Inspection Report Summary
Most inspections found deficiencies related primarily to medication management and resident safety, including missed or incorrect medication doses and failure to update care plans for residents with chronic falls. Several complaint investigations were substantiated, especially involving medication errors that posed immediate health and safety risks, resident supervision lapses leading to injuries, and failure to report incidents timely. The facility received multiple citations and civil penalties, including fines up to $1,000 and a $500 immediate civil penalty related to medication errors and resident injuries; no license suspensions or revocations were noted. The most recent report from October 2, 2025, cited a medication management deficiency involving discrepancies in medication administration records but no enforcement actions were mentioned. While serious issues occurred in earlier reports, recent inspections show some ongoing challenges with medication documentation, indicating no clear pattern of sustained improvement.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 101
Capacity: 144
Deficiencies: 1
Oct 2, 2025
Visit Reason
The visit was an annual audit inspection conducted as a subsequent annual continuation visit to review resident records and medication management.
Findings
The inspection revealed discrepancies in medication administration records for 6 residents, including off-count errors and leftover medications from prior cycles that were not properly disposed of or returned, indicating improper medication management and potential health and safety risks.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Initial dates of medication administration did not align with actual medication counts, resulting in off-count errors and leftover medications not destroyed or returned as required. | Type A |
Report Facts
Residents reviewed: 14
Residents with discrepancies: 6
Census: 101
Total capacity: 144
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Met with Licensing Program Analyst during inspection |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the annual continuation visit and authored the report |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 103
Capacity: 144
Deficiencies: 0
Sep 23, 2025
Visit Reason
The inspection was an annual continuation case management visit conducted to audit staff and resident records and to assess compliance with licensing requirements.
Findings
The Licensing Program Analyst reviewed 10 resident files and 10 staff files, finding that resident records had current physician reports and service plans, and staff records had up-to-date training, valid first aid/CPR certificates, and criminal record clearances. The annual inspection was not completed as medication records and resident medication audits were pending.
Report Facts
Resident files reviewed: 10
Staff files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Met with Licensing Program Analyst during inspection |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the annual continuation inspection |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 103
Capacity: 144
Deficiencies: 0
Sep 16, 2025
Visit Reason
Licensing Program Analyst Tuesday Cabiness conducted an Annual Required visit and inspection of the facility to evaluate compliance with licensing requirements.
Findings
The inspection included a review of resident files, physical plant inspection of residents' rooms, common areas, and kitchen. Due to time constraints, the annual inspection was not completed and will be continued at a later date.
Report Facts
Capacity: 144
Census: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Administrator/Director | Met with Licensing Program Analyst during inspection |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the annual inspection visit |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 144
Deficiencies: 1
May 8, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-02-21 regarding staffing shortages affecting resident care at Oakmont of Valencia.
Findings
The investigation found two allegations unsubstantiated: residents not being changed timely and residents not receiving timely assistance due to staffing shortages. One allegation was substantiated: staff failed to administer a prescribed inhaler dose to Resident #1, posing an immediate health and safety risk.
Complaint Details
The complaint included allegations that residents were not changed timely and not receiving assistance timely due to lack of staff, and that medications were not given as prescribed. The first two allegations were unsubstantiated based on interviews, observations, and record reviews. The medication administration allegation was substantiated based on a missed inhaler dose confirmed by the facility's internal investigation and Special Incident Report.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer prescribed inhaler dose to Resident #1 as ordered by physician. | Type A |
Report Facts
Capacity: 144
Census: 103
Deficiencies cited: 1
Plan of Correction due date: May 8, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Met with Licensing Program Analyst during investigation and named in findings. |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Follow-Up
Census: 101
Capacity: 144
Deficiencies: 2
Apr 17, 2025
Visit Reason
The visit was a case management follow-up to review two Special Incident Reports submitted by the facility involving a medication administration error and an un-witnessed altercation between two residents.
Findings
The inspection found that Resident #1 received medication daily instead of three times per week as prescribed, constituting a medication error with no adverse reactions but requiring hospital evaluation. Additionally, an un-witnessed altercation between two residents resulted in minor injuries and police involvement. A citation and civil penalty were issued for repeated violations.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care: If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff shall be permitted to assist. | Type A |
| Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR, Resident #1 was not giving medication according to doctor's orders. This is an immediate health and safety risk to residents in care. | Type A |
Report Facts
Capacity: 144
Census: 101
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Named in relation to medication error and resident altercation incidents |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the case management visit |
| Troy Agard | Licensing Program Manager | Named in report and deficiency section |
Inspection Report
Annual Inspection
Census: 101
Capacity: 144
Deficiencies: 0
Apr 8, 2025
Visit Reason
The inspection visit was a case management annual continuation to continue the annual inspection of the facility.
