Inspection Report Summary
Most inspections found deficiencies related primarily to medication management, resident supervision, and storage of hazardous items, with several complaint investigations unsubstantiated. The facility received citations for failing to prevent resident wandering, incomplete medication documentation, and improper medication and supply storage, including incidents posing immediate health and safety risks. Some deficiencies involved failure to update resident assessments after hospital returns and incomplete incident reporting. The most recent report from July 1, 2025, was a complaint investigation with no deficiencies found, indicating some improvement in compliance. Fines or license suspensions were not listed in the available reports.
Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 85
Capacity: 122
Deficiencies: 0
Jul 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that the facility did not ensure physician ordered diets and restrictions were followed, and that the facility did not prevent a resident from wandering away unassisted.
Findings
Both allegations were investigated through staff interviews, record reviews, and observations. The allegation regarding physician ordered diets was found to be unsubstantiated, and the allegation regarding resident wandering was found to be unfounded. No citations were issued.
Complaint Details
The complaint investigation addressed two allegations: 1) Facility does not ensure physician ordered diets and restrictions were followed, which was found unsubstantiated; 2) Facility did not prevent a resident from wandering away unassisted, which was found unfounded.
Report Facts
Capacity: 122
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Heidi Setty | Administrator | Spoke with Licensing Program Analyst during the investigation |
| Mary Davis | Marketing Director | Met with Licensing Program Analyst and was informed of the investigation reason and findings |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 84
Capacity: 122
Deficiencies: 3
May 6, 2025
Visit Reason
The inspection was an unannounced annual/random visit conducted to evaluate compliance with licensing requirements, including a tour of Memory Care, resident and staff file reviews, medication audit, and review of emergency and infection control procedures.
Findings
The facility was found generally clean and in good repair with required equipment and supplies. However, deficiencies were cited related to medication storage and documentation practices, with some deficiencies amended or dismissed during the visit. Plans of Correction were developed and submitted.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Gummy vitamins and medicated creams were stored in a resident's bathroom cabinet posing a potential hazard; medications were removed during the visit. | Type B |
| Failure to maintain accurate records of PRN medication administration for a resident; documentation was incomplete for doses given. | Type B |
| Medical assessment did not include determination of ambulatory status as required; this deficiency was dismissed. | Type B |
Report Facts
Census: 84
Total Capacity: 122
Deficiencies cited: 3
PRN medication doses given: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Heidi Setty | Administrator | Facility administrator present during inspection and exit interview |
| Nathaniel Domingez | Licensed Vocational Nurse (LVN) | Met with Licensing Program Analyst during inspection |
| Andrea Yescas | Memory Care Director (MCD) | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 86
Capacity: 122
Deficiencies: 0
Apr 29, 2025
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct the Annual Inspection of the facility.
Findings
The facility was found to have clean and well-maintained resident apartments and common areas, proper storage of supplies, functioning safety equipment, and a clean kitchen. Due to time constraints, the inspection was not completed and a return visit is required.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Setty | Administrator | Met with Licensing Program Analyst during the inspection. |
| Nathaniel Domingez | Health Services Director (LVN) | Met with Licensing Program Analyst during the inspection. |
| Andrea Yescas | Memory Care Director | Met with Licensing Program Analyst during the inspection. |
| Katie Brown | Licensing Program Analyst | Conducted the Annual Inspection. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 122
Deficiencies: 0
Feb 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff left a resident in soiled undergarments for an extended period and did not ensure the resident's grooming needs were met.
Findings
The investigation found the allegations to be unfounded based on observations, record reviews, and interviews. The resident was independent in toileting and grooming needs were met, with no citations issued.
Complaint Details
The complaint was investigated and found to be unfounded. Allegations included staff leaving a resident in soiled undergarments and not ensuring grooming needs were met. The resident was observed to be well groomed and independent in toileting, often refusing assistance.
