Inspection Report Summary
Most inspections found no deficiencies, including the most recent report on October 24, 2025, which was clean and fully compliant with regulations. Earlier reports showed some deficiencies mainly related to resident supervision, personal rights violations, and failure to report incidents such as falls and weight changes to physicians or responsible parties. Several complaint investigations were substantiated, particularly involving inadequate supervision leading to resident falls and safety risks from accessible hazardous items, but many other complaints were unsubstantiated. The facility received a $500 fine in late 2022 for fall prevention failures, and a few minor penalties were issued for issues like missing Ombudsman contact information and documentation gaps. The trend shows improvement over time, with recent annual inspections consistently free of deficiencies and no enforcement actions reported in the latest visits.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 86
Capacity: 140
Deficiencies: 0
Oct 24, 2025
Visit Reason
The visit was an unannounced continuation of the annual inspection to ensure compliance with Title 22 regulations and to conduct a case management annual continuation inspection.
Findings
The facility was found to be in compliance with Title 22 regulations with no citations issued. The inspection included a physical plant tour, review of personnel and resident records, medication audit, infection control and emergency disaster planning review, staff and resident interviews, and review of maintenance and safety systems.
Report Facts
Number of smoke alarms and detectors tested: 337
Number of recorded alerts: 44
Staff response time range (minutes): 37
Number of medication audit residents: 9
Number of staff interviewed: 9
Number of residents interviewed: 11
Number of quarterly inspections reviewed: 3
Number of facility vehicles inspected: Daily vehicle inspections and annual inspection report reviewed
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailey Vanderwall | Executive Director | Met with Licensing Program Analyst during inspection and advised on medication audit findings |
| Erica Mosley | Licensing Program Analyst | Conducted the inspection, interviews, and audit |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 86
Capacity: 140
Deficiencies: 0
Oct 23, 2025
Visit Reason
The visit was an unannounced required annual inspection conducted by the Licensing Program Analyst to ensure compliance with Title 22 Regulations and assess the health and safety conditions of the facility.
Findings
The facility was found to be generally compliant with regulations, with no immediate health or safety hazards observed. The physical plant, resident bedrooms, restrooms, kitchen, and records were all in order. Fire extinguishers were charged and alarms functioned properly. The facility serves residents with dementia and includes memory care and assisted living units.
Report Facts
Number of resident bedrooms observed: 9
Number of personnel files reviewed: 10
Number of resident files reviewed: 9
Hot water temperature range (degrees Fahrenheit): 106.0-120.0
Fire extinguisher last service date: Feb 27, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailey Vanderwall | Executive Director | Met with Licensing Program Analyst during inspection |
| Erica Mosley | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 140
Deficiencies: 1
May 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident losing significant weight, contracting scabies, and developing sores while in care.
Findings
The allegation that a resident lost a significant amount of weight was substantiated due to insufficient documentation and communication with the resident's physician. The allegations that the resident contracted scabies and developed sores were unsubstantiated as the resident was treated and staff followed protocols. A deficiency was cited for failure to notify the physician about the resident's weight loss.
Complaint Details
The complaint investigation was substantiated for the allegation that the resident lost significant weight, with evidence showing a 13 lbs weight loss over 6 months and lack of physician notification. The allegations that the resident contracted scabies and developed sores were unsubstantiated after review of treatment and interviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to document and bring to the attention of the resident's physician and responsible person changes such as unusual weight gains or losses. | Type B |
Report Facts
Weight loss: 13
Weight loss: 6
Census: 90
Total Capacity: 140
Plan of Correction Due Date: Jun 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation |
| Ricardo Viveros | Business Office Director | Met with Licensing Program Analyst during the visit and involved in findings |
| Keiley Vanderwall | Executive Director | Facility administrator mentioned in interviews related to findings |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 140
Deficiencies: 0
Mar 20, 2025
Visit Reason
The inspection was conducted as a follow-up on a self-reported death report received on 03/11/2025 concerning the death of Resident #1, who was hospitalized after a fall on February 23 and passed away on March 8.
Findings
The Licensing Program Analyst conducted interviews with the Executive Director, Health Service Director, and one resident, toured the facility, and obtained pertinent documents. Further investigation is required prior to issuing findings.
Complaint Details
The visit was triggered by a complaint related to a self-reported death of a resident following a fall and hospitalization. Substantiation status is not stated.
