Program Analysts |
| Christina Del Rosario | Health Services Director | Met with during inspection |
| Lavinia Muscan | Licensing Program Analyst | Conducted the annual inspection |
| Talwinder Bains | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 129
Deficiencies: 0
May 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-04-04 regarding allegations of staff mishandling a resident's medication and inappropriate staff behavior.
Findings
The investigation found insufficient evidence to substantiate the allegations of medication errors and inappropriate staff behavior. Interviews with staff and residents indicated no concerns, and the complaint was determined to be unsubstantiated or unfounded.
Complaint Details
The complaint involved allegations that staff mishandled a resident's medication and made inappropriate comments or exhibited behavior posing risks to residents. The findings concluded the medication error allegation was unsubstantiated and the behavior allegation was unfounded.
Report Facts
Capacity: 129
Census: 83
Staff interviews: 4
Resident interviews: 4
Staff interviews: 4
Resident interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Rogers | Administrator | Met with during investigation and named in report |
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 129
Deficiencies: 0
May 12, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations including questionable death, insufficient staffing, and failure to seek timely medical attention for a resident.
Findings
The investigation found all allegations to be unfounded. Documentation and interviews confirmed the resident's death was natural and timely medical attention was provided. Staffing levels were adequate to meet residents' needs.
Complaint Details
The complaint involved allegations of questionable death, insufficient staffing, and failure to seek timely medical attention. The investigation concluded all allegations were unfounded, meaning they were false or without reasonable basis.
Report Facts
Capacity: 129
Census: 83
Number of staff interviewed: 4
Number of residents interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation |
| Chad Rogers | Administrator | Facility administrator met during investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 129
Deficiencies: 0
May 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-03-19 regarding staff response times, resident pendant disrepair, facility conditions, communication with resident representatives, and meal service timeliness.
Findings
The investigation found all allegations to be unsubstantiated or unfounded. Staff response times to resident call buttons were timely, resident pendant systems were operable, the facility was clean and sanitary, staff properly followed universal precautions, and residents were provided meals in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated for allegations including staff not attending to residents timely and resident pendants in disrepair. Additional allegations of facility malodor, bathroom disrepair, failure to inform resident representatives of incidents, and untimely meal provision were found unfounded.
Report Facts
Capacity: 129
Census: 83
Call button response time (minutes): 5
Call button response time (minutes): 12
Staff reported response time (minutes): 10
Staff reported response time (minutes): 15
Staff interviews: 5
Resident interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Chad Rogers | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 129
Deficiencies: 2
Apr 8, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-09-25 regarding inadequate supervision and fall prevention resulting in resident injury.
Findings
The investigation substantiated that staff failed to provide adequate supervision and prevent multiple falls for resident R1, resulting in a serious injury including a fractured clavicle. The facility failed to develop and implement a personalized intervention plan and did not ensure staff training on fall prevention protocols. One allegation regarding failure to issue a refund was found to be unfounded.
Complaint Details
The complaint was substantiated regarding inadequate supervision and fall prevention leading to resident injury. The allegation about failure to issue a refund was unfounded.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure reassessments were conducted due to resident's change in conditions and failed to develop a personalized intervention plan as indicated in resident's needs and service plan, posing an immediate health and safety risk. | Type A |
| Facility failed to ensure staff were trained on personalized fall protocols for resident, posing an immediate health and safety risk. | Type A |
Report Facts
Civil penalty amount: 500
Resident falls: 15
Resident falls: 20
Plan of Correction Due Date: Apr 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation |
| Chad Rogers | Administrator | Facility administrator met during investigation and exit interview |
| Lydia Gravelyn | Administrator | Previous facility administrator mentioned in findings regarding resident care |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 129
Deficiencies: 0
Mar 5, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations received on 2025-02-10 regarding resident call pendant operability, staff response times, facility temperature, cleanliness, food service protocols, mail delivery, and a questionable death.
Findings
The investigation found all allegations to be unsubstantiated or unfounded. Residents and staff interviews, facility observations, and record reviews confirmed that call pendant systems were operable, staff responded timely, the facility was clean and odor free, food service was adequate and sanitary, mail was delivered properly, and the questionable death was consistent with hospice care and properly handled.
