Inspection Report Summary
Most inspections found no deficiencies, including the most recent report on September 18, 2025, which was clean and showed proper medication management and fire drill training. Earlier complaint investigations were largely unsubstantiated, with residents’ care, medication administration, and infection control generally meeting requirements. However, some deficiencies were cited in late 2024 related to resident supervision and personal rights, including staff failing to prevent a resident from entering others’ bedrooms and staff locking residents’ bedroom doors, which posed safety and rights concerns. A serious incident in October 2024 involved a staff member pushing a resident, resulting in injury and termination of the staff member, but no fines or license actions were listed in the reports. Since those events, the facility’s inspections have shown improvement with no further deficiencies noted.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
50% occupied
Based on a September 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 74
Capacity: 148
Deficiencies: 0
Sep 18, 2025
Visit Reason
An unannounced annual continuation inspection was conducted as part of the required yearly inspection to evaluate compliance with licensing requirements.
Findings
The inspection found that medication records were up to date, medications were properly labeled, and fire drill trainings were conducted on specified dates. No deficiencies were cited during the visit based on California Code of Regulations Title 22.
Report Facts
Residents reviewed for medication records: 6
Fire drill training dates: Fire drills conducted on 05/14/2025 and 07/03/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Minnie Lacson-Weber | Executive Director | Met with Licensing Program Analyst during inspection and involved in medication record review |
| Anomie De Los Reyes | Assisted Living Director | Met with Licensing Program Analyst during inspection and involved in medication record review |
| Maria Partoza | Licensing Program Analyst | Conducted the unannounced annual inspection |
Inspection Report
Annual Inspection
Census: 74
Capacity: 148
Deficiencies: 0
Sep 17, 2025
Visit Reason
The inspection was a required unannounced 1-year annual inspection visit to evaluate compliance with licensing requirements.
Findings
The facility was found to be generally sanitary and organized with no citations issued during the visit. Emergency supplies and safety systems were in place, resident rooms and common areas were inspected and found compliant, and staff records were complete and up to date. The annual inspection was to be continued at a later date due to time constraints.
Report Facts
Emergency food supply duration: 2
Emergency food supply duration: 7
Resident quarantine count: 3
Kitchen refrigerator temperature: 32
Kitchen freezer temperature: -4
Room temperature: 75
Water temperature range: 105
Water temperature range: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Ann Bangsal | Business Office Director | Met with Licensing Program Analyst during inspection and exit interview |
| Jaime Martinez | Maintenance Director | Accompanied Licensing Program Analyst during facility inspection |
| Minnie Lacson-Weber | Executive Director/Administrator | Named as facility administrator but was not present during inspection |
| Maria Partoza | Licensing Program Analyst | Conducted the inspection visit |
| Romeo Manzano | Licensing Program Manager | Named in report header |
Inspection Report
Monitoring
Census: 79
Capacity: 148
Deficiencies: 0
Jul 18, 2025
Visit Reason
The visit was an unannounced Case Management Visit to deliver two complaints that were under a previous facility license.
Findings
No deficiencies were cited at this time as per California Code of Regulations, Title 22. The report was reviewed with the Executive Director.
Complaint Details
The visit was related to delivering two complaints under a previous facility license. No deficiencies were cited during this visit.
Report Facts
Complaints delivered: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management Visit |
| Minnie Weber | Executive Director | Met with Licensing Program Analyst during the visit and reviewed the report |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 148
Deficiencies: 0
Jun 4, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-04-23 regarding neglect, staffing shortages, inadequate cleaning, medication administration delays, lack of assistance during meals, and failure to reposition residents.
Findings
The investigation found that resident rooms were clean and sanitary, medication was administered timely, and staff assisted residents appropriately. Interviews and observations did not substantiate the allegations, and no deficiencies were cited.
Complaint Details
The complaint included multiple allegations such as neglect resulting in falls, short staffing, inadequate cleaning, delayed medication administration, lack of meal assistance, and failure to reposition residents hourly. The investigation concluded these allegations were unsubstantiated due to insufficient evidence.
Report Facts
Staff interviewed: 10
Residents interviewed: 10
Resident rooms inspected: 7
Resident records reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcela Yanez | Licensing Program Analyst | Conducted the complaint investigation |
| Mary Ann Bangsal | Business Office Director | Met with Licensing Program Analyst during investigation and exit interview |
| Holly Suiter | Executive Director | Met with Licensing Program Analyst during initial investigation visit |
| Luisa Lopez | Health Services Director | Interviewed to verify resident repositioning orders |
| Romeo Manzano | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 148
Deficiencies: 1
Dec 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff did not prevent a resident from engaging in inappropriate behaviors and did not notify a resident's authorized representative of an incident in a timely manner.
Findings
The investigation found one allegation substantiated: staff failed to prevent resident R1 from entering other residents' bedrooms, posing a potential health and safety risk. Another allegation regarding timely notification to a resident's authorized representative was found unfounded. Deficiencies were cited related to insufficient care and supervision to meet individual resident needs.