Report Facts
Census: 92
Total Capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailey Vanderwall | Executive Director | Met with Licensing Program Analyst during inspection and involved in interviews |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 140
Deficiencies: 1
Jan 16, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff do not prevent a resident from entering other residents' rooms.
Findings
The allegation was substantiated after interviews and file reviews revealed that Resident 1 wandered into other residents' rooms and halls, posing a potential health and safety risk. Staff believed Resident 1 required a higher level of care and the resident was placed in memory care as of 04/24/2024.
Complaint Details
The complaint was substantiated. The allegation was that staff did not prevent Resident 1 from entering other residents' rooms. Investigations included interviews with residents, staff, and the Executive Director, as well as file reviews. Resident 1 was found to be wandering and confused, with incidents of entering rooms uninvited and biting another resident. Resident 1 was subsequently placed in memory care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by staff and file review revealing Resident 1 was declining and wandering into other residents' rooms, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 140
Census: 85
Plan of Correction Due Date: Jan 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
| Kailey Vanderwall | Executive Director | Interviewed during the investigation and involved in findings |
| Christopher Andersen | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 140
Deficiencies: 1
Dec 23, 2024
Visit Reason
The visit was conducted as a case management - deficiencies inspection due to deficiencies discovered during the investigation of complaint control number 29-AS-20231121093226.
Findings
Interviews with staff revealed concerns about the treatment of residents in the Traditions Memory care unit, including ignoring residents, yelling, and arguing with residents. Six out of ten staff reported observing such behaviors, which pose an immediate personal rights risk to residents.
Complaint Details
The visit was triggered by complaint control number 29-AS-20231121093226. Six out of ten staff in the Traditions Memory care unit voiced concerns about resident treatment, including ignoring residents and yelling. Concerns were reported to management but not addressed.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personal Rights. Residents in all residential care facilities for the elderly shall have dignity in their personal relationships with staff. This requirement was not met as evidenced by staff concerns regarding treatment of residents. | Type B |
Report Facts
Staff reporting concerns: 6
Total staff interviewed: 10
Capacity: 140
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailey Vanderwall | Executive Director | Met with Licensing Program Analyst during the inspection and mentioned in relation to the visit. |
| Erica Mosley | Licensing Program Analyst | Conducted the case management - deficiencies visit and investigation. |
| Kasandra Lopez | Licensing Program Manager | Named as supervisor and licensing program manager in the report. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 140
Deficiencies: 0
Dec 23, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff spoke inappropriately to a resident and refused to assist the resident with mobility and dressing.
Findings
The investigation found that staff denied the allegations, no staff by the name provided were currently employed, and there were no witnesses to support the claims. Six residents interviewed reported no concerns. Therefore, the allegations were deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint involved allegations that two staff members called a resident "fat," "heavy," and "disgusting," refused to assist with mobility and dressing. Interviews revealed that one staff member was no longer employed, the other was not identified, and no witnesses corroborated the allegations. The resident had memory issues and could not recall staff names. The complaint was deemed unsubstantiated.
Report Facts
Capacity: 140
Census: 85
Staff interviewed: 13
Residents interviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailey Vanderwall | Executive Director | Met with Licensing Program Analyst during investigation |
| Christopher Andersen | Administrator | Facility administrator named in report header |
| Erica Mosley | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 140
Deficiencies: 2
Dec 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident was left in an unkempt room overnight and had access to an item that could pose a danger.
Findings
The investigation substantiated that Resident 1 in Memory Care accessed a fire extinguisher, discharged it in their room, and was left in the room overnight with fire extinguisher powder until it was cleaned the next day. Fire extinguishers were found accessible to residents despite known behaviors. Two deficiencies were cited related to facility cleanliness and unsafe access to dangerous items.