Complaint Details
The complaint investigation was unsubstantiated or unfounded for all allegations including call pendant system operability, staff response times, facility temperature, cleanliness, food service, mail delivery, and questionable death. The complaint control number is 59-AS-20250210105545.
Report Facts
Response time range: 5
Response time range: 12
Facility capacity: 129
Resident census: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted complaint investigation |
| Laura Munoz | Licensing Program Manager | Conducted complaint investigation |
| Chad Rogers | Administrator | Facility administrator met during investigation |
| W1 | 1:1 aide | Present at time of resident R1's death |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 129
Deficiencies: 0
Jan 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that residents contracted an illness of unknown origin while in care.
Findings
The investigation found that the facility experienced a stomach bug/flu outbreak lasting 24-48 hours, not an unknown illness. The facility followed universal precautions, conducted staff in-service on handwashing, encouraged residents to stay in their rooms, and managed symptomatic staff appropriately. The allegation was determined to be unfounded.
Complaint Details
The complaint alleged residents contracted illness of unknown origin. The investigation found the allegation to be unfounded based on interviews with eight staff and six residents, document review, and observation of infection control measures.
Report Facts
Staff interviewed: 8
Residents interviewed: 6
Complaint control number: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Chad Rogers | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 129
Deficiencies: 0
Jan 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations of staff financially abusing a resident and not ensuring residents were properly fed.
Findings
The investigation found no evidence of financial abuse by staff and confirmed that residents were properly fed with adequate food supply and meal provision. Both allegations were determined to be unfounded.
Complaint Details
The complaint investigation was triggered by allegations of financial abuse and improper feeding of residents. After interviews with eight staff and six residents and document review, the allegations were found to be unfounded.
Report Facts
Staff interviewed: 8
Residents interviewed: 6
Food supply days: 2
Food supply days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on report |
| Chad Rogers | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Nov 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of medication errors and staff not following universal precautions.
Findings
The investigation found the medication error allegation unsubstantiated due to insufficient evidence and proper medication administration documentation. The allegation regarding staff not following universal precautions was found to be unfounded, with evidence showing proper infection control measures and staff compliance.
Complaint Details
The complaint investigation was unsubstantiated for medication errors, meaning there was not enough evidence to prove the alleged violation occurred. The allegation regarding universal precautions was unfounded, indicating the allegation was false or without reasonable basis.
Report Facts
Complaint Control Number: 59
Staff Interviews: 8
Resident Interviews: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lydia Gravelyn | Administrator | Facility administrator met during the investigation |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Nov 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not ensuring residents' hygiene needs were met and that the facility was not sanitary.
Findings
The investigation found both allegations to be unfounded. Staff interviews and resident interviews confirmed that hygiene needs and toileting assistance were adequately provided, and the facility was observed to be clean and sanitary with no issues noted.
Complaint Details
The complaint alleged that staff were not ensuring residents' hygiene needs were met and that the facility was not sanitary. After interviews with eight staff and six residents, and observations by the department, both allegations were found to be unfounded.
Report Facts
Staff interviews: 8
Resident interviews: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lydia Gravelyn | Administrator | Facility administrator met during the investigation |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Nov 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of staff mismanaging a resident's medication.
Findings
The investigation found insufficient evidence to substantiate the allegation of medication errors. Documentation and interviews with staff and residents indicated that medications were administered and logged correctly, and no concerns were reported.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Report Facts
Staff interviews: 8
Resident interviews: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lydia Gravelyn | Administrator | Met with investigator during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Nov 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-09-17 regarding facility maintenance, odor, and adequacy of resident care and supervision.
Findings
The investigation found the allegations to be unfounded based on staff and resident interviews and department observations, concluding the facility was clean, odor-free, and residents received adequate care and supervision.
Complaint Details
The complaint included allegations that staff did not properly maintain the facility, did not keep the facility free from odor, and did not provide adequate care and supervision to a resident. The investigation determined all allegations to be unfounded.
Report Facts
Staff interviews: 8
Resident interviews: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lydia Gravelyn | Administrator | Facility administrator met during the investigation |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Nov 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-10-03 regarding cleanliness, food service adequacy, and COVID precaution adherence at the facility.
