Deficiencies (last 3 years)

Deficiencies (over 3 years) 2.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

33% better than California average
California average: 4 deficiencies/year

Deficiencies per year

8 6 4 2 0
2023
2024
2025

Census

Latest occupancy rate 49% occupied

Based on a December 2025 inspection.

Occupancy over time

30 60 90 120 150 180 Oct 2023 Oct 2024 Dec 2024 Sep 2025 Dec 2025

Inspection Report

Complaint Investigation
Census: 72 Capacity: 148 Deficiencies: 0 Date: Dec 22, 2025

Visit Reason
An unannounced case management incident visit was conducted following an incident report received on 2025-12-12 regarding an altercation between two residents in the memory care unit.

Complaint Details
The visit was triggered by a complaint regarding an altercation between two residents (R1 and R2). The complaint is under review and a follow-up visit may be conducted if warranted. No deficiencies were cited during this visit.
Findings
The visit found no deficiencies based on California Code of Regulations Title 22. The incident involved one resident hitting another, with emergency services called but no hospital transfer. The facility has taken measures including one-on-one care for the aggressive resident and plans to move that resident to a different facility.

Report Facts
Facility capacity: 148 Resident census: 72

Employees mentioned
NameTitleContext
Minnie WeberExecutive Director/AdministratorMet with Licensing Program Analyst during the visit and provided information about the incident and staffing
Maria PartozaLicensing Program AnalystConducted the unannounced case management incident visit

Inspection Report

Complaint Investigation
Census: 73 Capacity: 148 Deficiencies: 3 Date: Oct 3, 2025

Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-07-21 regarding allegations that staff did not ensure a resident's injuries were properly treated and did not communicate with the resident's responsible party.

Complaint Details
The complaint investigation was substantiated for allegations that staff did not ensure proper treatment of a resident's injuries and failed to communicate with the resident's responsible party. The allegation of physical abuse was unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated that staff failed to timely treat and report a resident's wound injuries, resulting in worsening conditions and inadequate communication with the responsible party. Deficiencies were cited related to personal rights, reporting requirements, and care of persons with dementia. A second allegation of physical abuse was unsubstantiated due to lack of evidence.

Deficiencies (3)
Failure to ensure resident's wound was treated and addressed in a timely manner to prevent infection.
Failure to submit timely written reports to licensing agency and responsible party regarding incidents.
Failure to provide adequate care and supervision for persons with dementia, including proper skincare and communication.
Report Facts
Capacity: 148 Census: 73 Plan of Correction Due Date: 2025

Employees mentioned
NameTitleContext
Maria PartozaLicensing Program AnalystConducted the complaint investigation
Minnie Lacson-WeberExecutive DirectorMet with Licensing Program Analyst during investigation and exit interview
Holly SuiterAdministratorFacility administrator named in report header
Romeo ManzanoSupervisorSupervisor named in report

Inspection Report

Annual Inspection
Census: 74 Capacity: 148 Deficiencies: 0 Date: 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
NameTitleContext
Minnie Lacson-WeberExecutive DirectorMet with Licensing Program Analyst during inspection and involved in medication record review
Anomie De Los ReyesAssisted Living DirectorMet with Licensing Program Analyst during inspection and involved in medication record review
Maria PartozaLicensing Program AnalystConducted the unannounced annual inspection

Inspection Report

Annual Inspection
Census: 74 Capacity: 148 Deficiencies: 0 Date: 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
No deficiencies were cited during the inspection. The medication records were up to date and properly labeled, and fire drill training was verified. The facility was advised to maintain readable and organized medication records.

Report Facts
Residents' centrally stored medication record count: 6 Fire drill training dates: Fire drills conducted on 05/14/2025 and 07/03/2025

Employees mentioned
NameTitleContext
Minnie Lacson-WeberExecutive DirectorMet during inspection and involved in discussion of visit purpose and findings
Anomie De Los ReyesAssisted Living DirectorMet during inspection and involved in discussion of visit purpose and findings
Maria PartozaLicensing Program AnalystConducted the inspection

Inspection Report

Annual Inspection
Census: 74 Capacity: 148 Deficiencies: 0 Date: 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
NameTitleContext
Mary Ann BangsalBusiness Office DirectorMet with Licensing Program Analyst during inspection and exit interview
Jaime MartinezMaintenance DirectorAccompanied Licensing Program Analyst during facility inspection
Minnie Lacson-WeberExecutive Director/AdministratorNamed as facility administrator but was not present during inspection
Maria PartozaLicensing Program AnalystConducted the inspection visit
Romeo ManzanoLicensing Program ManagerNamed in report header

Inspection Report

Annual Inspection
Census: 74 Capacity: 148 Deficiencies: 0 Date: Sep 17, 2025

Visit Reason
The inspection was an unannounced required 1-year annual inspection visit conducted to evaluate compliance with licensing requirements for the facility.

