Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, including the most recent one on November 14, 2024, which found no issues with medical care, staffing, or fees. The facility had isolated deficiencies in the past, such as incomplete resident physician reports noted on August 28, 2023, and a failure to reappraise a resident’s wound in late 2022, both considered risks but without enforcement actions or fines listed. Earlier annual inspections and complaint investigations consistently showed compliance with infection control, safety, and care standards. The overall trend suggests improvement, with the latest reports showing no deficiencies after previous isolated issues. There were no license suspensions, fines, or severe enforcement actions reported in the available records.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 135
Capacity: 160
Deficiencies: 0
Nov 14, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations including staff not seeking timely medical care for a resident, the facility not meeting residents' needs timely, inadequate staffing, and charging extra fees not on the care plan.
Findings
The investigation included interviews, record reviews, and physical inspection. The allegations were found to be unsubstantiated based on evidence obtained from interviews and records. Staff responded appropriately to medical needs, call buttons were answered timely, staffing was adequate, and fee changes were communicated with the family.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to seek timely medical care, unmet resident needs, inadequate staffing, and unauthorized extra fees. Interviews and record reviews did not support these claims.
Report Facts
Capacity: 160
Census: 135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Brennan | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| John Rante | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 160
Deficiencies: 0
Oct 31, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 12/20/2021 regarding staff neglect, resident hygiene, and failure to follow a resident's care plan.
Findings
The investigation found no corroborating evidence to substantiate the allegations of staff neglect, residents being left soiled for extended periods, or failure to follow the resident's care plan. Interviews and record reviews indicated that care was provided according to updated plans and frequent checks were conducted.
Complaint Details
The complaint alleged staff neglect resulting in hospitalization, residents left soiled for extended periods, and failure to follow a resident's needs and services plan. The investigation concluded these allegations were unsubstantiated due to lack of corroborating evidence.
Report Facts
Complaint Control Number: 08-AS-20211220132223
Number of reassessments: 3
Response time to pendent calls: 5
Check frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation |
| John Brennan | Executive Director | Facility representative met during investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 131
Capacity: 160
Deficiencies: 0
Aug 23, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with regulatory requirements.
Findings
The facility was found to be clean, well-maintained, and in good repair with no deficiencies observed. All reviewed client and employee records met requirements, and safety and infection control measures were adequate.
Report Facts
Fire extinguishers on site: 22
Fire extinguisher last charged date: Oct 5, 2023
Client records reviewed: 5
Employee records reviewed: 5
Food supply duration: 7
Food supply duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Brennan | Executive Director | Met with during inspection and named in report |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the inspection |
| Jazmond D Harris | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 138
Capacity: 160
Deficiencies: 1
Aug 28, 2023
Visit Reason
The visit was an unannounced annual inspection to ensure the facility is following California Code of Regulations, Title 22, Division 6.
Findings
The facility generally met operational, infection control, and environmental safety requirements. However, a deficiency was cited due to 7 out of 10 resident physician reports being incomplete or missing, posing an immediate health, safety, or personal rights risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 7 out of 10 resident physician reports were not current, failing to meet medical assessment requirements. | Type A |
Report Facts
Staff count: 25
Resident records reviewed: 10
Deficient resident records: 7
Food supply: 7
Food supply: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Salvador Jimenez | Director | Met with Licensing Program Analyst during inspection and signed receipt of appeal rights |
| Cheryl Goodrich | Licensing Program Analyst | Conducted the inspection and signed the report |
| Jazmond D Harris | Licensing Program Manager | Supervisor overseeing the inspection |
| Sal Hernandez | Director | Named in plan of correction to complete annual physician reports |
Inspection Report
Follow-Up
Census: 120
Capacity: 160
Deficiencies: 1
Nov 2, 2022
Visit Reason
The visit was an unannounced follow-up on an incident report received on 2022-10-31 concerning Resident #1, to review the incident and assess the facility's response.
Findings
The facility failed to reappraise the resident for a change in condition related to an unstageable wound, which was not documented or reported prior to 2022-10-13. The resident was transferred to the hospital on 2022-10-25 and later appraised for hospice services. This failure poses an immediate health, safety, or personal rights risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate reappraisal for the resident resulting in an unstageable wound. | Type A |
Report Facts
Capacity: 160
Census: 120
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Brennan | Executive Director | Met with Licensing Program Analyst during the visit and named in findings |
| Janira Arreola | Licensing Program Analyst | Conducted the unannounced visit and authored the report |
| Joel Esquivel | Licensing Program Manager | Named as Licensing Program Manager overseeing the evaluation |
Inspection Report
Annual Inspection
Census: 113
Capacity: 160
Deficiencies: 0
Aug 30, 2022
Visit Reason
Licensing Program Analyst Chinwe Nwogene made an unannounced visit to conduct an annual inspection focused on infection control.
Findings
The facility had no positive or suspected COVID-19 cases, adequate infection control measures including hand hygiene supplies, PPE, and cleaning protocols were observed. No deficiencies were noted at the time of the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Briana Espinoza | Health Services Director | Met with Licensing Program Analyst during inspection and provided information on infection control. |
Inspection Report
Census: 111
Capacity: 160
Deficiencies: 0
Dec 2, 2021
Visit Reason
The visit was an unannounced Case Management Visit in response to the self-reported death of a resident at the facility.
Findings
No health or safety issues were identified during the wellness check, and no deficiencies were cited or observed on this date.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Brennan | Executive Director | Met with Licensing Program Manager and Analyst during the visit. |
Inspection Report
Original Licensing
Census: 103
Capacity: 160
Deficiencies: 0
Aug 10, 2021
Visit Reason
The inspection was conducted as an announced Pre-Licensing and Component III inspection to evaluate the facility for compliance with California regulations as part of a change of ownership application.
Findings
The facility was found to be in compliance with all applicable regulations, including resident accommodations, medication storage, food service, safety equipment, and physical environment. No deficiencies were observed during the visit.
Report Facts
Non-perishable food supply days: 7
Perishable food supply days: 2
Water temperature degrees Fahrenheit: 109
Water temperature degrees Fahrenheit: 111
Water temperature degrees Fahrenheit: 115.4
Facility ambient room temperature degrees Fahrenheit: 75
Facility capacity: 160
Facility census: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hamer | Licensing Program Analyst | Conducted the pre-licensing inspection and Component III evaluation |
| Angela Scott-Kapiloff | Administrator | Facility administrator who met with the Licensing Program Analyst during the inspection |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report |
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