Complaint Details
The complaint was substantiated. Resident 1 was able to access and discharge a fire extinguisher in their room on 10/15/2024, and was left in the room overnight with the powder until cleaned the next day. Staff acknowledged the behavior was known and fire extinguishers were accessible.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility was not maintained in a clean, safe, sanitary, and good repair condition as Resident 1 was left in a room overnight with fire extinguisher powder all over, posing an immediate health and safety risk. | Type A |
| Items that could constitute a danger to residents with dementia, specifically fire extinguishers, were accessible to Resident 1 despite staff knowledge of this behavior. | Type B |
Report Facts
Facility capacity: 140
Census: 85
Deficiencies cited: 2
Plan of Correction due dates: POC due dates are 12/24/2024 for Type A and 12/27/2024 for Type B deficiencies
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailey Vanderwall | Executive Director | Met with during investigation and named in findings |
| Erica Mosley | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 84
Capacity: 140
Deficiencies: 0
Nov 6, 2024
Visit Reason
The inspection was an unannounced annual case management continuance visit to ensure compliance with Title 22 regulations and to check for health and safety hazards at the facility.
Findings
The facility was found to be in compliance with Title 22 regulations with no citations issued. Fire safety equipment was properly maintained, emergency drills were conducted quarterly, and required postings were observed. Personnel and resident records were reviewed and found to be in order.
Report Facts
Staff files reviewed: 8
Resident records reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailey Vanderwall | Administrator | Named as Administrator who was not present due to training |
| Ricardo Viveros | Business Office Director | Met with during inspection and involved in facility tour |
| Ian Gadea | Health Services Director | Met with during inspection and involved in facility tour |
| Erica Mosley | Licensing Program Analyst | Conducted the unannounced inspection |
| Kasandra Lopez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 88
Capacity: 140
Deficiencies: 0
Sep 28, 2024
Visit Reason
Licensing Program Analysts conducted an unannounced required annual visit to evaluate the facility's compliance with Title 22 regulations.
Findings
The facility was found to be in compliance with Title 22 regulations with no citations issued. The physical plant, kitchen, resident bedrooms, restrooms, common areas, and surrounding grounds were all observed to be clean, safe, and properly maintained. Infection control practices and emergency disaster plans were adequate. Medication audit revealed no errors.
Report Facts
Resident interviews conducted: 6
Staff interviews conducted: 6
Medication audit: 5
Resident bedrooms observed: 8
Fire extinguisher last serviced: Dec 19, 2023
Fire alarm testing date: Aug 27, 2024
Emergency disaster drill date: Jul 26, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kailey Vanderwall | Executive Director | Met with Licensing Program Analyst during inspection |
| Erica Mosley | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kasandra Lopez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Lace Szelesteywoodfi | Sales and Marketing Coordinator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 140
Deficiencies: 2
Sep 27, 2024
Visit Reason
The visit was an unannounced complaint investigation to deliver final findings for complaints received on 09/05/2023 regarding staff notification failures and communication issues with a resident's responsible party and family.
Findings
Two allegations were substantiated: staff did not notify the responsible party of a resident's fall incident and did not communicate medication increases to the resident's family. Other allegations regarding timely medical attention, resident hygiene, and staff taunting were unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not notify the resident's responsible party of a fall incident on 06/22/2023 and did not communicate with the resident's family regarding an increase in medication between 6/24/2023 and 8/24/2023. Other allegations including failure to seek timely medical attention, unmet hygiene needs, and staff taunting were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to inform resident's responsible party of any change in condition or care needs. | Type B |
| Failure to report incidents to the Department and responsible party involving Resident #1. | Type B |
Report Facts
Capacity: 140
Census: 88
Deficiencies cited: 2
Plan of Correction Due Date: Oct 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Conway | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
| Kailey Vanderwall | Executive Director | Facility representative met during the investigation |
| Christopher Andersen | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 140
Deficiencies: 0
Apr 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations that facility staff failed to provide appropriate supervision, resulting in Resident #1 being sexually and physically assaulted by Resident #2.
Findings
The investigation found no evidence to substantiate the allegations. Interviews with residents, staff, and review of records indicated that Resident #1 did not suffer any abuse from Resident #2, and the resident representative was supportive of their interactions. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged neglect and lack of supervision leading to sexual and physical assault of Resident #1 by Resident #2. The investigation included interviews, record reviews, and contact with the police department, which did not investigate further. The allegation was found unsubstantiated.