Complaint Details
The complaint investigation was triggered by allegations that staff did not prevent resident R1 from engaging in inappropriate behaviors, specifically entering other residents' bedrooms, and that staff did not notify a resident's authorized representative of an incident in a timely manner. The allegation regarding prevention of inappropriate behavior was substantiated, while the notification allegation was unfounded.
Deficiencies (1)
| Description |
|---|
| Failure to provide care, supervision, and services that meet individual needs, evidenced by resident R1 entering other residents' bedrooms and staff not redirecting appropriately. |
Report Facts
Capacity: 148
Census: 74
Instances of entering other residents' bedrooms: 10
Plan of Correction Due Date: Dec 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Dial | Administrator | Interviewed regarding the incident and care plan for resident R1 |
| Holly Suiter | Executive Director/Administrator | Met during the investigation and exit interview |
| Manuel Monter | Licensing Program Analyst | Conducted the complaint investigation |
| Steve Chang | Licensing Program Analyst | Interviewed staff and residents during the investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 148
Deficiencies: 1
Dec 16, 2024
Visit Reason
The visit was conducted as a complaint investigation following complaint 26-AS-20240315163012, focusing on case management deficiencies discovered during the investigation.
Findings
The investigation found that facility staff were locking residents' bedroom doors, requiring residents to ask staff for assistance to enter their rooms, which posed a potential health, safety, or personal rights risk to persons in care.
Complaint Details
Complaint investigation for complaint 26-AS-20240315163012. Deficiency substantiated as staff locking resident bedroom doors, restricting resident access and posing risks.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff is locking resident’s bedroom doors, requiring residents to ask staff for assistance in opening their bedroom door, posing a potential health, safety or personal rights risk. | Type A |
Report Facts
Capacity: 148
Census: 74
Plan of Correction Due Date: Dec 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Suiter | Executive Director/Administrator | Met during inspection and involved in review of report and plan of correction |
| Manuel Monter | Licensing Program Analyst | Conducted complaint investigation and inspection |
| Romeo Manzano | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 148
Deficiencies: 1
Oct 18, 2024
Visit Reason
An unannounced Case Management-Inspection visit was conducted to deliver an immediate exclusion order regarding staff member S1 following a reported incident of physical abuse to resident R1 on 2024-10-03.
Findings
The investigation found that staff member S1 pushed resident R1, causing R1 to fall and sustain abrasions and contusions, violating R1's personal rights and posing immediate health and safety risks. S1's employment was terminated and an immediate exclusion order was issued.
Complaint Details
The visit was complaint-related due to a reported incident of physical abuse involving staff member S1 and resident R1. The complaint was substantiated as S1's actions violated resident rights and resulted in injury.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff member S1 pushed resident R1 causing R1 to fall, violating R1's personal rights and posing immediate health, safety, and personal rights risks. | Type A |
Report Facts
Census: 74
Total Capacity: 148
Deficiency Type Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Ann Bangsal | Business Office Director | Met during inspection and involved in discussion regarding immediate exclusion order |
| James Dial | Administrator/Director | Facility Administrator named in report header |
| Holly Suiter | Executive Director/Administrator | Not available during inspection due to training |
| Maria Partoza | Licensing Program Analyst | Conducted inspection and signed report |
| Marcela Yanez | Licensing Program Analyst | Conducted inspection |
| Romeo Manzano | Licensing Program Manager/Supervisor | Supervisor and Licensing Evaluator named in report |
Inspection Report
Annual Inspection
Census: 79
Capacity: 148
Deficiencies: 0
Oct 15, 2024
Visit Reason
The inspection was an unannounced required 1-year comprehensive inspection visit to evaluate compliance with California Code of Regulation Title 22.
Findings
The facility was found to be in compliance with no deficiencies cited. The kitchen, facility environment, resident and staff records were reviewed and found to be satisfactory.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Fire extinguisher last serviced: Dec 15, 2023
Kitchen water temperature range: 107.9
Kitchen water temperature range: 112.4
Bathroom water temperature: 112.4
Perishable food days observed: 2
Non-perishable food days observed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Ann Bangsal | Business Office Director | Met during inspection and exit interview |
| James Dial | Administrator/Director | Facility Administrator named in report header |
| Maria Partoza | Licensing Program Analyst | Conducted inspection |
| Marcella Tarin | Licensing Program Analyst | Conducted inspection and toured facility |
| Romeo Manzano | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 148
Deficiencies: 0
Oct 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on October 7, 2024, regarding infection control, timely assistance to residents, medication accessibility, and record maintenance.
Findings
Based on interviews with residents, staff, and the administrator, as well as observations and records review, all allegations were found to be unfounded, meaning the complaints were false, could not have happened, or lacked a reasonable basis.
Complaint Details
The complaint investigation addressed four allegations: staff not following infection control protocols, staff not assisting residents timely, staff not ensuring medications are inaccessible, and staff not maintaining complete resident records. All allegations were investigated through interviews and observations and were determined to be unfounded.