Findings
During the visit, the Licensing Program Analyst reviewed 11 client files and 11 staff records. Medication review and continuation of resident records will be completed at a later date. An exit interview and copy of the report were provided.
Report Facts
Client files reviewed: 11
Staff records reviewed: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the inspection visit and reviewed client and staff records |
| Myla Belson | Administrator/Director | Facility administrator met during the inspection |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 144
Deficiencies: 2
Mar 27, 2025
Visit Reason
A case management visit was conducted regarding a Special Incident Report (SIR) about eight residents who were not administered their prescribed medication on 03/17/2025.
Findings
The facility failed to administer medication to eight residents as prescribed, posing an immediate health and safety risk. The facility was previously on a non-compliance plan and has had multiple complaints and case management visits related to medication errors and reporting failures.
Complaint Details
The visit was complaint-related due to a Special Incident Report involving eight residents not receiving their prescribed medication. The facility had prior complaints and case management visits related to medication errors and reporting failures. The complaint was substantiated as deficiencies were found.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Personnel Requirements-General: All personnel shall be given on the job training to safely assist with prescribed medications which are self-administered. This requirement was not met as eight residents missed their daily medication, posing an immediate health and safety risk. | Type A |
| Incidental Medical and Dental Care: Facility staff failed to give medication according to physician's orders for eight residents, posing an immediate health and safety risk. | Type A |
Report Facts
Residents missed medication: 8
Complaints received: 6
Case management visits: 5
Non-compliance plan extension: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Met with Licensing Program Analyst regarding medication error findings. |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Troy Agard | Licensing Program Manager | Oversaw the licensing program and recommended extension of non-compliance plan. |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 144
Deficiencies: 0
Mar 10, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not notice a resident's change in condition, resulting in a urinary tract infection (UTI) that staff failed to detect.
Findings
The investigation found that Resident 1 (R1) was admitted and developed multiple UTIs, with appropriate treatment and communication with the family and primary care physician. The allegation that staff failed to notice R1's UTI was determined to be unsubstantiated based on documentation and interviews.
Complaint Details
The complaint alleged that staff did not notice a resident's change in condition, leading to an undetected UTI. The allegation was found to be unsubstantiated after review of documentation and interviews.
Report Facts
Capacity: 144
Census: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Administrator | Met with Licensing Program Analyst during investigation |
| Tuesday Cabiness | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 144
Deficiencies: 0
Feb 6, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 07/13/2023 regarding medication dispensing, resident positioning resulting in a fall, and infection control policy maintenance.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Medication was administered according to doctor's orders once received, the resident's fall was documented with no injuries and no evidence of improper positioning, and infection control policies were maintained with no recent infection exposures reported.
Complaint Details
The complaint involved three allegations: 1) staff did not ensure medication was dispensed as prescribed, 2) staff did not ensure proper resident positioning resulting in a fall, and 3) staff did not maintain infection control policies. All allegations were found unsubstantiated based on interviews, document reviews, and incident reports.
Report Facts
Capacity: 144
Census: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Myla Belson | Administrator / Executive Director | Facility representative met during the investigation |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 144
Deficiencies: 0
Dec 3, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-07-13 regarding feeding assistance, food quality, and bathing assistance at the facility.
Findings
Based on interviews, observations, and record reviews, there was insufficient evidence to substantiate the allegations. Staff were observed providing feeding assistance as needed, food quality was found to be good with resident input, and bathing assistance was provided timely with support from private caregivers.
Complaint Details
The complaint investigation addressed three allegations: 1) staff not providing feeding assistance, 2) staff not serving food of good quality, and 3) staff not providing bathing assistance in a timely manner. All allegations were determined to be unsubstantiated based on evidence collected during the investigation.