Report Facts
Facility capacity: 140
Census: 89
Complaint received date: Aug 31, 2023
Investigation interview dates: Sep 21, 2023
Investigation interview dates: Oct 24, 2023
Resident admission dates: Mar 6, 2020
Resident admission date: Nov 30, 2022
Resident marriage duration: 53
Skin tear treatment date: Jun 13, 2023
Skin tear redress date: Jun 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted complaint investigation and delivered final findings |
| Christopher Andersen | Executive Director | Met with Licensing Program Analyst during investigation |
| Douglas Real | Investigator | Conducted interviews and reviewed documents during investigation |
| Teresa Camara | Licensing Program Analyst | Conducted initial complaint visit and reviewed records |
| Desaree Perera | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 140
Deficiencies: 0
Dec 7, 2023
Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations received on 2023-02-01 regarding staff behavior including unauthorized video recording, mocking of a resident, and disrespectful communication with residents.
Findings
The investigation found insufficient evidence to substantiate the allegations of staff video recording a resident without permission, mocking the resident, or speaking disrespectfully to residents. Conflicting staff statements and lack of corroborating evidence led to the allegations being deemed unsubstantiated.
Complaint Details
The complaint involved allegations that staff video recorded a resident without permission and mocked the resident, as well as spoke disrespectfully to residents. The investigation included interviews with staff, residents, visitors, and review of internal investigations. The allegations were found unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 140
Census: 89
Number of staff interviewed: 6
Number of visits to reach former staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation |
| Jason Russo | Administrator | Facility administrator named in the report |
| Chris Andersen | Executive Director | Met with Licensing Program Analyst during investigation |
| Sheila Ramirez | Memory Care Director | Participated in Memory Care unit tour and investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 140
Deficiencies: 0
Dec 7, 2023
Visit Reason
The visit was an unannounced complaint investigation to conclude an investigation initiated on 2022-12-14 regarding allegations of lack of supervision resulting in resident injury and other care concerns.
Findings
The investigation substantiated a prior finding related to lack of supervision causing a resident fall and injury. Four other allegations regarding rough handling, meal provision, unattended residents, and shower provision were investigated and deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged lack of supervision leading to a resident fall and injury, rough handling of residents, failure to ensure residents receive meals and showers, and leaving residents unattended. The fall and injury allegation was substantiated in a prior investigation with deficiencies and penalties issued. The other allegations were unsubstantiated after interviews, observations, and document reviews.
Report Facts
Capacity: 140
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
| Chris Andersen | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jason Russo | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 87
Capacity: 140
Deficiencies: 2
Oct 24, 2023
Visit Reason
The visit was an unannounced required annual inspection to evaluate compliance with Title 22 regulations and ensure health and safety standards at the facility.
Findings
The inspection found that the facility was generally compliant with health and safety regulations, including fire safety and infection control. However, deficiencies were noted related to the storage of disinfectants and cleaning solutions accessible to residents in locked rooms, and one staff member lacking a criminal record clearance. These issues posed immediate health and safety risks but were addressed during the visit.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Four out of ten locked resident rooms had disinfectants and/or cleaning solutions accessible to residents, posing an immediate health and safety risk. | Type A |
| One staff member did not have a criminal record clearance, posing an immediate health and safety risk. | Type A |
Report Facts
Residents present: 87
Total licensed capacity: 140
Staff files reviewed: 5
Resident files reviewed: 5
Medication audit residents: 3
Locked resident rooms with disinfectants accessible: 4
Total resident rooms observed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Andersen | Administrator | Facility administrator present during inspection |
| Jeannette Olson | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 140
Deficiencies: 0
Jul 27, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2022-10-26 regarding staff handling residents roughly and staff not being properly trained.
Findings
The investigation found insufficient evidence to substantiate the allegations that staff handled residents roughly or were not properly trained. Interviews with staff, residents, and family members, as well as record reviews, supported that staff training was adequate and no mistreatment occurred.
Complaint Details
The complaint alleged that staff handled Resident #1 roughly during a sponge bath and that staff were not properly trained to care for hospice residents. The investigation included interviews with staff, residents, family members, and review of resident assessments and training records. Both allegations were deemed unsubstantiated due to lack of sufficient evidence.
Report Facts
Complaint Control Number: 29-AS-20221026142548
Facility Capacity: 140
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Chris Anderson | Executive Director | Met with Licensing Program Analyst during the investigation |
| Eric Mensah | Administrator | Facility administrator named in the report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 140
Deficiencies: 0
May 4, 2023
Visit Reason
The visit was conducted as an unannounced complaint investigation regarding allegations that residents were being handled roughly, specifically focusing on Resident #1 who was reported to have sustained repeated unexplained bruising on face and body.