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 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 Quarantined residents: 3 Refrigerator temperature: 32 Freezer temperature: -4 Room temperature: 75 Water temperature range: 105 Water temperature range: 109

Employees mentioned
NameTitleContext
Mary Ann BangsalBusiness Office DirectorMet with Licensing Program Analyst during inspection and exit interview
Jaime MartinezMaintenance DirectorAccompanied Licensing Program Analyst during inspection
Minnie Lacson-WeberExecutive Director/AdministratorNot present during inspection due to prior commitment
Maria PartozaLicensing Program AnalystConducted the inspection
Romeo ManzanoLicensing Program ManagerNamed as Licensing Program Manager on report
Memory Care DirectorMet with Licensing Program Analyst during memory care area inspection
Executive ChefMet with Licensing Program Analyst during kitchen inspection

Inspection Report

Monitoring
Census: 79 Capacity: 148 Deficiencies: 0 Date: Jul 18, 2025

Visit Reason
The visit was an unannounced Case Management Visit to deliver two complaints that were under a previous facility license.

Complaint Details
The visit was related to delivering two complaints under a previous facility license. No deficiencies were cited during this visit.
Findings
No deficiencies were cited at this time as per California Code of Regulations, Title 22. The report was reviewed with the Executive Director.

Report Facts
Complaints delivered: 2

Employees mentioned
NameTitleContext
David MarrufoLicensing Program AnalystConducted the unannounced Case Management Visit
Minnie WeberExecutive DirectorMet with Licensing Program Analyst during the visit and reviewed the report

Inspection Report

Census: 79 Capacity: 148 Deficiencies: 0 Date: Jul 18, 2025

Visit Reason
The purpose of the visit was 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.

Employees mentioned
NameTitleContext
Minnie WeberExecutive DirectorMet with during the unannounced Case Management Visit.
David MarrufoLicensing Program AnalystConducted the unannounced Case Management Visit.
Maria PartozaLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 66 Capacity: 148 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Staff interviewed: 10 Residents interviewed: 10 Resident rooms inspected: 7 Resident records reviewed: 4

Employees mentioned
NameTitleContext
Marcela YanezLicensing Program AnalystConducted the complaint investigation
Mary Ann BangsalBusiness Office DirectorMet with Licensing Program Analyst during investigation and exit interview
Holly SuiterExecutive DirectorMet with Licensing Program Analyst during initial investigation visit
Luisa LopezHealth Services DirectorInterviewed to verify resident repositioning orders
Romeo ManzanoLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Complaint Investigation
Census: 66 Capacity: 148 Deficiencies: 0 Date: 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 hourly.

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 the allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found no substantiated evidence to support the allegations. Observations, interviews, and document reviews indicated that resident rooms were clean, medication was administered timely, and staff assisted residents appropriately. No deficiencies were cited during the visit.

Report Facts
Staff interviewed: 10 Residents interviewed: 10 Resident rooms inspected: 7 Resident records reviewed: 5 Resident records reviewed: 4

Employees mentioned
NameTitleContext
Marcela YanezLicensing Program AnalystConducted the complaint investigation visit
Holly SuiterExecutive DirectorMet with investigator during initial visit
Mary Ann BangsalBusiness Office DirectorMet with investigator during complaint investigation visit and exit interview
Luisa LopezHealth Services DirectorInterviewed to verify resident repositioning orders
Romeo ManzanoSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 74 Capacity: 148 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
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
NameTitleContext
James DialAdministratorInterviewed regarding the incident and care plan for resident R1
Holly SuiterExecutive Director/AdministratorMet during the investigation and exit interview
Manuel MonterLicensing Program AnalystConducted the complaint investigation
Steve ChangLicensing Program AnalystInterviewed staff and residents during the investigation

Inspection Report

Complaint Investigation
Census: 74 Capacity: 148 Deficiencies: 1 Date: 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.

Complaint Details
Complaint investigation for complaint 26-AS-20240315163012. Deficiency substantiated as staff locking resident bedroom doors, restricting resident access and posing risks.
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.