Report Facts
Facility capacity: 122
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Heidi Setty | Administrator | Facility administrator met during investigation and received report |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 122
Deficiencies: 1
Sep 25, 2024
Visit Reason
The visit was a Case Management visit conducted in conjunction with an initial complaint visit to evaluate compliance and address concerns.
Findings
During the visit, a disposable razor was found stored in an unlocked bathroom cabinet in Memory Care resident apartments, which was immediately removed. A deficiency was cited related to the care of persons with dementia.
Complaint Details
The visit was triggered by an initial complaint and conducted as a complaint investigation. The deficiency cited is under appeal.
Deficiencies (1)
| Description |
|---|
| Disposable razor stored in an unlocked bathroom cabinet in Memory Care area. |
Report Facts
Facility capacity: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Setty | Administrator | Met during the visit and involved in the inspection |
| Andrea Yescas | Memory Care Director | Met during the visit and involved in the inspection; removed the razor |
| Katie Brown | Licensing Program Analyst | Conducted the Case Management and complaint visit |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the visit |
Inspection Report
Annual Inspection
Census: 85
Capacity: 122
Deficiencies: 3
Apr 16, 2024
Visit Reason
The visit was an unannounced annual inspection conducted by Licensing Program Analysts to evaluate compliance with regulatory requirements at the assisted living and memory care facility.
Findings
The facility was generally found to be in good repair with clean and properly equipped resident apartments and common areas. However, deficiencies were cited related to incidental medical and dental care, residents with special health needs, and storage space. Civil penalties were assessed for repeat violations.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to assist resident R5 with self-administered Spiriva Respimat inhaler; inhaler not located despite medication administration record indicating it should have been given. | Type A |
| Centrally stored medications were not kept in a safe and locked place; over-the-counter medications stored in resident apartments where residents with dementia reside. | Type A |
| Storage space violations including mold observed in ice machine, a chef's knife left unattended in dining prep area, and disinfecting supplies stored in bathroom cabinet of a resident with dementia. | Type B |
Report Facts
Capacity: 122
Census: 85
Deficiency count: 3
Fire detection system last serviced: Apr 11, 2024
Fire extinguishers last serviced: Jan 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Setty | Administrator | Met with Licensing Program Analysts during inspection and named in medication assistance deficiency |
| Katie Brown | Licensing Program Analyst | Conducted inspection and authored report |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor of licensing evaluation |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 122
Deficiencies: 3
Jan 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including resident falls due to staff neglect, failure to prevent resident wandering, and failure to report incidents.
Findings
The investigation substantiated that the facility failed to follow a resident's hospice care plan resulting in a fall, did not prevent a resident from wandering off the premises, and failed to report the fall to the licensing agency. Other allegations related to basic care and notification were unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for allegations that a resident fell due to staff neglect, the facility failed to prevent a resident from wandering off the premises, and the facility did not report a resident fall. Other allegations including questionable death, failure to notify authorized representatives timely, and failure to provide basic activities of daily living were unsubstantiated.
Severity Breakdown
Type A: 2
Deficiency Dismissed Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Licensee did not ensure R1's hospice care plan was implemented; R1 received a shower instead of a bed bath and sustained a fall during the shower. | Type A |
| Licensee did not ensure supervision of R2 who exited the Dementia wing and walked out of the facility. | Type A |
| Licensee did not ensure an Incident Report was submitted to CCLD when R1 fell and hit head while receiving a shower by the wrong hospice agency and facility staff member. | Deficiency Dismissed Type B |
Report Facts
Facility Capacity: 122
Census: 82
Plan of Correction Due Date: 2024
Plan of Correction Due Date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Setty | Administrator | Met with Licensing Program Analyst during complaint investigation and named in findings |
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 122
Deficiencies: 0
Dec 12, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-08-09 regarding allegations including lack of care and supervision, personal rights violations, failure to safeguard resident belongings, medication log issues, and food service requirements.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Observations, interviews, and record reviews indicated that resident care, medication documentation, and food service were appropriately managed. No citations were issued.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of care and supervision, personal rights violations, failure to safeguard resident belongings, failure to record medications in logs, and general food service concerns. Interviews and record reviews did not support these allegations.