Findings
The investigation found that the bruising on Resident #1 was likely caused by accidental contact with a wooden backrest used as a restraint and a full bed rail, with no staff admitting to physical abuse. Due to lack of evidence and inability to interview a key caregiver, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged physical abuse resulting in repeated unexplained bruising on Resident #1. Multiple interviews and document reviews were conducted. The allegation was found unsubstantiated as the cause of injuries could not be determined to be intentional or accidental.
Report Facts
Capacity: 140
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Chris Andersen | Administrator | Met with during investigation and exit interview |
| Jose Santana | Investigator | Assigned to the complaint investigation and conducted interviews |
| Amber Silverman | Memory Care Director, LVN | Interviewed during initial complaint visit |
| Sylvia Williams | Health Services Director, LVN | Interviewed during initial complaint visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 140
Deficiencies: 2
May 4, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including failure to report resident falls and inadequate resident care.
Findings
The investigation substantiated that facility staff failed to report multiple resident falls to Community Care Licensing. Other allegations regarding over-medication, lack of assistance with ambulating, showering, changing undergarments, and staff distraction by personal phones were found unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding failure to report resident falls. Other allegations were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to accord dignity in personal relationships; staff distracted by personal cell phones posing potential health and safety risk. | Type B |
| Failure to report incidents threatening resident welfare, specifically multiple falls not reported to Community Care Licensing. | Type B |
Report Facts
Capacity: 140
Census: 90
Deficiencies cited: 2
Plan of Correction Due Date: May 11, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
| Chris Andersen | Executive Director | Met with Licensing Program Analyst during the investigation |
| Eric Mensah | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 140
Deficiencies: 1
Mar 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/28/2022 regarding staff not showering residents and not meeting residents' incontinence needs.
Findings
The allegation that staff are not showering residents was found to be unsubstantiated as residents were observed to be clean and on a consistent shower schedule. The allegation that staff are not meeting residents' incontinence needs was substantiated due to evidence of residents being left in soiled diapers, pendants not being answered timely, and a heavy urine odor in a resident's room indicating inadequate care.
Complaint Details
The complaint alleged that staff were not showering residents and were not meeting residents' incontinence needs, including yelling at residents for asking for help and leaving them in soiled diapers. The showering allegation was unsubstantiated. The incontinence allegation was substantiated based on interviews, observations, and record reviews.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents’ incontinence was properly managed, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 140
Census: 88
Plan of Correction Due Date: Mar 4, 2023
In-service Training Due Date: Mar 11, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Chris Andersen | Facility administrator met during visits and findings delivery | |
| Sheila Ramirez | Memory Care Director | Interviewed during investigation |
| Sylvia Williams | Memory Care Director, LVN | Interviewed during initial complaint visit |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 140
Deficiencies: 1
Feb 16, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following complaints received on 06/28/2022 regarding allegations that staff denied resident food and did not respond timely to residents' call buttons.
Findings
The allegation that staff denied resident food was found to be unsubstantiated after interviews and observations confirmed residents were offered meals and food was set aside for late arrivals. The allegation that staff were not responding timely to residents' call buttons was substantiated based on interviews, observations, and call log reviews showing delayed or no responses to call pendants, posing a potential personal risk to residents.
Complaint Details
The complaint investigation involved two main allegations: 1) staff denied resident food, which was unsubstantiated; 2) staff were not responding timely to residents' call buttons, which was substantiated. The investigation included interviews with staff, residents, and review of call button alert logs. The substantiated allegation identified a failure to respond timely to call pendants for Residents #1 and #2, with documented delays up to 37 minutes and multiple unresponded alerts.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to respond timely to residents' call buttons, violating CCR 87468.1(a)(2) regarding personal rights of residents to safe, healthful, and comfortable accommodations. | Type B |
Report Facts
Number of call pendant alerts for Resident #1: 9
Number of call pendant alerts for Resident #2: 10
Plan of Correction Due Date: Feb 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the complaint investigation visits and authored the report. |
| Sheila Ramirez | Memory Care Director | Interviewed during the investigation regarding allegations and facility practices. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation process. |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 140
Deficiencies: 1
Feb 15, 2023
Visit Reason
The visit was conducted as a Case Management - Deficiencies visit due to deficiencies discovered during the investigation of complaint control number 29-AS-20220708092257.
