Inspection Report Summary
Most inspections found no deficiencies, with routine visits and complaint investigations consistently showing the facility to be clean, well-maintained, and compliant with regulations. Several complaint investigations were unsubstantiated, including allegations related to resident care, food service, and staff responsiveness. However, there were isolated deficiencies substantiated in late 2023 and early 2024 involving lack of supervision that led to a resident wandering away and suffering hypothermia, as well as failure to issue a proper refund, resulting in a civil penalty. The most recent report from May 12, 2025, had no deficiencies and found no health or safety concerns during a follow-up on resident falls, indicating improvement in oversight and care. No fines or license suspensions were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Census: 80
Capacity: 126
Deficiencies: 0
May 12, 2025
Visit Reason
The visit was an unannounced Case Management follow-up on an incident report submitted for three residents who experienced falls or fractures.
Findings
The Licensing Program Analyst inspected the facility, interviewed the residents involved, and reviewed relevant documents. No deficiencies or health and safety concerns were observed or cited during the visit.
Report Facts
Residents involved in incident report: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Uy | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Wendy Gibbs | Licensing Program Analyst | Conducted the unannounced Case Management visit and inspection. |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 81
Capacity: 126
Deficiencies: 0
Apr 21, 2025
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be clean, sanitary, and appropriately furnished with no observed deficiencies. All safety equipment was operable, and records including residents' service files, staff personnel files, and medication administration records were maintained in order. No citations were issued during this visit.
Report Facts
Residents in memory care: 28
Residents in assisted living: 59
Bedrooms inspected: 6
Bathrooms inspected: 6
Residents' service files reviewed: 5
Staff personnel files reviewed: 6
Medication Administration Records reviewed: 4
Water temperature range (°F): 109.1
Water temperature range (°F): 115.3
Room temperature range (°F): 76
Room temperature range (°F): 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Uy-Villaruz | Executive Director | Met with Licensing Program Analyst during inspection and received the Facility Evaluation Report |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 82
Capacity: 126
Deficiencies: 0
Mar 25, 2025
Visit Reason
An unannounced Case Management Visit was conducted to deliver an Immediate Exclusion Letter for a staff member due to conduct inimical.
Findings
No deficiencies were observed or cited during the visit. An Immediate Exclusion Letter was delivered for Daniel Castro, who is prohibited from contact with clients and presence at the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Uy | Executive Director | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Wendy Gibbs | Licensing Program Analyst | Conducted the unannounced Case Management Visit and delivered the Immediate Exclusion Letter. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 126
Deficiencies: 0
Jan 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-09-25 alleging that staff did not adequately assist a resident with repositioning.
Findings
The investigation found that the resident requiring repositioning had documented pressure ulcers and care plans in place, staff were trained and reported assisting residents every two hours, and residents interviewed denied sustaining pressure injuries. The Licensing Program Analyst was unable to find sufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Complaint Details
The complaint alleged that staff did not adequately assist a resident with repositioning, leading to redness on the sacrum and a blister on the heel. The allegation was unsubstantiated after review of records, staff interviews, resident interviews, and observations.
Report Facts
Staff trained on skin and pressure injuries: 5
Staff interviewed: 10
Residents interviewed denying pressure injuries: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Uy-Villaruz | Executive Director | Met with department during exit interview and investigation. |
| Matthew Ryan | Administrator | Named as facility administrator in report. |
| Angel Pasa | Health Services Director | Met with department during investigation. |
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation. |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 126
Deficiencies: 0
Jan 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff did not follow advanced directives and requests regarding resuscitative measures.
Findings
The investigation found that resident R1 had a Do Not Attempt Resuscitation (DNAR) order on file, and all interviewed staff confirmed they followed this directive. The Nurse Practitioner confirmed the POLST was consistent with the resident's and family's wishes. No evidence was found to support the allegation, and no deficiencies were cited.
Complaint Details
The complaint alleged that staff did not perform Cardiopulmonary Resuscitation (CPR) or use an Automated External Defibrillator (AED) when a resident was found without a pulse and not breathing. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Capacity: 126
Census: 83
Staff interviewed: 6
Date complaint received: Jan 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelie Pasa | Health Service Director | Met with during the investigation and exit interview |
| Wendy Gibbs | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 126
Deficiencies: 0
Sep 12, 2024
Visit Reason
An unannounced case management visit was conducted due to two Special Incident Reports regarding resident falls submitted to Community Care Licensing on 08/30/2024.