Findings
The investigation found all allegations to be unfounded after interviews with staff and residents, observations, and document reviews. The facility was observed to be clean and sanitary, food service was adequate and nutritious, and COVID precautions were properly followed.
Complaint Details
The complaint included allegations that staff did not keep the facility clean or sanitary, did not provide adequate food service, and were not following precautions to mitigate the spread of COVID. All allegations were found to be unfounded.
Report Facts
Staff interviews: 6
Resident interviews: 5
Facility capacity: 129
Facility census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lydia Gravelyn | Administrator | Facility administrator met during investigation |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Nov 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not preventing a resident from being abused by another resident while in care.
Findings
The investigation found that the residents involved are independent and do not want interference in their personal lives. Staff and residents reported no physical violence or abuse, and the allegation was determined to be unfounded.
Complaint Details
The complaint alleged that staff were not preventing a resident from being abused by another resident. The allegation was found to be unfounded based on interviews and documentation reviewed.
Report Facts
Complaint Control Number: 59
Capacity: 129
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lydia Gravelyn | Administrator | Met with the investigator during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Nov 26, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were financially abusing residents.
Findings
The investigation found the allegation to be unfounded after interviews with staff and residents and review of documentation. It was determined that the Resident Council, not staff, organizes a voluntary surprise fund for front-line workers during the winter holidays.
Complaint Details
The allegation of financial abuse by staff was investigated and found to be unfounded based on interviews and documentation.
Report Facts
Capacity: 129
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lydia Gravelyn | Administrator | Met with the investigator during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Sep 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-06-03 regarding staff sleeping during evening hours, leaving residents soiled, and leaving residents unattended.
Findings
The investigation found all allegations to be unfounded. Although one staff member was sleeping during the evening shift, sufficient awake staff were present as required by regulation. Care plans were followed, and staff provided appropriate assistance to residents, including toileting every two hours or as needed.
Complaint Details
The complaint allegations included staff sleeping during evening hours, leaving residents soiled, and leaving residents unattended. All allegations were determined to be unfounded based on interviews and record reviews.
Report Facts
Staff interviews: 11
Facility capacity: 129
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Jimmy Duong | Regional Nurse | Met with during the investigation |
| Lydia Gravelyn | Administrator | Facility administrator named in report |
Inspection Report
Annual Inspection
Census: 88
Capacity: 129
Deficiencies: 0
Jul 1, 2024
Visit Reason
The visit was an unannounced required annual inspection conducted to evaluate compliance with regulatory standards and ensure the health and safety of residents.
Findings
The facility was found to be clean, well organized, and compliant with all required paperwork, staff training, fire drills, and safety measures. No health or safety violations were observed during the inspection.
Report Facts
Resident files reviewed: 8
Staff files reviewed: 6
Perishable food supply days: 2
Non-perishable food supply days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Lydia Gravelyn | Administrator | Facility administrator who accompanied the analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 129
Deficiencies: 0
Jun 3, 2024
Visit Reason
The visit was an unannounced case management inspection following up on an incident report regarding a resident choking during dinner on 2024-05-18.
Findings
The department reviewed the incident where staff performed the Heimlich maneuver and chest compressions on the resident, who subsequently passed away. All requested documents were received, and no citations were issued per Title 22 Regulations.
Complaint Details
The visit was triggered by an incident report of a resident choking and subsequent death. The case is under review and no citations were issued at this time.
Report Facts
Facility capacity: 129
Resident census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Health Services Director | Met with Licensing Program Analyst during the inspection |
| Lavinia Muscan | Licensing Program Analyst | Conducted the case management visit |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 129
Deficiencies: 0
May 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-14 regarding staff response to residents' call buttons, nighttime supervision, and toileting needs.
Findings
The investigation found no evidence to substantiate the allegations. Staff were observed and interviewed, and records reviewed, showing timely response to call buttons, adequate nighttime supervision, and appropriate assistance with toileting needs. All allegations were determined to be unsubstantiated or unfounded.
Complaint Details
The complaint involved allegations that staff did not respond to residents' call buttons in a timely manner, did not ensure adequate nighttime supervision, and did not meet residents' toileting needs. After investigation including interviews and record reviews, all allegations were found to be unsubstantiated or unfounded.