Report Facts
Complaint received date: Aug 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Heidi Setty | Administrator | Facility Administrator met with during the investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 122
Deficiencies: 0
Dec 12, 2023
Visit Reason
The visit was an unannounced Case Management inspection conducted in conjunction with a complaint investigation (Control Number 24-AS-20230809115225).
Findings
During the visit, additional concerns related to a resident were reported and investigated through interviews and record review. No citations were issued as a result of this visit.
Complaint Details
The visit was triggered by a complaint (Control Number 24-AS-20230809115225). Additional concerns were reported during the investigation, but no citations were issued.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Setty | Administrator | Met with Licensing Program Analyst during the visit and signed the report. |
| Katie Brown | Licensing Program Analyst | Conducted the unannounced Case Management visit and complaint investigation. |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 122
Deficiencies: 0
Nov 16, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the licensee did not abide by the terms of a resident’s admission agreement.
Findings
The allegation was found to be unsubstantiated as there was not a preponderance of evidence to prove the alleged violation occurred. No citations were issued during the investigation.
Complaint Details
The complaint was unsubstantiated. The investigation included record review and interviews which revealed a discrepancy regarding notification of physician ordered lab work to the resident’s responsible party. Medication was ordered from the wrong pharmacy but this was not found to be a violation of the admission agreement.
Report Facts
Capacity: 122
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Heidi Setty | Administrator | Facility administrator interviewed during investigation |
| Nathaniel Dominguez | Health Services Director | Facility health services director interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 122
Deficiencies: 0
Nov 16, 2023
Visit Reason
Unannounced complaint investigation conducted in response to allegations including personal rights violations, lack of care and supervision, maintenance and operation violations, incidental medical/dental care violations, and training requirements.
Findings
The investigation found no substantiated evidence of the alleged violations. Resident observations, staff interviews, and record reviews indicated that the facility maintained cleanliness and appropriate care, with no citations issued.
Complaint Details
The complaint investigation was unsubstantiated. Although allegations may have occurred, there was insufficient evidence to prove violations. No citations were issued.
Report Facts
Capacity: 122
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Yescas | Memory Care Director | Met with Licensing Program Analyst during investigation |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 122
Deficiencies: 1
Nov 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-01 alleging staff mismanagement of resident's medications and inaccurate incident reporting.
Findings
The investigation substantiated the allegation that the Centrally Stored Medication and Destruction Record (CSMDR) for Resident 1 was not maintained accurately, resulting in inaccurate documentation and medication counts. Another allegation regarding inaccurate incident reporting was unsubstantiated. A deficiency was cited related to medication record-keeping.
Complaint Details
The complaint investigation was substantiated for the allegation that staff mismanaged resident's medications due to inaccurate medication records. The allegation that incidents were not reported accurately was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain an accurate and up-to-date Centrally Stored Medication and Destruction Record (CSMDR) for Resident 1, with missing received and start dates for multiple medications from April to August 2023. | Type B |
Report Facts
Capacity: 122
Census: 89
Deficiencies cited: 1
Plan of Correction Due Date: Nov 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw the complaint investigation |
| Mary Davis | Marketing Director | Met with Licensing Program Analyst during the visit and received report documents |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 122
Deficiencies: 0
Oct 16, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff do not provide adequate assistance to a resident in care and that a resident's room is malodorous.
Findings
The investigation found the resident's room and bathroom to be odor free, the resident was clean and resting comfortably, and staff interviews and documentation review did not substantiate the allegations. The complaint was determined to be unsubstantiated with no citations issued.
Complaint Details
The complaint was unsubstantiated as there was not a preponderance of evidence to prove that the alleged violations occurred.