Findings
The Licensing Program Analyst toured the facility and reviewed relevant resident records, observing that all areas were clean and free of hazards. No deficiencies were observed or cited during the visit.
Complaint Details
The visit was triggered by two resident falls: Resident R1 fell on 08/25/2024 resulting in an injury requiring stitches, and Resident R2 fell on 08/26/2024 resulting in a fracture requiring surgery. Both residents' care plans and assessments were reviewed, with no history of falls or indications of fall risk noted for Resident R1, and Resident R2 was found to be independent with no prior falls.
Report Facts
Facility capacity: 126
Resident census: 87
Incident report dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the unannounced case management visit |
| Judith Uy-Villaruz | Executive Director | Met with Licensing Program Analyst during the visit |
| Angelie Pasa | Health Service Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 126
Deficiencies: 0
Apr 24, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not provide adequate food service and that staff were untrained.
Findings
The investigation included interviews with staff and residents, review of training materials and policies, and observation of meal service. The findings showed that staff were properly trained, cell phone use policies were in place and followed, and meal service wait times were shorter than alleged. No deficiencies were observed or cited, and the allegations were unsubstantiated due to lack of evidence.
Complaint Details
The complaint alleged untrained staff and inadequate food service, including long wait times and cold food. The investigation found no evidence to support these allegations, with most residents and staff confirming proper training and acceptable meal service times.
Report Facts
Capacity: 126
Census: 88
Wait time observed: 10
Average wait time observed: 8
Staff reporting longest wait time: 15
Residents reporting extended wait time: 5
Residents reporting no cold food: 13
Staff trained regarding serving residents: 8
Residents believing staff properly trained: 12
Residents not observing staff phone use: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Judith Uy-Villaruz | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Matthew Ryan | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 87
Capacity: 126
Deficiencies: 0
Apr 19, 2024
Visit Reason
The inspection was an unannounced annual required visit using the CARE Inspection Tool to evaluate compliance with licensing regulations.
Findings
The facility was found to be sanitary, appropriately furnished, and in compliance with Title 22 regulations. No deficiencies or citations were observed or issued during the inspection.
Report Facts
Rooms inspected: 6
Residents' service files reviewed: 6
Staff personnel files reviewed: 6
Medication Administration Records reviewed: 4
Fire/Disaster Drills date: Mar 3, 2024
Annual fire clearance date: Apr 16, 2024
Water temperature range (Fahrenheit): 113.5-115.2
Room temperature range (Fahrenheit): 76-78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Judith Uy-Villaruz | Executive Director | Met with Licensing Program Analyst during inspection and received the report. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 126
Deficiencies: 0
Mar 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-11-28 regarding resident falls, timely medical attention, and pressure injuries at Oakmont of Torrance.
Findings
The investigation found no evidence to support the allegations of neglect or lack of care related to a resident fall, failure to seek timely medical attention, or development of multiple pressure injuries. The allegations were determined to be unsubstantiated based on interviews, record reviews, and observations.
Complaint Details
The complaint included three allegations: 1) Resident sustained a fall while in care; 2) Staff did not seek timely medical attention for a resident; 3) Resident developed multiple pressure injuries while in care. The investigation included interviews with staff, residents, family representatives, and review of medical and hospice records. All allegations were found unsubstantiated.
Report Facts
Facility capacity: 126
Resident census: 89
Number of allegations: 3
Number of residents interviewed: 9
Number of staff interviewed: 3
Number of residents denying knowledge of pressure injuries: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Uy-Villaruz | Administrator | Met with during investigation and exit interview |
| Ernand Dabuet | Licensing Program Analyst | Conducted complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 126
Deficiencies: 0
Feb 14, 2024
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to allegations received on 2024-02-06 regarding inadequate resident care including grooming, clothing cleanliness, bed linens, and bathing assistance.
Findings
Based on interviews, observations, and records reviewed, there was insufficient evidence to substantiate any of the allegations. The facility was found to be operational and in good repair, and residents were reported to receive appropriate grooming, clean clothing, clean bed linens, and bathing assistance as needed.