Report Facts
Capacity: 129
Census: 91
Staff interviews: 9
Resident interviews: 5
Visit start time: 1245
Visit end time: 1330
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation |
| Lydia Gravelyn | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 129
Deficiencies: 0
Nov 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-09-22 regarding medication record maintenance, timely treatment, care plan adherence, overcharging, and communication with residents' responsible parties.
Findings
The investigation found all allegations to be either unsubstantiated or unfounded. Medication records were properly maintained, treatment was timely, care plans were followed, no overcharging occurred, and effective communication with residents' responsible parties was ensured.
Complaint Details
The complaint investigation was unsubstantiated for the allegation that staff did not properly maintain medication records. Other allegations including failure to seek timely treatment, failure to follow care plans, overcharging, and ineffective communication were found to be unfounded.
Report Facts
Capacity: 129
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lydia Gravelyn | Administrator | Facility administrator met during investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 129
Deficiencies: 0
Oct 30, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations regarding staff not dispensing medication as prescribed and various care deficiencies.
Findings
The investigation found insufficient evidence to substantiate the medication allegation, and all other allegations related to diet, care plans, supervision, call systems, hygiene, dental care, bathroom cleanliness, toileting, and laundering were determined to be unfounded based on interviews, observations, and documentation review.
Complaint Details
The complaint involved multiple allegations including failure to dispense medication as prescribed, failure to follow diabetic diet and care plans, inadequate supervision, lack of call assistance, and unmet hygiene, dental, bathroom, toileting, and laundering needs. The medication allegation was unsubstantiated, and all other allegations were unfounded.
Report Facts
Capacity: 129
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lydia Gravelyn | Administrator | Facility administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 129
Deficiencies: 0
Oct 11, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff gave a resident another resident's medication.
Findings
The investigation found that the medication was incorrectly labeled by the pharmacy and administered to the wrong resident for four days. The facility ceased administration upon discovery, notified the physician, and the resident experienced no side effects. The allegation was determined to be unfounded.
Complaint Details
The complaint alleged that staff gave a resident another resident's medication. The investigation concluded the allegation was unfounded due to pharmacy labeling error and no harm to the resident.
Report Facts
Days medication administered: 4
Facility capacity: 129
Facility census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Lydia Gravelyn | Administrator | Facility administrator met during the investigation and involved in the findings. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 129
Deficiencies: 0
Oct 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-07-10 regarding resident care issues including soiled diapers, lack of showers, and delayed response to call bells.
Findings
The investigation included interviews with staff and residents, record reviews, and facility observations. All allegations were found to be unfounded, meaning the complaints were false or without reasonable basis.
Complaint Details
The complaint included three allegations: residents left in soiled diapers for extended periods, staff not providing showers, and staff not responding to call bells timely. After investigation, all allegations were determined to be unfounded.
Report Facts
Capacity: 129
Census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Lydia Gravelyn | Administrator | Facility administrator met during investigation |
Inspection Report
Annual Inspection
Census: 75
Capacity: 129
Deficiencies: 0
Jul 18, 2023
Visit Reason
The inspection was conducted as the required annual unannounced inspection to evaluate compliance with regulatory standards.
Findings
The facility was found to be clean, well organized, and compliant with health and safety regulations. All resident and staff files contained the required paperwork, staff had current first aid and CPR training, and no health or safety violations were observed during the tour.
Report Facts
Resident files reviewed: 8
Staff files reviewed: 8
Perishable food supply duration (days): 2
Non-perishable food supply duration (days): 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Lydia Gravelyn | Administrator | Met with Licensing Program Analyst during inspection and toured the facility |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 1
Dec 28, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to a complaint received on 10/12/2022 regarding the facility not reimbursing or replacing stolen or lost resident property at its current value.
Findings
The investigation substantiated the allegation that the facility had not reimbursed or replaced stolen or lost resident property at its current value. However, the facility provided a refund in the form of one-month free rent valued at $8,793.00 as of 11/10/2022, resolving the issue without citation.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The facility resolved the issue by providing a refund in the form of one-month free rent at $8,793.00. No citation was issued.