Report Facts
Capacity: 144
Census: 104
Complaint received date: Jul 13, 2023
Private caregiver hours: 8
Private caregiver hours: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation and follow-up visit |
| Myla Belson | Executive Director | Met with Licensing Program Analyst during investigation |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 144
Deficiencies: 0
Dec 2, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-03-21 regarding multiple allegations including resident falls, failure to seek timely medical attention, unattended residents, failure to meet reporting requirements, and failure to protect residents from harm.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. The resident falls were deemed unavoidable due to medical conditions, medical attention was appropriately sought, residents were not left unattended for extended periods, incident reports were submitted timely, and there was no evidence of harm caused by another resident.
Complaint Details
The complaint involved five allegations: 1) Resident sustained a fall and injuries while in care; 2) Staff failed to seek medical attention timely; 3) Staff left resident unattended for extended periods; 4) Staff failed to meet reporting requirements; 5) Staff failed to protect resident from harm by another resident. All allegations were found unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Facility capacity: 144
Census: 104
Number of allegations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation and follow-up visits |
| Myla Belson | Executive Director | Facility representative met during investigation |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 103
Capacity: 144
Deficiencies: 0
Oct 30, 2024
Visit Reason
Licensing Program Analyst Tuesday Cabiness conducted an Annual Required visit and inspection of the facility to evaluate compliance with licensing requirements.
Findings
The facility was toured and observed to be generally sanitary and properly furnished, with adequate food supplies and safety equipment. Due to time constraints, the annual inspection was not completed and will be resumed later to audit resident, staff, and medication records.
Report Facts
Capacity: 144
Census: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Administrator/Director | Met with Licensing Program Analyst during inspection |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the annual inspection visit |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 144
Deficiencies: 1
Oct 30, 2024
Visit Reason
The visit was a case management inspection triggered by a Special Incident Report (SIR) regarding a medication error where staff administered the wrong medication to resident #1.
Findings
The facility reported the medication error incident and implemented additional medication training. The resident was sent to the hospital for evaluation and returned with no adverse effects documented. A citation was issued and a follow-up visit is planned.
Complaint Details
The complaint was substantiated as staff administered the wrong medication to resident #1. The facility reported the incident via SIR and took corrective action including additional training. Further review and follow-up are planned.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff #1 administered the wrong medication to resident #1, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 144
Census: 103
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Reported the medication error and corrective actions |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the case management visit and evaluation |
| Troy Agard | Licensing Program Manager | Supervisor and Licensing Program Manager involved in follow-up |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 144
Deficiencies: 3
Aug 28, 2024
Visit Reason
This was an unannounced complaint investigation visit triggered by multiple allegations received on 05/06/2022 concerning resident hygiene, room odor, laundry service, soiled diapers, food service, safeguarding personal belongings, and dehydration.
Findings
The investigation substantiated allegations that staff failed to meet resident hygiene needs, including failure to clean shoes saturated with diarrhea, malodorous resident rooms due to clogged toilets, and inadequate laundry service related to soap issues. Other allegations regarding soiled diapers, food service, safeguarding personal belongings, and dehydration were unsubstantiated based on interviews, observations, and record reviews.
Complaint Details
The complaint investigation was substantiated for allegations related to hygiene needs, malodorous rooms, and laundry service. Other allegations including soiled diapers, inadequate food service, safeguarding personal belongings, and severe dehydration were unsubstantiated.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Staff failed to clean resident's shoes saturated with diarrhea found in the cabinet with the resident's toothbrush. | Type B |
| Strong odor of feces/urine in room #122B and Memory Care Unit. | Type B |
| Laundry detergent damaged residents' personal items including clothing and bedsheets. | Type B |
Report Facts
Capacity: 144
Census: 106
Deficiencies cited: 3
Plan of Correction Due Date: Sep 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation |
| Myla Belson | Administrator | Met with Licensing Program Analysts during the inspection |
| Cyntia Drachenberg | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 144
Deficiencies: 1
Jun 24, 2024
Visit Reason
The inspection was conducted as a Case Management visit in conjunction with a complaint investigation regarding multiple falls sustained by resident #1 (R1) at the facility.
Findings
The facility failed to report all falls of resident #1 accurately, submitting only one Special Incident Report (SIR) when multiple falls occurred. This failure to report is considered a potential health and safety risk to residents in care. A citation was issued and the Plan of Correction was cleared.