Deficiencies (1)
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.
Report Facts
Capacity: 148 Census: 74 Plan of Correction Due Date: Dec 17, 2024

Employees mentioned
NameTitleContext
Holly SuiterExecutive Director/AdministratorMet during inspection and involved in review of report and plan of correction
Manuel MonterLicensing Program AnalystConducted complaint investigation and inspection
Romeo ManzanoLicensing Program ManagerSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 74 Capacity: 148 Deficiencies: 1 Date: Dec 16, 2024

Visit Reason
The inspection was conducted as a complaint investigation following complaint 26-AS-20240315163012, which triggered a case management deficiencies visit due to violations discovered during the investigation.

Complaint Details
Complaint 26-AS-20240315163012 triggered the investigation. The complaint was substantiated as deficiencies were cited related to resident personal rights and safety concerning locked bedroom doors.
Findings
The investigation found that a resident (R1) exhibited behavior of attempting to enter other residents' bedrooms. Staff were observed locking resident bedroom doors and requiring residents to ask for assistance to enter their rooms, which posed a potential health, safety, or personal rights risk to persons in care.

Deficiencies (1)
Facility staff is locking resident bedroom doors, requiring residents to ask staff for assistance in opening their bedroom door, posing a potential health, safety, or personal rights risk.
Report Facts
Capacity: 148 Census: 74 Plan of Correction Due Date: Dec 17, 2024

Employees mentioned
NameTitleContext
Holly SuiterExecutive Director/AdministratorMet with Licensing Program Analyst and reviewed the report
Manuel MonterLicensing Program AnalystConducted the complaint investigation and inspection

Inspection Report

Complaint Investigation
Census: 74 Capacity: 148 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
Staff member S1 pushed resident R1 causing R1 to fall, violating R1's personal rights and posing immediate health, safety, and personal rights risks.
Report Facts
Census: 74 Total Capacity: 148 Deficiency Type Count: 1

Employees mentioned
NameTitleContext
Mary Ann BangsalBusiness Office DirectorMet during inspection and involved in discussion regarding immediate exclusion order
James DialAdministrator/DirectorFacility Administrator named in report header
Holly SuiterExecutive Director/AdministratorNot available during inspection due to training
Maria PartozaLicensing Program AnalystConducted inspection and signed report
Marcela YanezLicensing Program AnalystConducted inspection
Romeo ManzanoLicensing Program Manager/SupervisorSupervisor and Licensing Evaluator named in report

Inspection Report

Complaint Investigation
Census: 74 Capacity: 148 Deficiencies: 1 Date: 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.

Complaint Details
The visit was complaint-related due to a reported incident of physical abuse by staff S1 against resident R1. The complaint was substantiated, resulting in immediate termination of S1 and issuance of an exclusion order.
Findings
The investigation found that staff S1 pushed resident R1, causing R1 to fall and sustain abrasions and swelling, violating R1's personal rights. S1's employment was terminated immediately and an immediate exclusion order was issued.

Deficiencies (1)
Staff S1 engaged in conduct inimical to the facility by pushing resident R1, causing injury and violating personal rights under CCR 87468.1(a)(3).
Report Facts
Capacity: 148 Census: 74 Deficiencies cited: 1

Employees mentioned
NameTitleContext
Mary Ann BangsalBusiness Office DirectorMet during inspection and involved in discussion of immediate exclusion order
James DialAdministrator/DirectorFacility Administrator listed in report
Holly SuiterExecutive Director/AdministratorNot available during visit due to training

Inspection Report

Annual Inspection
Census: 79 Capacity: 148 Deficiencies: 0 Date: 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
NameTitleContext
Mary Ann BangsalBusiness Office DirectorMet during inspection and exit interview
James DialAdministrator/DirectorFacility Administrator named in report header
Maria PartozaLicensing Program AnalystConducted inspection
Marcella TarinLicensing Program AnalystConducted inspection and toured facility
Romeo ManzanoLicensing Program ManagerNamed in report

Inspection Report

Annual Inspection
Census: 79 Capacity: 148 Deficiencies: 0 Date: Oct 15, 2024

Visit Reason
The inspection was an unannounced required 1-year comprehensive inspection visit conducted by Licensing Program Analysts to evaluate compliance with regulations.

Findings
The facility was found to be in compliance with no deficiencies cited. The kitchen, bathrooms, and safety systems were observed to be in good condition, and resident and staff records were complete and updated.