Deficiencies (1)
| Description |
|---|
| Facility has not reimbursed resident or replaced stolen or lost resident property at its current value. |
Report Facts
Refund amount: 8793
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Carmen Calvillo | Administrator | Facility Administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 129
Deficiencies: 1
Aug 11, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff were not adhering to the resident's care plan and not assisting residents with activities of daily living (ADLs).
Findings
The investigation substantiated that the facility did not meet resident R1's needs from August 2021 through March 2022 due to an incorrect assessment at admission. The facility conducted a reassessment in March 2022 and is currently meeting R1's needs.
Complaint Details
The complaint was substantiated based on evidence that the facility failed to meet resident R1's needs between August 2021 and March 2022 due to an incorrect needs assessment at admission. The facility has since reassessed and corrected the service plan.
Deficiencies (1)
| Description |
|---|
| Failure to timely safeguard confidentiality of resident records and reveal confidential information only with resident's written consent or designated representative's consent. |
Report Facts
Capacity: 129
Census: 80
Deficiency Type: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DeAnna Williams-Lyons | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Laura Munoz | Licensing Program Manager | Named in relation to the investigation and report |
| Kathleen Olson | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 80
Capacity: 129
Deficiencies: 0
Aug 11, 2022
Visit Reason
The visit was an unannounced required 1 year Annual Inspection conducted by the Licensing Program Analyst.
Findings
No deficiencies were observed or cited during the visit. The facility was found to be in compliance with California Code of Regulations, Title 22, and the fire extinguisher and fire code inspection were up to date and compliant.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Olson | Executive Director | Met with Licensing Program Analyst during the inspection and involved in completing the Infectious Control Questionnaire. |
| DeAnna Williams-Lyons | Licensing Program Analyst | Conducted the annual inspection and completed Covid-19 protocols and facility risk assessment. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 129
Deficiencies: 1
Aug 11, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including medication administration errors and failure to release medical records upon request.
Findings
The complaint regarding medication administration errors was substantiated based on record review showing one medication administered at incorrect times and misclassification of medication orders. The facility conducted an internal audit and is currently administering medications as prescribed.
Complaint Details
The complaint was substantiated based on evidence that facility staff made medication administration errors with resident R1's medications. The preponderance of evidence standard was met.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care: Failure to administer medication according to physician's directions and improper input of medication orders into the facility E-MAR system. | Type A |
Report Facts
Census: 80
Total Capacity: 129
Days medication administered incorrectly: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DeAnna Williams-Lyons | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
| Kathleen Olson | Executive Director | Met with Licensing Program Analyst during investigation |
| Heather Younan | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 0
Mar 4, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not allowing family member visitation.
Findings
The investigation found the allegation to be unfounded. The facility was following the strictest guidelines set by local public health authorities regarding visitation restrictions due to a COVID-19 outbreak.
Complaint Details
The complaint alleged that facility staff were not allowing family member visitation. The allegation was found to be unfounded after interviews and record reviews, confirming the facility was complying with local public health directives to restrict visitation in portions of the facility during a COVID-19 outbreak.
Report Facts
Capacity: 129
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephen W MacDonald | Administrator | Met with Licensing Program Analyst during the investigation and exit interview |
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 129
Deficiencies: 0
Feb 17, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff did not keep a resident's medical condition confidential.
Findings
The investigation found that a resident overheard staff discussing her medical condition outside her apartment door, but there was no evidence that unauthorized persons overheard the conversation. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint was unsubstantiated. Although the allegation may have happened or is valid, there was not enough evidence to prove the violation occurred.
Report Facts
Complaint Control Number: 25
Capacity: 129
Census: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Stephen MacDonald | Met with during the investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 129
Deficiencies: 1
Feb 17, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff did not follow doctor's orders.
Findings
The facility admitted to failing to follow medical doctor orders, resulting in a treatment delay of approximately two weeks for a resident. The allegation was substantiated based on witness statements and evidence.