Complaint Details
Complaint control #31-AS-20240618151354 regarding multiple falls of resident #1. The complaint was substantiated as the facility failed to report all falls.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit required reports to the licensing agency, specifically submitting only one SIR for resident #1 when multiple falls occurred. | Type B |
Report Facts
Deficiencies cited: 1
Capacity: 144
Census: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the Case Management visit and complaint investigation |
| Troy Agard | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 144
Deficiencies: 0
Apr 30, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to allegations received on 01/11/2024 regarding hot water availability, residents' incontinence and bathing needs, and elevator functionality at Oakmont of Valencia facility.
Findings
The investigation found that although there were plumbing issues causing low water temperature in some resident rooms and an elevator malfunction, the facility took appropriate corrective actions including notifying families, using vacant rooms for hot water needs, and contacting repair services. All allegations were deemed unsubstantiated based on documentation and interviews.
Complaint Details
The complaint included four allegations: 1) lack of hot water for residents, 2) unmet incontinence needs, 3) unmet bathing needs, and 4) elevator not in working condition. All allegations were investigated and found unsubstantiated after review of documents, interviews, and observation of corrective actions.
Report Facts
Capacity: 144
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Met during investigation and involved in corrective actions |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation visit |
| Gary Tan | Licensing Program Analyst involved in initial physical plant inspection | |
| Michael Cava | Licensing Program Analyst involved in initial physical plant inspection |
Inspection Report
Census: 96
Capacity: 144
Deficiencies: 0
Mar 20, 2024
Visit Reason
A Case Management visit was conducted to amend previous reports related to a complaint and a case management incident dated 06/15/2023.
Findings
The visit involved reviewing and amending prior reports; an exit interview was conducted and a copy of the report was signed and delivered.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the Case Management visit and named in the report. |
| Myla Belson | Administrator | Facility administrator met during the visit. |
| Nichelle Gillyard | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 144
Deficiencies: 0
Mar 18, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were mismanaging residents' medication logs.
Findings
The investigation found no substantial evidence or witnesses to support the allegation of medication log mismanagement. Medication records for three residents were reviewed and found to be complete, and interviews with staff confirmed proper medication administration procedures. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged staff mismanagement of residents' medication logs. The investigation was unannounced and included interviews with staff and residents, and review of medication records. The complaint was found to be unsubstantiated.
Report Facts
Capacity: 144
Census: 96
Number of residents' medication records reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Myla Belson | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 144
Deficiencies: 1
Jun 15, 2023
Visit Reason
The visit was conducted as an initial complaint investigation related to an incident where a resident alleged an attempted sexual assault by another resident. The investigation was triggered by Complaint Control #31-AS-20230608081726.
Findings
The investigation found that the alleged incident could not be confirmed, but there was a lack of information and a plan to address the sexual behaviors of the involved resident. A deficiency was issued due to this lack of planning and documentation.
Complaint Details
The complaint investigation was initiated due to an allegation by resident R1 that resident R2 had tried to rape them. The Executive Director stated the incident was alleged but could not be confirmed. An incident report and SOC341 were submitted. The deficiency was issued due to inadequate planning for R2's behaviors.
Deficiencies (1)
| Description |
|---|
| Lack of information and plan to address resident R2's sexual behaviors. |
Report Facts
Census: 97
Total Capacity: 144
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Administrator | Met with during inspection and mentioned in report |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager and Supervisor |
| Angela Panushkina | Licensing Program Analyst | Conducted record review and authored report |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 144
Deficiencies: 1
Jun 15, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a resident choked another resident in care.
Findings
The investigation substantiated the allegation that resident #2 choked or physically grabbed resident #1 by the neck, causing injury that required emergency hospital evaluation. The incident was not isolated, with a prior related incident documented. Deficiencies were issued but cleared as of the visit date.
Complaint Details
The complaint was substantiated. The incident involved an unwitnessed altercation on 6/6/2023 where resident #1 was choked by resident #2, resulting in hospital evaluation. Previous incidents involving the same residents were documented, confirming ongoing behavior issues and immediate health and safety risks.
Deficiencies (1)
| Description |
|---|
| Failure to accord residents safe, healthful, and comfortable accommodations, furnishings and equipment as required by CCR 87468.1(a)(2). |
Report Facts
Facility Capacity: 144
Census: 97
Deficiency Due Date: Jun 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Interviewed regarding the incident and facility operations |
| Melissa Ruiz | Licensing Program Analyst | Conducted the complaint investigation |
| Nichelle Gillyard | Licensing Program Manager | Oversaw licensing program and signed report |
| Angela Panushkina | Licensing Program Analyst | Involved in licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 144
Deficiencies: 1
Apr 7, 2023
Visit Reason
The visit was a case management investigation triggered by a Special Incident Report (SIR) regarding a medication error where staff administered the wrong medication to a resident.