Findings
During the investigation, it was found that on 07/06/2022, Staff #1 pressed their body against Resident #1 to restrict movement and stop the resident from hitting them, which is a personal rights violation. Management noted that Resident #1 now requires a two-person assist for showers.
Complaint Details
The visit was triggered by a complaint investigation related to Staff #1's inappropriate physical intervention with Resident #1. The complaint was substantiated by the findings.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff #1 restricted Resident #1's movement by pressing their body against the resident, violating personal rights. | Type B |
Report Facts
Census: 92
Total Capacity: 140
Plan of Correction Due Date: Feb 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit and authored the report |
| Chris Andersen | Executive Director | Met with the Licensing Program Analyst during the visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 140
Deficiencies: 1
Feb 15, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 07/08/2022 regarding staff causing injury to a resident and staff yelling at residents in care.
Findings
The investigation found insufficient evidence to substantiate the allegations that staff caused injury to a resident or yelled at residents. However, a personal rights violation was noted due to staff pressing their body against a resident during care, and a Case Management report will address this deficiency.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff causing injury to Resident #1 by pulling their arm and choking them, and staff yelling at residents. Interviews, record reviews, and observations did not provide sufficient evidence to support these claims. Resident #1 was diagnosed with shoulder pain but no fracture or dislocation. Staff admitted to pressing their body against Resident #1 during showering to prevent hitting and scratching, which was deemed a personal rights violation.
Deficiencies (1)
| Description |
|---|
| Staff pressing their shoulder and body against Resident #1 while showering, restricting movement, constituting a personal rights violation. |
Report Facts
Capacity: 140
Census: 92
Staff interviewed: 11
Residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Chris Andersen | Executive Director | Met with Licensing Program Analyst during inspection |
| Kim Bergan | Administrator | Facility administrator named in the report header |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Staff #1 | Staff involved in the alleged injury incident with Resident #1 |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 140
Deficiencies: 1
Feb 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-09-06 alleging neglect and lack of supervision resulting in Resident #1 falling and sustaining a fracture.
Findings
The investigation substantiated the allegation that facility staff failed to provide appropriate supervision, resulting in Resident #1 falling and sustaining a fractured right humerus and bruising to the right eye. The fall occurred when Resident #1 ambulated without their walker and left the activity room undetected by staff.
Complaint Details
The complaint was substantiated. It alleged neglect/lack of supervision causing Resident #1 to fall and sustain a fractured right shoulder. The investigation included interviews, medical record reviews, and incident report analysis. The allegation was supported by evidence and deemed substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87464(f)(1) Basic Services. Staff did not supervise Resident #1 which resulted in Resident #1’s fall sustaining a fracture of the right humerus and bruise of the right eye, posing an immediate health and safety risk to residents in care. | Type A |
Report Facts
Civil penalty amount: 1000
Census: 92
Total capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Anderson | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Kelly Dulek | Licensing Program Analyst | Conducted initial complaint investigation visit |
| Douglas Real | Investigator | Assigned to complaint investigation and conducted interviews |
| Zabel Chochian | Evaluator / Licensing Program Analyst | Conducted subsequent complaint visit and signed report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 140
Deficiencies: 0
Jan 31, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility was not making the disaster plan available to residents.
Findings
The investigation found that the Emergency Disaster Manual was available at the concierge desk and residents were aware of and had practiced the emergency disaster protocol. Staff had mixed awareness, but documentation of emergency disaster training was provided. The allegation was deemed unsubstantiated due to insufficient evidence of a violation.
Complaint Details
The complaint alleged that the facility was not making the disaster plan available to residents. After investigation including interviews, document review, and observations, the allegation was unsubstantiated.
Report Facts
Capacity: 140
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Chris Andersen | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 140
Deficiencies: 1
Nov 29, 2022
Visit Reason
The visit was conducted as a case management - deficiencies visit due to deficiencies discovered during the investigation of complaint control number 29-AS-20220627090021.
Findings
The investigation found that Resident #1 had been restrained in bed by a wooden daybed backrest used as a bed rail for approximately one month prior to being placed on hospice, resulting in unexplained bruising on the resident's face and body. The facility did not comply with regulations prohibiting the use of full-length bed rails except for hospice residents with a care plan specifying their need.