Complaint Details
The complaint was substantiated. Facility staff did not follow doctor's orders, causing a treatment delay of approximately two weeks for a resident's medical condition.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement a plan for incidental medical and dental care, resulting in failure to follow MD orders and a two-week treatment delay, posing an immediate health and safety risk to residents. | Type A |
Report Facts
Capacity: 129
Census: 91
Deficiencies cited: 1
Plan of Correction due date: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Stephen MacDonald | Met with the investigator during the unannounced complaint visit |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 129
Deficiencies: 0
Feb 14, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2021-12-01 regarding staff mismanaging and inappropriately logging resident medication.
Findings
The investigation found no conclusive evidence to support the allegations. The facility's medication administration records were reviewed and appeared to be in order, resulting in the allegations being unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on investigation, documentation, and witness statements. Although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violation occurred.
Report Facts
Complaint Control Number: 25-AS-20211201151231
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Conducted the complaint investigation and signed the report. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Stephen MacDonald | Met with the investigator during the complaint visit. |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 129
Deficiencies: 0
Jan 12, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2020-12-09 regarding staff not responding to resident call lights timely, residents not fed timely, poor food quality, and unmet hygiene needs.
Findings
The investigation found no witnesses or evidence to substantiate the allegations. The complaint was determined to be unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.
Complaint Details
The complaint was unsubstantiated due to lack of witnesses and evidence to confirm or deny the allegations related to staff response times, feeding, food quality, and hygiene.
Report Facts
Facility capacity: 129
Census: 129
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Smith | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Heather Younan | Administrator | Facility administrator named in report header |
| Stephen MacDonald | Met with during the investigation | |
| Laura Munoz | Licensing Program Manager | Named in report |
Inspection Report
Monitoring
Census: 90
Capacity: 129
Deficiencies: 0
Dec 17, 2021
Visit Reason
Case management visit to review documents from a previous complaint, including admission agreement documents, unusual incident reports, and LIC 9060s.
Findings
The licensing program analyst received, reviewed, and retained copies of the requested documents related to a prior complaint.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephen W MacDonald | Administrator | Facility administrator met during the visit. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager overseeing the visit. |
| Michael Smith | Licensing Program Analyst | Licensing Program Analyst who received and reviewed documents. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 129
Deficiencies: 1
Nov 29, 2021
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations that the facility was not safeguarding residents' personal property, following multiple reported thefts.
Findings
The allegation that the facility failed to safeguard residents' personal property was substantiated based on numerous documented thefts from resident rooms over the past four months, including a police report for theft/burglary. The licensee did not take necessary steps to prevent continued thefts, posing a potential health and safety risk.
Complaint Details
The complaint was substantiated. The allegation was that the facility was not safeguarding resident's personal property, supported by multiple theft reports and a police report. The preponderance of evidence standard was met.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87218-Theft and Loss-A licensee who fails to make reasonable efforts to safeguard resident property shall reimburse or replace stolen or lost resident property at its current value. Licensee did not take necessary steps to alleviate continued thefts, violating this section and posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 129
Census: 89
Deficiency count: 1
Plan of Correction due date: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Laura Munoz | Licensing Program Manager | Named in relation to the licensing program and report |
Inspection Report
Plan of Correction
Census: 93
Capacity: 129
Deficiencies: 1
Oct 19, 2021
Visit Reason
Plan of correction visit to clear the deficiency from the 10/11/21 complaint visit. The plan of correction was due on 10/18/21 but had not been submitted as of 10/19/21.
Findings
The plan of correction had not been submitted for review and clearance by the due date. A civil penalty of $100 was issued and will accrue at $100 per day until the deficiency is corrected.
Complaint Details
This visit was a follow-up to a complaint visit dated 10/11/21. The deficiency from that complaint was not corrected as the plan of correction was not submitted by the due date.
Deficiencies (1)
| Description |
|---|
| Failure to submit plan of correction by due date for deficiency from 10/11/21 complaint visit. |
Report Facts
Civil penalty amount: 100
Civil penalty daily accrual: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephen MacDonald | Met with during the inspection visit |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 129
Deficiencies: 2
Oct 11, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that facility staff did not safeguard a resident's property and did not clean/sanitize a resident's room.
Findings
The investigation substantiated the allegations that facility staff failed to safeguard a resident's wheelchair, which was missing, and did not properly clean/sanitize the resident's room, as evidenced by photographic documentation.