Findings
The facility reported that the medication error occurred due to confusion between residents with the same first name. The resident was sent to the hospital for evaluation and returned with no adverse effects. The facility implemented additional medication training and changed medication procedures to improve resident identification. A citation and repeat civil penalty were issued due to the incident.
Complaint Details
The visit was complaint-related due to a medication error incident involving resident #1. The incident was substantiated as evidenced by the citation and repeat civil penalty issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Requirements-General: Staff #1 administered the wrong medication to resident #1, posing an immediate health and safety risk to residents in care. | Type A |
Report Facts
Capacity: 144
Census: 97
Plan of Correction Due Date: Apr 10, 2023
Training Dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Reported the medication error incident and corrective actions |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Cassandra Harris | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 144
Deficiencies: 5
Mar 29, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 11/10/2022 alleging that a resident died due to staff administering the wrong medication.
Findings
The investigation substantiated the allegation that a resident (R1) was administered five incorrect medications prescribed to another resident, resulting in death. The facility failed to update resident appraisals, provide adequate medication training to staff, and did not obtain timely medical attention for the resident. Documentation and staff interviews confirmed lack of proper monitoring and follow-up after the medication error.
Complaint Details
The complaint was substantiated. The investigation revealed that the resident died due to staff administering the wrong medication. Staff failed to monitor the resident's condition or obtain timely medical attention. A $500 immediate civil penalty was assessed for the violation resulting in the resident's death.
Severity Breakdown
Type A: 4
Type B: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to regularly observe residents for changes in condition and provide appropriate assistance. | Type A |
| Failure to immediately telephone 9-1-1 when an injury or other circumstance posed an imminent threat to a resident's health. | Type A |
| Failure to update resident appraisals as frequently as necessary to note significant changes. | Type B |
| Failure to provide required on-the-job training and knowledge to safely assist with prescribed medications for staff. | Type A |
| Administrator/Executive Director failed to carry out medication policy, posing immediate health and safety risk. | Type A |
Report Facts
Incorrect medications administered: 5
Civil penalty amount: 500
Staff interviewed: 13
Plan of Correction due date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit. |
| Christine Ferris | Investigator | Assigned investigator who conducted interviews and gathered evidence. |
| Myla Belson | Executive Director | Facility representative met during the investigation. |
| Cyntia Drachenberg | Administrator | Facility administrator named in the report related to medication policy noncompliance. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 144
Deficiencies: 2
Mar 29, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 10/06/2022 regarding unexplained injury, multiple falls due to lack of supervision, and inadequate nighttime supervision for a resident.
Findings
The investigation substantiated that a resident sustained unexplained injuries including fractures from multiple falls due to inadequate supervision and lack of updated care plans. The facility failed to meet the resident's nighttime supervision needs and did not provide adequate staffing or fall prevention plans. One allegation regarding personal hygiene needs was unsubstantiated.
Complaint Details
The complaint investigation was substantiated with findings that the resident sustained unexplained injuries and multiple falls due to lack of supervision and inadequate nighttime supervision. The facility was aware of the resident's decline but failed to update care plans or provide adequate staffing. A $500 immediate civil penalty was assessed for a violation resulting in injury.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide an updated care plan to address resident's chronic falls, posing immediate health and safety risk. | Type A |
| Failure to have an adequate number of direct care staff to support resident's physical, social, emotional, safety and health care needs as identified in current appraisal. | Type A |
Report Facts
Civil penalty amount: 500
Unwitnessed fall incident reports: 12
Estimated days for Plan of Correction: Plan of Correction due date was 03/31/2023 for deficiencies.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and unannounced visits. |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation and signed the report. |
| Myla Benson | Executive Director | Met with Licensing Program Analyst during inspection and involved in findings. |
| Cyntia Drachenberg | Administrator | Facility administrator named in the report. |
| Laarni Santiago | Investigator | Conducted investigation and reviewed medical records. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 144
Deficiencies: 2
Mar 29, 2023
Visit Reason
An unannounced complaint investigation was conducted due to allegations that a resident sustained multiple falls while in care.