Report Facts
Residents interviewed: 7
Staff interviewed: 6
Memory care residents with incontinence: 19
Residents in memory care unit: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manuel Monter | Licensing Program Analyst | Conducted the complaint investigation |
| Romeo Manzano | Licensing Program Manager | Oversaw the complaint investigation |
| Holly Suiter | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Follow-Up
Census: 82
Capacity: 148
Deficiencies: 0
Oct 8, 2024
Visit Reason
The visit was an unannounced follow-up case management inspection triggered by an incident report alleging that a resident was pushed by a staff member, resulting in injury.
Findings
The investigation found that a staff member physically responded to a resident's behavior causing skin tears and discoloration; the staff member was terminated. No deficiencies were cited at this time.
Complaint Details
The visit was complaint-related due to an incident report received on October 4, 2024, regarding an incident on October 3, 2024, involving physical response by staff to a resident resulting in injury. The incident required further investigation but no deficiencies were cited.
Report Facts
Incident date: Oct 3, 2024
Incident report received date: Oct 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Suiter | Administrator | Met with Licensing Program Analysts during the visit and reviewed the report |
| Manuel Monter | Licensing Program Analyst | Conducted the unannounced follow-up case management visit |
| Romeo Manzano | Licensing Program Manager | Reviewed the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 148
Deficiencies: 0
Oct 7, 2024
Visit Reason
The visit was an unannounced case management inspection triggered by an incident report alleging that a resident was physically pushed by a staff member.
Findings
The investigation found that a resident sustained a skin tear and discoloration due to staff physical response. The staff member involved was terminated. No deficiencies were cited at this time, and further investigation was deemed necessary.
Complaint Details
The complaint involved an incident on October 3, 2024, where a resident was physically handled by staff resulting in injury. The staff member was terminated. The complaint requires further investigation.
Report Facts
Incident date: Oct 3, 2024
Incident report received date: Oct 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Suiter | Administrator | Met with Licensing Program Analysts during the visit and reviewed the report |
| Manuel Monter | Licensing Program Analyst | Conducted the unannounced case management visit |
| Romeo Manzano | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 148
Deficiencies: 0
Oct 3, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations that a resident sustained multiple falls due to neglect and lack of supervision, residents were not accorded dignity and respect, and staff were rough when providing assistance with residents' care.
Findings
The investigation found that the resident's falls were related to their mental and physical condition and increased supervision was in place. Staff consistently respected residents' dignity and no recent rough treatment was observed. The allegations were unsubstantiated due to lack of preponderance of evidence and no deficiencies were cited.
Complaint Details
The complaint alleged neglect leading to multiple falls, lack of dignity and respect for residents, and rough care by staff. Interviews with staff and review of documentation did not substantiate these allegations. A prior caregiver was terminated for abuse over a year ago, but no recent incidents were found.
Report Facts
Complaint Control Number: 26
Complaint received date: Sep 19, 2024
Number of staff interviewed: 4
Supervision frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Partoza | Licensing Program Analyst | Conducted the complaint investigation |
| Holly Suiter | Executive Director/Administrator | Met with investigator during the visit and exit interview |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 148
Deficiencies: 0
Oct 3, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were not distributing a resident's medications as prescribed.
Findings
Based on review of medication logs for 3 residents, no missed medications or medication administration errors were found. The allegation was unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged that staff were not distributing a resident's medications as prescribed. The investigation found no evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Report Facts
Resident medication logs reviewed: 3
Medication passes per day: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Partoza | Licensing Program Analyst | Conducted the complaint investigation visit |
| Holly Suiter | Executive Director/Administrator | Met with investigator during exit interview |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Original Licensing
Census: 70
Capacity: 148
Deficiencies: 0
Oct 6, 2023
Visit Reason
An unannounced pre-licensing inspection visit was conducted for changing ownership of the facility.
Findings
The facility was toured and inspected, including resident and staff files, fire safety equipment, food supplies, and medication security. No citations were noted during the visit.
Report Facts
Fire extinguisher service date: Dec 23, 2022
Facility temperature: 75
Hot water temperature: 106
Perishable food supply duration: 2
Nonperishable food supply duration: 7
Resident files checked: 5
Staff files checked: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Ann Bangsal | Business Office Director | Met with Licensing Program Analyst during inspection. |
| Judith Diaz | Memory Care Director | Met with Licensing Program Analyst during inspection. |
| Jaime Martinez | Maintenance Director | Conducted facility tour and tested carbon monoxide detectors. |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced pre-licensing inspection visit. |
Inspection Report
Original Licensing
Capacity: 148
Deficiencies: 0
Jul 28, 2023
Visit Reason
The visit was conducted as part of the original licensing process for the facility, including verification of the applicant/administrator's identity and understanding of licensing laws and regulations.
Findings
The applicant/administrator participated in a telephone interview confirming understanding of community care facility licensing laws, facility operation, admission policies, staffing requirements, and other regulatory provisions. Signed documentation and photo ID were obtained.
Report Facts
Capacity: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Dial | Administrator | Applicant/Administrator participating in licensing interview |
| Mirella Quaranta | Licensing Program Manager | Named in report header |
| Stefania Fonteno | Licensing Program Analyst | Named in report header and signed report |
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