Report Facts
Licensed capacity: 148 Current census: 79 Fire extinguisher last serviced: Dec 15, 2023 Perishable food observed: 2 Non-perishable food observed: 7 Resident records reviewed: 5 Staff records reviewed: 5 Care providers: 3 Servers: 1 Housekeepers: 1

Employees mentioned
NameTitleContext
Mary Ann BangalBusiness Office DirectorMet during inspection and exit interview
James DialAdministrator/DirectorFacility administrator named in report
Maria PartozaLicensing Program AnalystConducted inspection and signed report
Marcella TarinLicensing Program AnalystConducted inspection
Romeo ManzanoSupervisorSupervisor named in report

Inspection Report

Complaint Investigation
Census: 82 Capacity: 148 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Residents interviewed: 7 Staff interviewed: 6 Memory care residents with incontinence: 19 Residents in memory care unit: 21

Employees mentioned
NameTitleContext
Manuel MonterLicensing Program AnalystConducted the complaint investigation
Romeo ManzanoLicensing Program ManagerOversaw the complaint investigation
Holly SuiterAdministratorFacility administrator interviewed during investigation

Inspection Report

Follow-Up
Census: 82 Capacity: 148 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Incident date: Oct 3, 2024 Incident report received date: Oct 4, 2024

Employees mentioned
NameTitleContext
Holly SuiterAdministratorMet with Licensing Program Analysts during the visit and reviewed the report
Manuel MonterLicensing Program AnalystConducted the unannounced follow-up case management visit
Romeo ManzanoLicensing Program ManagerReviewed the report

Inspection Report

Complaint Investigation
Census: 82 Capacity: 148 Deficiencies: 0 Date: Oct 8, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on October 7, 2024, regarding infection control protocols, timely assistance with care needs, medication accessibility, and completeness of resident records.

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. After interviews and observations, all allegations were determined to be unfounded.
Findings
Based on interviews with residents, staff, and the administrator, as well as observations and records review, the department found all allegations to be unfounded, meaning the complaints were false or without reasonable basis.

Report Facts
Capacity: 148 Census: 82 Residents in memory care with incontinence: 19 Residents randomly reviewed: 3 Staff interviewed: 6 Residents interviewed: 7

Employees mentioned
NameTitleContext
Manuel MonterLicensing Program AnalystConducted the complaint investigation and interviews
Holly SuiterAdministratorFacility administrator interviewed during the investigation
James DialAdministratorNamed as facility administrator in report header

Inspection Report

Follow-Up
Census: 82 Capacity: 148 Deficiencies: 0 Date: Oct 8, 2024

Visit Reason
An unannounced follow-up case management visit was conducted regarding an incident report alleging a resident was pushed by a staff member.

Complaint Details
The visit was complaint-related due to an incident report alleging physical response by staff to a resident. The incident was substantiated by the termination of the staff member, but no deficiencies were cited during this visit.
Findings
The incident involved a resident sustaining a skin tear to the elbows and discoloration to the back of the head. The staff member who responded physically was terminated. No deficiencies were cited at this time, but further investigation was deemed necessary.

Report Facts
Capacity: 148 Census: 82

Employees mentioned
NameTitleContext
Holly SuiterAdministratorMet with Licensing Program Analyst during the visit and reviewed the report
Manuel MonterLicensing Program AnalystConducted the unannounced follow-up case management visit
Romeo ManzanoSupervisorSupervisor named in the report

Inspection Report

Complaint Investigation
Census: 82 Capacity: 148 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Incident date: Oct 3, 2024 Incident report received date: Oct 4, 2024

Employees mentioned
NameTitleContext
Holly SuiterAdministratorMet with Licensing Program Analysts during the visit and reviewed the report
Manuel MonterLicensing Program AnalystConducted the unannounced case management visit
Romeo ManzanoLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 82 Capacity: 148 Deficiencies: 0 Date: Oct 7, 2024

Visit Reason
An unannounced case management visit was conducted regarding an incident report alleging that a resident was pushed by a staff member, resulting in injury.

Complaint Details
The complaint involved an incident on October 3, 2024, where staff responded physically to a resident's behavior causing injury. The staff member was terminated. The incident requires further investigation.
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.

Report Facts
Capacity: 148 Census: 82

Employees mentioned
NameTitleContext
Holly SuiterAdministratorMet with Licensing Program Analyst during visit
Manuel MonterLicensing Program AnalystConducted the unannounced case management visit
Romeo ManzanoSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Complaint Investigation
Census: 64 Capacity: 148 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Complaint Control Number: 26 Complaint received date: Sep 19, 2024 Number of staff interviewed: 4 Supervision frequency: 1

Employees mentioned
NameTitleContext
Maria PartozaLicensing Program AnalystConducted the complaint investigation
Holly SuiterExecutive Director/AdministratorMet with investigator during the visit and exit interview
Romeo ManzanoLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 64 Capacity: 148 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Resident medication logs reviewed: 3 Medication passes per day: 4

Employees mentioned
NameTitleContext
Maria PartozaLicensing Program AnalystConducted the complaint investigation visit
Holly SuiterExecutive Director/AdministratorMet with investigator during exit interview
Romeo ManzanoLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 64 Capacity: 148 Deficiencies: 0 Date: Oct 3, 2024

Visit Reason
An unannounced complaint investigation was conducted due to 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.