Findings
The investigation found that Resident #1 had multiple falls resulting in bruising, skin tears, a nasal tip fracture, and rib fractures between September and October 2022. The facility was aware of the resident's decline but failed to update reappraisals or fall plans to manage the resident's changing condition, substantiating the complaint.
Complaint Details
The complaint was substantiated. Resident #1 sustained multiple falls from 09/12/22 to 10/26/22 causing injuries including bruising, skin tears, nasal tip fracture, and rib fractures. The facility failed to update care plans or fall management despite awareness of the resident's decline.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Inadequate number of direct care staff to support resident's needs as identified in current appraisal. | Type A |
| Failure to provide updated care plan addressing resident's chronic falls. | Type A |
Report Facts
Capacity: 144
Census: 97
Deficiencies cited: 2
Plan of Correction Due Date: Mar 31, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and issued findings |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation report |
| Myla Benson | Executive Director | Met with Licensing Program Analyst during inspection |
| Laarni Santiago | Investigator | Conducted investigation and reviewed medical records |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 144
Deficiencies: 0
Mar 3, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2023-02-27 alleging that facility staff were not providing residents with their records.
Findings
The investigation found that the records requested were no longer needed and the complaint was retracted. The Executive Director reported that requests from attorney offices are handled by the facility's corporate legal team, and documentation confirmed the allegation was unsubstantiated.
Complaint Details
The complaint alleged that facility staff were not providing residents with their records. The allegation was found to be unsubstantiated after investigation and communication with the complainant and facility staff.
Report Facts
Facility capacity: 144
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myla Belson | Executive Director | Interviewed during the complaint investigation |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation |
| Cassandra Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 144
Deficiencies: 0
Jan 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff were not assisting residents in a timely manner and that staff do not answer the phone when residents call for assistance.
Findings
The investigation included interviews with staff and residents, a physical plant walk-through, and testing of resident emergency pendants and pull cords. The allegations were found to be unsubstantiated, with no deficiencies issued during the visit.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not assisting residents timely and not answering phones. Interviews and inspections showed staff responded within reasonable times and residents were satisfied with assistance.
Report Facts
Residents interviewed: 8
Pendants tested: 7
Emergency pull cords tested: 4
Staff interviewed: 5
Facility capacity: 144
Facility census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and inspection. |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation report. |
| Mayla Belson | Executive Director | Met with Licensing Program Analyst and interviewed during investigation. |
| Julius C Osorio | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 144
Deficiencies: 0
Dec 14, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not meeting residents' showering needs.
Findings
The investigation found that all hygiene needs were being met, residents were scheduled for showers at least two to three times a week or as needed, and caregivers were available to assist. The allegation was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that a resident did not shower for weeks. After interviews, observations, and document reviews, the allegation was found to be unsubstantiated.
Report Facts
Capacity: 144
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation |
| Julius Osorio | Executive Director | Met with Licensing Program Analyst during investigation |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 144
Deficiencies: 0
Nov 22, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-11-18 regarding resident care and facility operations at Oakmont of Valencia.
Findings
The investigation found no substantiated violations; all allegations including resident care, staff training, meal service, and food supply were deemed unsubstantiated based on interviews, observations, and document reviews.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to assist residents with incontinence needs, not following admission agreements, inadequate staff training, failure to ensure hearing aid use, not showering residents, late meal service, lack of full-time food service employee, not following menu plans, and insufficient food purchase. All were found unsubstantiated after thorough investigation.
Report Facts
Capacity: 144
Census: 101
Staff training hours: 40
Staff shadowing days: 5
Meal delay: 5
Meal delay: 10
Food restock frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Cava | Licensing Program Analyst | Assisted in the complaint investigation |
| Julius Osorio | Regional Operations Specialist | Met with LPAs during the investigation |
| Cyntia Drachenberg | Administrator | Facility administrator named in report |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 144
Deficiencies: 0
Nov 22, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 11/18/2022 regarding inadequate staffing, medication administration without physician's orders, and injury from over medication.
Findings
The investigation included interviews with staff, residents, and review of facility records. All allegations were found to be unsubstantiated based on interviews and document review, with no immediate health and safety issues observed during the visit.