Report Facts
Capacity: 122
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation visit |
| Heidi Setty | Administrator | Facility administrator met with the Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 122
Deficiencies: 0
Oct 16, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 06/30/2023 alleging insufficient staffing, unattended residents, unsafe environment, and malodor at the facility.
Findings
The investigation found the allegations to be unsubstantiated based on observations, interviews, and record reviews. Resident rooms were clean and odor free, staff and hospice nurse interviews were conducted, and no evidence supported the allegations.
Complaint Details
The complaint was unsubstantiated after investigation. Although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 122
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Heidi Setty | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 122
Deficiencies: 1
Oct 16, 2023
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted to follow up on an incident that occurred on 2023-10-12 involving resident R1 going absent without leave (AWOL) for approximately 13 minutes.
Findings
The inspection confirmed that the facility did not ensure adequate care and supervision for resident R1, who left the facility unassisted despite a physician's report stating R1 cannot leave unassisted due to a diagnosis of Dementia. A deficiency was cited related to this failure.
Complaint Details
The visit was complaint-related, following up on an incident where resident R1 went absent without leave. The incident was substantiated by the finding that the facility failed to provide required supervision.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure the care and supervision to R1. R1 AWOL the facility 10/12/23. R1's Physician's Report states R1 cannot leave the facility unassisted. R1 has diagnosis of Dementia. This poses a potential health and safety risk to residents in care. | Type B |
Report Facts
Census: 76
Total Capacity: 122
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Setty | Administrator | Met with Licensing Program Analyst during the visit and involved in the incident follow-up |
| Katie Brown | Licensing Program Analyst | Conducted the Case Management - Incident visit and evaluation |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 122
Deficiencies: 2
Sep 12, 2023
Visit Reason
The visit was an unannounced Health and Safety Inspection conducted in conjunction with a 10-Day complaint visit (Control Number 24-AS-20230911151045) to evaluate compliance and address complaint concerns.
Findings
The facility was generally clean and well-maintained with proper resident accommodations and safety measures observed. However, deficiencies were cited related to medication storage and accessibility of cleaning supplies posing immediate health and safety risks.
Complaint Details
The visit was triggered by a complaint (Control Number 24-AS-20230911151045). The deficiencies cited pose immediate health, safety, or personal rights risks to persons in care.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not ensure that medications were centrally stored and locked. Over the counter medications were observed accessible to residents R1 and R2. Required documentation and assessments were not maintained in resident files. | Type A |
| Licensee did not ensure that disinfectants, cleaning supplies, and poisons were inaccessible to residents in Memory Care. Cleaning supplies and laundry detergent were observed in room 116. | Type A |
Report Facts
Deficiencies cited: 2
Capacity: 122
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Yescas | Memory Care Director | Met with Licensing Program Analyst and received report and appeal rights |
| Katie Brown | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 77
Capacity: 122
Deficiencies: 0
Sep 12, 2023
Visit Reason
The visit was an unannounced Case Management - Incident follow-up to review an altercation between two residents reported on 09/04/2023.
Findings
During the visit, resident files were reviewed, assessments were in the process of being updated, and required notifications had been made. No citations were issued.
Complaint Details
The visit was triggered by a complaint involving an altercation between Residents R1 and R2. No citations were issued, and the complaint appears to have been addressed.
Report Facts
Capacity: 122
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Yescas | Memory Care Director | Met with Licensing Program Analyst during the visit |
| Katie Brown | Licensing Program Analyst | Conducted the unannounced Case Management - Incident follow-up visit |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 122
Deficiencies: 1
Aug 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-05-16 regarding the facility's failure to conduct an assessment of a resident prior to returning from the hospital with a change of condition.