Complaint Details
The complaint investigation addressed allegations that facility staff did not assist residents with grooming, ensure residents wore clean clothing, ensure residents had clean bed linens, and assist residents with bathing as needed. After interviews with staff and residents, and observations, all allegations were found to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 126
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation visit |
| Matthew Ryan | Administrator / Executive Director | Facility administrator involved in the investigation |
| Angelie Pasa | Health Services Director | Met with Licensing Program Analyst during investigation |
| Charisma lepue | Resident Care Coordinator | Met with Licensing Program Analyst during investigation |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 126
Deficiencies: 2
Jan 27, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that a resident wandered away from the facility due to lack of supervision resulting in hypothermia, and that staff did not notify police of the missing resident.
Findings
The investigation substantiated the allegations of neglect/lack of supervision resulting in the resident wandering away and suffering hypothermia, and failure of staff to notify police in a timely manner. Deficiencies were cited related to observation of residents and reporting requirements, with a civil penalty assessed.
Complaint Details
The complaint investigation was substantiated. Resident #1, diagnosed with dementia and a history of wandering, was found outside the facility after wandering away due to lack of supervision. Staff delayed notifying others and failed to notify police promptly. The resident was hospitalized for severe hypothermia and discharged pending Memory Care Unit availability.
Severity Breakdown
Type A: 2
Deficiencies (2)
| 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. This requirement was not met as evidenced by Resident #1 wandering away resulting in hospitalization for hypothermia. | Type A |
| Reporting Requirements: Facility staff failed to call 9-1-1 and report to local law enforcement that Resident #1 had been missing from the facility from 10:00 p.m. on 01/15/23 to 4:00 a.m. on 01/16/23, posing immediate health and safety risk. | Type A |
Report Facts
Civil Penalty: 500
Deficiency Plan of Correction Due Date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina Guilo | Caregiver | Failed to notify staff of missing resident during routine rounds. |
| Latasha Ramirez | Med Tech | Began search for missing resident but failed to look outside due to rain; notified others late. |
| Jacklyn Lefeiloai | Resident Care Coordinator | Notified of missing resident during investigation. |
| Julius Osorio | Executive Director/Administrator | Management approval given to call 9-1-1; involved in notification process. |
| Courtney Clark | Health Services Specialist | Notified of missing resident during investigation. |
| Cortney Holmes | Activity Director | Met with Licensing Program Analyst during investigation and received complaint report. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 126
Deficiencies: 2
Nov 15, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that facility staff did not issue a proper refund and did not safeguard resident's property.
Findings
The investigation substantiated the allegation that the facility staff did not issue a proper refund to resident #1 who did not move into the facility, citing failure to adhere to the admission agreement regarding pre-admission fees. The allegation that the facility did not safeguard resident's property was found unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff did not issue a proper refund. The allegation that the facility did not safeguard resident's property was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee failed to adhere to the admission agreement regarding the pre-admission fee for resident #1. | Type B |
| Resident #1 did not move into the facility and was not issued any refund. | Type B |
Report Facts
Capacity: 126
Census: 87
Community Fee: 11195
Prorated Charge: 7996
Plan of Correction Due Date: Nov 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Ryan | Administrator / Regional Operations Specialist | Interviewed regarding refund policy and complaint allegations |
| Grace Farwell | Memory Care Director | Met with Licensing Program Analyst during investigation visit |
| Lizeth Villegas | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Janae Hammond | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 86
Capacity: 126
Deficiencies: 0
Aug 12, 2023
Visit Reason
An unannounced annual required inspection was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the facility.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with Title 22 regulations. No deficiencies or citations were observed or issued during the inspection.
Report Facts
Rooms inspected: 8
Residents' service files reviewed: 8
Staff personnel files reviewed: 8
Fire/Disaster Drills date: Mar 9, 2023
Annual fire clearance date: Jul 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Matthew Ryan | Administrator | Facility administrator met with LPA during inspection |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 126
Deficiencies: 0
Jul 28, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 07/12/2023 regarding staff not affording resident dignity, not responding timely to resident calls, not waking residents for breakfast, and a resident not receiving a copy of their care plan.