Complaint Details
The complaint included three allegations: 1) Facility does not have adequate staffing, 2) Staff administered medications to residents without physician's orders, and 3) Resident sustained an injury from being over medicated. All allegations were deemed unsubstantiated after investigation.
Report Facts
Capacity: 144
Census: 101
Staff interviewed: 5
MedTechs interviewed: 3
Residents interviewed: 10
Resident files reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Cava | Licensing Program Analyst | Assisted in the complaint investigation |
| Julius Osorio | Regional Operations Specialist | Met with investigators during the visit |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 144
Deficiencies: 1
Nov 15, 2022
Visit Reason
The visit was a Case Management inspection conducted to issue a deficiency related to a complaint control number 31-AS-20221110143440 regarding a failure to submit an Incident Report in a timely manner.
Findings
The licensee failed to submit a written Unusual Incident / Injury Report to the Community Care Licensing Department within seven days of the incident occurring on 11/06/22, which is a repeated violation resulting in a civil penalty of $1,000 and a citation.
Complaint Details
The visit was triggered by a complaint control number 31-AS-20221110143440. The deficiency was substantiated as the licensee did not comply with reporting requirements for an incident that posed a potential health and safety risk to persons in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency regarding an incident that occurred on 11/06/22 within the required timeframe. | Type B |
Report Facts
Civil penalty amount: 1000
Plan of Correction Due Date: Nov 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the Case Management visit and issued the deficiency |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 144
Deficiencies: 1
Nov 15, 2022
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 06/28/2022 alleging that a resident sustained a severe fracture while in care.
Findings
The investigation found that a staff member left dementia residents unsupervised in a movie theater, which led to a resident falling and sustaining a severe hip fracture requiring surgery. The allegation was substantiated and a $500 immediate civil penalty was assessed.
Complaint Details
The complaint was substantiated. The investigation included interviews with the resident's family, facility staff, administrator, former residents, and review of medical records. The staff member admitted leaving their post before being relieved, leading to unsupervised residents and the injury.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision of residents, resulting in a resident sustaining a severe hip fracture. | Type A |
Report Facts
Civil penalty amount: 500
Census: 95
Total capacity: 144
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and signed the report. |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Dennis Sang | Investigator | Conducted interviews and investigation for the complaint. |
| Cyntia Drachenberg | Administrator | Facility administrator involved in the investigation. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 144
Deficiencies: 1
Nov 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit in response to an allegation of lack of supervision resulting in a resident being assaulted by another resident while in care.
Findings
The investigation found that resident R1 exhibited aggressive behavior and assaulted resident R2 without staff supervision, causing injury. The facility failed to protect residents from assault by R1, substantiating the complaint.
Complaint Details
The complaint was substantiated. The allegation was that lack of supervision resulted in a resident being assaulted by another resident. Interviews and document review confirmed the facility failed to protect residents from assault by R1.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide basic services as required by Health and Safety Code section 1569.312, resulting in failure to protect resident R2 from assault by resident R1. | Type A |
Report Facts
Capacity: 144
Census: 95
Incident reports: 3
Plan of Correction due date: Dec 1, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation |
| Julius Osorio | Regional Operations Specialist | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 144
Deficiencies: 1
Nov 7, 2022
Visit Reason
An unannounced case management visit was conducted due to an incident reported to licensing.
Findings
The facility was found non-compliant with medication documentation requirements, specifically medications were not documented on Centrally Stored Medication and Destruction Records (CSMDR), posing an immediate health and safety risk. A civil penalty of $1,000 was issued for this repeated violation.
Complaint Details
Visit was triggered by an incident reported to licensing. Further investigation was determined to be needed and a return visit was planned.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff handling medications were not properly documenting prescribed and PRN medications on Centrally Stored Medication and Destruction Records (CSMDR), posing an immediate health and safety risk to residents. | Type A |
Report Facts
Civil penalty amount: 1000
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the inspection and authored the report |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
| Sukjeevan Saund | Health Service Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 144
Deficiencies: 0
Oct 26, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that a resident sustained injuries from falls while in care.
Findings
The investigation found insufficient evidence to substantiate the allegation that the resident sustained injuries from a fall. Interviews and document reviews indicated the resident did not fall but folded in half and was caught by a caretaker, and the resident has a tendency to injure self.