Findings
The investigation found that the facility did not conduct an assessment or obtain updated documentation of the resident's changes in condition or care needs prior to the resident's return from the hospital. Allegations related to lack of supervision, failure to address multiple falls, signal system issues, and notification of the resident's authorized representative were unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for failure to conduct an assessment or obtain updated documentation for a resident returning from the hospital with a significant change in condition. Other allegations regarding supervision, fall prevention, signal system, and notification of responsible party were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to update pre-admission appraisal in writing to note significant changes in resident's physical, medical, illness, injury, trauma, or change in health care needs prior to resident's return from hospital. | Type B |
Report Facts
Capacity: 122
Census: 76
Deficiency count: 1
Plan of Correction Due Date: Sep 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Heidi Setty | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 122
Deficiencies: 1
Aug 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2023-05-16 regarding the facility's failure to conduct an assessment of a resident prior to returning from the hospital with a change of condition.
Findings
The investigation substantiated that the facility did not conduct an assessment or obtain updated documentation of the resident's changes in condition or care needs prior to the resident's return on 2023-05-06. Deficiencies were cited accordingly.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation involved failure to assess a resident after hospital discharge with a change in condition.
Deficiencies (1)
| Description |
|---|
| The facility did not conduct an assessment of resident prior to returning from the hospital with a change of condition |
Report Facts
Facility capacity: 122
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Heidi Setty | Administrator | Met with Licensing Program Analyst during exit interview |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 122
Deficiencies: 0
May 18, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 05/16/2023 regarding personal rights at the facility.
Findings
The investigation found insufficient information to substantiate the allegations at this time, and no citations were issued. Further investigation is needed.
Complaint Details
The complaint was unsubstantiated based on the investigation conducted by Licensing Program Analysts Katie Brown and Mariam Flores.
Report Facts
Capacity: 122
Census: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Mariam Flores | Licensing Program Analyst | Conducted the complaint investigation |
| Heidi Setty | Facility representative met during the investigation and received the report |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 122
Deficiencies: 0
May 18, 2023
Visit Reason
The visit was an unannounced Health & Safety Inspection conducted in conjunction with a 10-day initial complaint visit to evaluate the facility's compliance and resident safety.
Findings
The facility was found to be clean and well-maintained with no deficiencies cited during the Health & Safety Inspection. Required supplies, furniture, lighting, and safety equipment were observed to be in place and functional.
Complaint Details
The visit was conducted as part of a 10-day initial complaint investigation; no deficiencies were cited during the inspection.
Report Facts
Facility capacity: 122
Resident census: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Davis | Marketing Director | Met with Licensing Program Analysts during the inspection |
Inspection Report
Annual Inspection
Census: 80
Capacity: 122
Deficiencies: 1
May 1, 2023
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with regulatory requirements.
Findings
The facility was generally found to be in compliance with required standards including cleanliness, safety, and medication storage; however, a deficiency was cited related to medication administration where extra pills were found without documentation, posing an immediate health and safety risk.
Deficiencies (1)
| Description |
|---|
| Failure to comply with medication administration requirements as evidenced by extra pills found without documentation despite MAR indicating all meds were given on time. |
Report Facts
Deficiency due date: May 2, 2023
Audit percentage: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the annual inspection and cited the medication administration deficiency |
| Heidi Setty | Administrator | Met with Licensing Program Analyst during inspection and received report and appeal rights |
| Sergiy Pidgirny | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 80
Capacity: 122
Deficiencies: 0
Apr 26, 2022
Visit Reason
The inspection was an unannounced Annual Infection Control Inspection conducted to evaluate infection control procedures at the facility.
Findings
The inspection found that infection control procedures were properly implemented including symptom screenings, testing, vaccination, visitation requirements, quarantine/isolation procedures, PPE availability, and cleaning protocols. No deficiencies were cited during this inspection.
Report Facts
Administrator Certificate Expiration Date: Administrator Certificate expiration date is 7/29/2022
Forms Requested Due Date: Updated forms requested by 5/9/22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Annual Infection Control Inspection |
| Heidi Setty | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Capacity: 122
Deficiencies: 0
Apr 26, 2022
Visit Reason
The visit was an unannounced Case Management in conjunction with the Infection Control Annual, conducted to review an incident involving an altercation between two residents reported via a Special Incident Report.