Complaint Details
The complaint was unsubstantiated. Allegations included neglect causing multiple falls, lack of dignity and respect for residents, and rough treatment by staff. Interviews with staff and review of documentation did not support these claims.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff reported increased supervision of the resident with fall risk, respect for residents' personal rights, and no recent incidents of rough care. No deficiencies were cited during the visit.

Report Facts
Capacity: 148 Census: 64

Employees mentioned
NameTitleContext
Maria PartozaLicensing Program AnalystConducted the complaint investigation
Holly SuiterExecutive Director/AdministratorMet with evaluator during investigation and exit interview
James DialAdministratorFacility administrator named in report header
Romeo ManzanoSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 64 Capacity: 148 Deficiencies: 0 Date: Oct 3, 2024

Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were not distributing a resident's medications as prescribed.

Complaint Details
The complaint alleged that staff were not distributing a resident's medications as prescribed. The investigation found no preponderance of evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Findings
Based on review of medication logs for 3 residents, no missed medications or medication administration errors were found. The allegation was unsubstantiated and no deficiencies were cited.

Report Facts
Medication passes per day: 4 Staff interviewed: 3 Residents' medication logs reviewed: 3

Employees mentioned
NameTitleContext
Maria PartozaLicensing Program AnalystConducted the complaint investigation visit.
Holly SuiterExecutive Director/AdministratorMet with investigator during the visit and participated in exit interview.

Inspection Report

Original Licensing
Census: 70 Capacity: 148 Deficiencies: 0 Date: 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
NameTitleContext
Mary Ann BangsalBusiness Office DirectorMet with Licensing Program Analyst during inspection.
Judith DiazMemory Care DirectorMet with Licensing Program Analyst during inspection.
Jaime MartinezMaintenance DirectorConducted facility tour and tested carbon monoxide detectors.
Steve ChangLicensing Program AnalystConducted the unannounced pre-licensing inspection visit.

Inspection Report

Original Licensing
Census: 70 Capacity: 148 Deficiencies: 0 Date: Oct 6, 2023

Visit Reason
An unannounced pre-licensing inspection visit was conducted for changing ownership of the facility.

Findings
The inspection included review of resident and staff files, a facility tour, and safety checks. No citations were noted, and all safety equipment and supplies were found to be in proper condition.

Report Facts
Resident files checked: 5 Staff files checked: 5 Fire extinguisher service date: Dec 23, 2022 Facility temperature: 75 Hot water temperature: 106 Perishable food supply duration: 2 Nonperishable food supply duration: 7

Employees mentioned
NameTitleContext
Steve ChangLicensing Program AnalystConducted the unannounced pre-licensing inspection visit
Mary Ann BangsalBusiness Office DirectorMet with Licensing Program Analyst during inspection and conducted Component III
Judith DiazMemory Care DirectorMet with Licensing Program Analyst during inspection
Jaime MartinezMaintenance DirectorAccompanied Licensing Program Analyst during facility tour and tested carbon monoxide detectors

Inspection Report

Original Licensing
Capacity: 148 Deficiencies: 0 Date: 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
NameTitleContext
James DialAdministratorApplicant/Administrator participating in licensing interview
Mirella QuarantaLicensing Program ManagerNamed in report header
Stefania FontenoLicensing Program AnalystNamed in report header and signed report

Inspection Report

Capacity: 148 Deficiencies: 0 Date: Jul 28, 2023

Visit Reason
The visit was an office evaluation involving a telephone interview with the applicant/administrator to verify identification and confirm understanding of community care facility licensing laws and regulations.

Findings
The applicant/administrator demonstrated understanding of facility operation, admission policies, staffing requirements and training, restrictive/prohibited health conditions, and general provisions as confirmed by the CAB analyst during the COMP II telephone interview.

Employees mentioned
NameTitleContext
James DialAdministratorApplicant/administrator who participated in the COMP II telephone interview and confirmed understanding of licensing laws.
Mirella QuarantaSupervisorSupervisor named in the report.
Stefania FontenoLicensing EvaluatorLicensing evaluator named in the report.

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