Findings
The investigation found no sufficient evidence to support any of the allegations. Staff and residents denied the allegations, and document reviews and interviews confirmed compliance. All allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not affording resident dignity, not responding timely to calls, not waking residents for breakfast, and failure to provide a copy of the care plan. Interviews with staff (S1-S8) and residents (R1-R7), review of call logs, resident files, and policies found no evidence to support the allegations.
Report Facts
Capacity: 126
Census: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeremiah Randle | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Matt Ryan | Executive Director | Facility representative present during exit interview |
| Julius Osorio | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 126
Deficiencies: 0
May 19, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not answer a resident's call button in a timely manner.
Findings
The investigation found that the resident did activate the call button and staff responded, but the resident declined assistance from one staff member due to gender preference. Assistance was provided by another staff member. Interviews and call logs indicated staff responded promptly and residents reported no issues with timely response. The allegation was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff did not answer a resident's call button in a timely manner. The investigation included interviews with staff and residents, review of call logs, and observation. The allegation was found unsubstantiated.
Report Facts
Capacity: 126
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeremiah Randle | Licensing Program Analyst | Conducted the complaint investigation |
| Anita Csukardi | Executive Director | Facility representative met during the investigation and exit interview |
| Myla Belson | Administrator | Facility administrator listed in the report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 126
Deficiencies: 0
Jan 17, 2023
Visit Reason
The visit was an unannounced case management incident investigation following a report that a resident left the facility and was found outside, currently hospitalized.
Findings
The report documents that a resident left the facility and was found outside, currently receiving hospital care. The facility administrator will follow up with the Licensing Program Analyst and provide requested documents.
Complaint Details
The visit was complaint-related due to an incident where a resident left the facility unsupervised. The complaint is under follow-up with the administrator providing requested documentation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julius Osorio | Executive Director | Interviewed during the incident investigation. |
Inspection Report
Census: 88
Capacity: 126
Deficiencies: 0
Sep 9, 2022
Visit Reason
An unannounced Case Management - Incident visit was conducted to evaluate the facility and investigate an incident.
Findings
The facility was observed to be operational and in good repair with no obstructions in passageways. Residents were engaged in activities and dining. No citations were issued during this visit. Further investigation and analysis of documentation were needed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Administrator | Met with Licensing Program Analyst during the visit and involved in the facility tour and document provision. |
| Jeremiah Randle | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Janae Hammond | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 126
Deficiencies: 0
May 17, 2022
Visit Reason
The visit was an unannounced Case Management Visit to amend the allegations for Complaint Investigation Report LIC9099 and LIC9099-Cs dated 12/22/2021, related to the facility's closed facility #198320078.
Findings
The facility was found clear of COVID-19 infection, with proper screening and sanitizing measures observed. No deficiencies were cited during this visit.
Complaint Details
The visit was conducted to amend allegations from a prior complaint investigation report dated 12/22/2021. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Met with Licensing Program Analyst during the visit and involved in the complaint investigation discussion. |
| Pamela Bunker | Licensing Program Analyst | Conducted the unannounced Case Management Visit and explained the purpose of the visit. |
| Angela J Kendrick | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Original Licensing
Census: 87
Capacity: 126
Deficiencies: 0
Apr 5, 2022
Visit Reason
A pre-licensing inspection was conducted following an application submitted on 2021-10-21 for a Residential Care Facility for the Elderly with a requested capacity of 126 individuals.
Findings
The facility was found to be in substantial compliance with no corrections needed. The inspection covered structure, appliances, toxins, water temperature, medications, resident and staff files, emergency preparedness, and fire safety.
Report Facts
Capacity requested: 126
Census: 87
Memory care rooms: 28
Assisted living rooms: 58
Apartment rooms inspected: 87
Water temperature range: 105
Water temperature range: 118
Refrigerator temperature: 38
Freezer temperature: -4
Fire extinguishers: 27
Fire clearance approval date: Jan 13, 2022
Fire clearance capacity: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeremiah Randle | Licensing Program Analyst | Conducted pre-licensing inspection and signed report |
| Gail Johnson | Licensing Program Analyst | Participated in pre-licensing inspection and conducted Component III |
| Martessa Brown | Licensing Program Analyst | Participated in pre-licensing inspection |
| Myla Belson | Administrator | Facility administrator met during inspection |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
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