Findings
No deficiencies were cited during this Case Management visit after interviews and file review were conducted.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and interview. |
| Heidi Setty | Administrator | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 122
Deficiencies: 0
Dec 17, 2021
Visit Reason
The visit was a Case Management follow-up on a Special Incident Report (SIR) submitted to the Community Care Licensing Division, related to an incident that occurred on 10/7/2021 involving resident R1.
Findings
The Licensing Program Analyst interviewed staff and reviewed facility documentation related to the incident. No deficiencies were cited during this unannounced visit.
Complaint Details
The visit was triggered by a complaint in the form of a Special Incident Report. The report indicates no deficiencies were cited, implying no substantiated violations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and interviews. |
| Anjeanette Franco | Health Services Director | Met with the Licensing Program Analyst and was involved in the visit. |
| Heidi Setty | Administrator | Arrived during the visit and participated in the exit interview. |
Inspection Report
Census: 71
Capacity: 122
Deficiencies: 0
Dec 17, 2021
Visit Reason
The visit was a Case Management follow-up on a Special Incident Report (SIR) submitted to the Community Care Licensing Division, related to an incident involving Resident R1 on 10/21/2021.
Findings
The Licensing Program Analyst interviewed staff and reviewed the resident's file. No deficiencies were cited during this unannounced visit.
Complaint Details
The visit was complaint-related as it followed up on a Special Incident Report involving Resident R1. No substantiation status was stated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and interviewed staff. |
| Anjeanette Franco | Health Services Director | Met with Licensing Program Analyst to discuss the purpose of the visit. |
| Heidi Setty | Administrator | Arrived during the visit and participated in the exit interview. |
Inspection Report
Follow-Up
Census: 71
Capacity: 122
Deficiencies: 0
Dec 17, 2021
Visit Reason
The visit was a Case Management follow-up to a Special Incident Report (SIR) submitted to the Community Care Licensing Division regarding an incident that occurred on 10/24/2021 involving a resident.
Findings
The Licensing Program Analyst conducted an unannounced visit, interviewed staff, and reviewed the resident's file. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and interview. |
| Anjeanette Franco | Health Services Director | Met with Licensing Program Analyst to discuss the visit. |
| Heidi Setty | Administrator | Arrived during the visit and participated in the exit interview. |
Inspection Report
Follow-Up
Census: 71
Capacity: 122
Deficiencies: 1
Dec 17, 2021
Visit Reason
The visit was an unannounced Case Management follow-up to review Special Incident Reports (SIR) submitted to the licensing agency on 10/15/21 and 11/5/21, which were not submitted within the required seven days following the occurrence.
Findings
The facility failed to submit complete Special Incident Reports to the licensing agency within seven days for incidents dated 11/12/21, 11/13/21, 11/15/21, 11/28/21, and 9/14/21, posing a potential health and safety risk to persons in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not submit complete Special Incident Reports to CCLD within 7 days for incidents dated 11/12/21, 11/13/21, 11/15/21, 11/28/21, and 9/14/21. | Type B |
Report Facts
Incident dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and signed the report |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager overseeing the visit |
| Anjeanette Franco | Health Services Director | Met with Licensing Program Analyst during the visit |
| Heidi Setty | Administrator | Arrived during the visit and participated in the exit interview |
Inspection Report
Monitoring
Census: 71
Capacity: 122
Deficiencies: 0
Dec 17, 2021
Visit Reason
The visit was a Case Management follow-up to a Special Incident Report (SIR) submitted to the Community Care Licensing Division, related to an incident on 2021-11-24 involving a resident.
Findings
The Licensing Program Analyst conducted an unannounced visit, interviewed staff, and reviewed the resident's file. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the Case Management visit and interview. |
| Anjeanette Franco | Health Services Director | Met with Licensing Program Analyst during the visit. |
| Heidi Setty | Administrator | Present during the visit and exit interview. |
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