Complaint Details
The visit was triggered by complaint control number 29-AS-20220627090021. The complaint was substantiated based on the findings of improper restraint and resulting injuries to Resident #1.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Use of a full length wooden backrest in place of full bed rails prior to Resident #1 being placed on hospice, resulting in multiple bruises and posing an immediate health and safety risk. | Type A |
Report Facts
Census: 86
Total Capacity: 140
Deficiency Type: 1
Plan of Correction Due Date: Dec 2, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Santana | Community Care Licensing Investigations Branch Investigator | Discovered the restraint and bruising on Resident #1 during the complaint investigation |
| Chris Andersen | Administrator | Met with Licensing Program Analyst during the visit and was informed of the visit reason |
| Teresa Camara | Licensing Program Analyst | Conducted the case management - deficiencies visit and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 140
Deficiencies: 1
Nov 29, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to a complaint received on 06/27/2022 alleging that facility staff do not treat residents with dignity, specifically concerning Resident #1 who sustained a fractured right wrist after a fall due to staff neglecting the resident's wishes to get out of bed.
Findings
The investigation substantiated that the facility failed to implement all fall precautions for Resident #1, resulting in a fall from bed and a fractured right wrist. The facility did not place the fall mat as instructed, and the bed alarm was not used because it was considered a restraint. The facility's motion sensor pagers were misplaced for about a year, rendering fall alerts ineffective. A $500 immediate civil penalty was assessed.
Complaint Details
The complaint was substantiated. Resident #1 sustained a fractured right wrist after a fall from bed due to staff neglecting the resident's wishes to get out of bed. The resident was a known fall risk with multiple prior falls. The facility failed to use fall prevention measures consistently, including failure to place a fall mat and non-use of a bed alarm. The motion sensor pagers were misplaced for about a year, reducing fall alert effectiveness.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not make use of fall precautions for Resident #1 which resulted in a fall from bed and fracturing right wrist, posing an immediate health and safety risk. | Type A |
Report Facts
Civil penalty: 500
Facility capacity: 140
Census: 86
Plan of Correction due date: Dec 2, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation. |
| Chris Andersen | Facility representative met during the investigation. | |
| Amber Silverman | Memory Care Director, LVN | Interviewed during the investigation. |
| Sylvia Williams | Health Services Director, LVN | Interviewed during the investigation. |
| Jose Santana | Investigator | Assigned to the complaint investigation. |
Inspection Report
Annual Inspection
Census: 86
Capacity: 140
Deficiencies: 2
Oct 27, 2022
Visit Reason
Unannounced annual inspection with a specific emphasis on infection control practices and procedures.
Findings
The facility was found generally compliant with Title 22 regulations, including kitchen, dining, and common areas. Infection control practices were adequate with proper PPE and symptom screening. However, deficiencies were cited related to water temperature exceeding regulatory limits and a staff member's fingerprint clearance not being associated with the facility.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Water temperature readings in 4 of 10 locations exceeded the maximum allowed temperature, posing an immediate safety risk. | Type A |
| Staff #1's fingerprint clearance was not associated with the facility despite being employed since 11/10/2021, posing an immediate safety risk. | Type A |
Report Facts
Civil Penalties: 500
Water temperature readings above allowed range: 4
Facility census: 86
Facility capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Anderson | Executive Director | Met with Licensing Program Analyst during inspection and involved in exit interview. |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Eric Mensah | Administrator | Named as facility administrator in report header. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 140
Deficiencies: 1
Oct 10, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff were violating residents' personal rights by waking Memory Care residents early in the morning.
Findings
The investigation substantiated the allegation that staff were waking Memory Care residents beginning at 4:00 AM without specified consent, which violates residents' personal rights. Staff and resident interviews, along with record reviews, confirmed this practice and the difficulty residents have with being woken early.
Complaint Details
The complaint was substantiated. It was found that staff violated residents' personal rights by waking Memory Care residents early without consent, confirmed through interviews and record review.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87468.1 Personal Rights of Residents in All Facilities (a)(3) To be free from punishment or interfering with daily living functions such as eating, sleeping, or elimination. Staff were instructed to wake residents beginning at 4:00 AM, posing an immediate personal rights risk. | Type A |
Report Facts
Residents in Memory Care: 29
Care staff per shift: 3
Residents per caregiver: 9
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation. |
| Diego Cortez | Licensing Program Analyst | Conducted the complaint investigation. |
| Chris Andersen | Executive Director | Met with investigators and participated in exit interview. |
| Silvia Williams | Health Services Director | Accompanied investigators during facility tour. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 140
Deficiencies: 1
Jul 1, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-06-27 regarding the facility not having contact information for the Ombudsman posted in the memory care unit.