Complaint Details
The complaint was substantiated based on evidence including a missing wheelchair and photographic evidence of unsanitary conditions in a resident's room.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not safeguard resident's wheelchair which was missing and its location unknown. | Type B |
| Facility did not maintain resident's room in a clean and sanitary manner, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 129
Census: 92
Deficiency due date: 15
Deficiency due date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Laura Munoz | Licensing Program Manager | Named in relation to the complaint investigation report |
| Stephen MacDonald | Met with during the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 129
Deficiencies: 1
Oct 5, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that a resident was not receiving the proper care needed.
Findings
The allegation was substantiated based on photographic evidence, medical documentation, and witness testimony showing uncut toenails and unbrushed teeth on a resident, indicating lack of routine hygienic care.
Complaint Details
The complaint was substantiated based on evidence including photographic and medical documentation and witness testimony. The allegation that the resident was not receiving proper care was found valid.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to regularly observe residents for changes in physical, mental, emotional, and social functioning, resulting in neglect of resident's teeth and toenails over a period of time. | Type B |
Report Facts
Capacity: 129
Census: 92
Deficiencies cited: 1
Plan of Correction Due Date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Conducted the complaint investigation and cited deficiencies |
| Laura Munoz | Licensing Program Manager | Named in relation to deficiency citation and report |
Inspection Report
Annual Inspection
Census: 96
Capacity: 129
Deficiencies: 0
Sep 13, 2021
Visit Reason
Unannounced annual visit utilizing the infection control domain was performed to evaluate compliance and staff background clearances.
Findings
No deficiencies were found during the inspection; however, 2 technical violations were issued.
Report Facts
Technical violations issued: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Performed the infection control domain inspection |
| Stephen MacDonald | Facility contact during the inspection | |
| Laura Munoz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 129
Deficiencies: 2
Jul 30, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to complaints received on 12/14/2020 regarding resident dehydration and visitation restrictions.
Findings
The investigation substantiated that the resident was severely dehydrated while in care and that the facility restricted visitation improperly. Other allegations including failure to follow care plan for feeding and hydration, retaining resident beyond level of care, falsifying resident's name, chemical restraint, and failure to follow mandated reporter requirements were found unsubstantiated.
Complaint Details
Complaint was substantiated for allegations of severe dehydration and visitation restrictions. Other allegations including failure to follow care plan, retaining resident beyond level of care, falsifying resident's name, chemical restraint, and failure to follow mandated reporter requirements were unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure that resident's hydration needs were met, resulting in multiple hospitalizations for dehydration and IV fluid treatment. | Type A |
| Licensee did not ensure resident's visitors were allowed without prior approval from resident's POA, who lacked legal authority to restrict visitation. | Type B |
Report Facts
Capacity: 129
Census: 93
Deficiencies cited: 2
Plan of Correction Due Date: Aug 13, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation |
| Stephen MacDonald | Executive Director | Facility representative met during inspection |
| Heather Younan | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 129
Deficiencies: 1
May 14, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including inadequate medication management, resident neglect resulting in a pressure injury, and residents not getting their needs met.
Findings
The investigation substantiated the allegation of inadequate medication management due to staff failing to provide medications timely, resulting in termination of the responsible staff. The allegation of resident neglect causing a pressure injury was unsubstantiated, and the allegation that residents were not getting their needs met was found to be unfounded.
Complaint Details
The complaint investigation was substantiated for medication management inadequacies, unsubstantiated for neglect resulting in pressure injury, and unfounded for residents not getting their needs met.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement a plan for incidental medical and dental care, including assisting residents with self-administered medications as needed. | Type A |
Report Facts
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Lusby | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Heather Younan | Administrator | Facility administrator named in the report |
Inspection Report
Census: 82
Capacity: 129
Deficiencies: 1
Feb 24, 2021
Visit Reason
Case management visit regarding the review of the facility Disaster Plan - LIC 610E and the facility Disaster and Emergency Manual.
Findings
The facility is in compliance with Title 22, Section 87212 Emergency Disaster Plan. However, a staff member was observed wearing a mask improperly, constituting a technical violation.
Deficiencies (1)
| Description |
|---|
| Staff member observed with mask under chin exposing nose and mouth. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aseem Sidhu | Observed wearing mask improperly in the lobby area. |
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