Findings
The investigation found that the facility did not have an Ombudsman poster displayed in the memory care unit where residents could see it, although a poster was present in the assisted living activity room. This deficiency was substantiated and cited as a violation of CCR 87468.2(a)(10).
Complaint Details
The complaint was substantiated based on observations during the unannounced visit. The allegation was that the facility did not have contact information for the Ombudsman posted in the memory care unit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not post the telephone numbers and addresses for the local offices of the Ombudsman program conspicuously in the memory care unit where residents could observe it. | Type B |
Report Facts
Capacity: 140
Census: 95
Plan of Correction Due Date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Amber Silverman | Memory Care Director | Met with LPAs during the investigation and was explained the reason for the visit |
| Kim Bergan | Administrator | Facility administrator who was out during the visit |
| Sylvia Williams | Health Services Director, LVN | Interviewed during the investigation |
Inspection Report
Census: 88
Capacity: 140
Deficiencies: 3
Apr 14, 2022
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted to evaluate compliance with licensing requirements and to identify any deficiencies at the facility.
Findings
The inspection found multiple deficiencies including accessible medications and toxic substances to residents, and lack of documentation for quarterly disaster drills for each shift. A civil penalty of $250.00 was issued.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| S1's medication was observed accessible to residents which poses an immediate health risk to persons in care. | Type A |
| Toxic substances such as cleaning supplies and disinfectants were observed accessible to residents which poses an immediate health risk to persons in care. | Type A |
| Quarterly disaster drills were not documented for each shift which posed a potential safety risk to persons in care. | Type B |
Report Facts
Civil Penalty Amount: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jorge Moreno | Business Office Director | Met with Licensing Program Analyst during the inspection and authorized to review and sign reports. |
| Joann Rosales | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit and authored the report. |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 140
Deficiencies: 2
Nov 29, 2021
Visit Reason
The visit was a case management investigation of an incident where resident #1 eloped from the facility unassisted on 11/19/2021.
Findings
The investigation found that staff failed to supervise resident #1, who left the facility unassisted, posing an immediate health and safety risk. Additionally, laundry detergent was found accessible to residents, which is a violation of care standards for persons with dementia.
Complaint Details
The visit was complaint-related due to an incident where resident #1 eloped from the facility on 11/19/2021. The complaint was substantiated as staff failed to supervise the resident.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff failed to provide adequate care and supervision as resident #1 left the facility unassisted, posing an immediate health and safety risk. | Type A |
| Laundry detergent was accessible to residents with dementia, posing an immediate health and safety risk. | Type A |
Report Facts
Census: 87
Total Capacity: 140
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Bergan | Administrator | Met with Licensing Program Analyst during investigation and provided information about the incident and corrective actions |
| Joann Rosales | Licensing Program Analyst | Conducted the case management visit and investigation |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Original Licensing
Census: 87
Capacity: 140
Deficiencies: 1
Sep 28, 2021
Visit Reason
Pre-licensing visit conducted as part of a change of ownership application for Oakmont of Riverpark. The visit included inspection of fire safety, personal accommodations and services, medication procedures, and food service.
Findings
The facility was found to have adequate linen, water, and nonperishable food supplies. Resident rooms and common areas were appropriately furnished and equipped. Fire safety equipment and systems were tested and found operable. One item, a current First Aid manual, was noted as needing to be submitted prior to licensing.
Deficiencies (1)
| Description |
|---|
| Current First Aid manual needs to be completed/proof submitted prior to licensing. |
Report Facts
Capacity: 140
Census: 87
Fire clearance: 140
Hot water temperature: 105.2
Rooms: 21
Rooms: 6
Rooms: 13
Rooms: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Bergan | Administrator | Met with Licensing Program Analyst during pre-licensing visit |
| JoAnn Rosales | Licensing Program Analyst | Conducted the pre-licensing visit and inspection |
| Kristin Heffernan | Licensing Program Manager | Named in report header and signature section |
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