Complaint Details
The complaint alleged that on 10/18/22, a resident sustained injuries from falls while in care. The investigation included interviews with staff and witnesses and review of incident reports. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 144
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the investigation |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 144
Deficiencies: 0
Oct 26, 2022
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that staff were inappropriately administering medication to a resident.
Findings
Based on interviews with the Executive Director and MedTech staff, and review of relevant documents, the allegation was found to be unsubstantiated. Staff were reported to follow residents' doctor's orders and maintain proper medication records.
Complaint Details
The complaint alleged inappropriate medication administration by staff. The investigation included interviews and document review and concluded the allegation was unsubstantiated.
Report Facts
Facility capacity: 144
Census: 102
Number of MedTechs interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 144
Deficiencies: 0
Oct 26, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff were retaliating against a resident.
Findings
Based on interviews and document review, the allegation of staff retaliation against the resident was found to be unsubstantiated. The facility did not issue an eviction letter nor retaliate against the resident.
Complaint Details
The complaint alleged staff retaliation against a resident. The investigation included interviews with the Executive Director and staff, a physical plant tour, and review of relevant records. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 144
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during investigation |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 144
Deficiencies: 0
Oct 22, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility was malodorous.
Findings
Based on interviews with staff and observations during the visit, there was no evidence of a bad smell at the facility and no complaints were received regarding odor. Therefore, the allegation was unsubstantiated.
Complaint Details
The complaint allegation was that the facility was malodorous. The investigation found insufficient evidence to verify the allegation, resulting in an unsubstantiated status.
Report Facts
Capacity: 144
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager |
| Rhonda Bunnin | Memory Care Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 106
Capacity: 144
Deficiencies: 0
Oct 7, 2022
Visit Reason
The visit was conducted to address an incorrect deficiency report issued on 09/28/22 due to a technical/computer glitch issue.
Findings
During the visit, a new Case Management Deficiency report was issued with a corrected civil penalty of $1,000, replacing the previously issued incorrect penalty of $23,100.
Report Facts
Civil penalty amount: 23100
Civil penalty amount: 1000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the unannounced visit and issued the corrected deficiency report |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the visit |
| Nichelle Gillyard | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 144
Deficiencies: 1
Sep 28, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 07/21/2022 regarding residents' pull cords being in disrepair and staff not responding timely to call buttons, as well as allegations about visitor mask compliance and timely resident showers.
Findings
The investigation substantiated that residents' pull cords in the Memory Care Unit were in disrepair and non-operational, and staff response to call buttons was not timely. Other allegations regarding visitor mask compliance and timely resident showers were found unsubstantiated based on interviews and observations.
Complaint Details
The complaint investigation was substantiated for allegations that residents' pull cords were in disrepair and staff did not respond timely to call buttons. Allegations that facility staff were not ensuring visitors wore masks and that residents were not showered timely were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents' pendant and emergency cord devices in both Memory Care Units were in poor repair and non-operational, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 144
Census: 102
Deficiencies cited: 1
Plan of Correction Due Date: Oct 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation |
| Cyntia Drachenberg | Executive Director | Facility representative interviewed during investigation |
Inspection Report
Annual Inspection
Census: 102
Capacity: 144
Deficiencies: 0
Sep 28, 2022
Visit Reason
Annual required visit and inspection of the facility conducted by Licensing Program Analyst Angela Panushkina to ensure compliance with licensing regulations.
Findings
The facility was found to be in compliance with no deficiencies cited. Observations included proper infection control, sanitary conditions in kitchen and resident rooms, proper medication documentation, and well-maintained common and outside areas.
Report Facts
Number of resident rooms: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the annual required visit and inspection. |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Follow-Up
Census: 102
Capacity: 144
Deficiencies: 1
Sep 28, 2022
Visit Reason
This unannounced case management visit was conducted to address issues previously noted during a complaint investigation visit on 2022-09-14 regarding staff dispensing wrong medications not prescribed to a resident.
Findings
The facility failed to properly document prescribed and PRN medications on Centrally Stored Medication and Destruction Records (CSMDR), posing a potential health and safety risk to residents. A civil penalty of $23,100 was previously issued for this repeated violation.
Complaint Details
The visit followed a complaint investigation alleging staff dispensed wrong medications not prescribed to a resident (Complaint Control # 31-AS-20220805133307).
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff handling medications were not properly documenting prescribed and PRN medications on Centrally Stored Medication and Destruction Records (CSMDR). | Type B |
Report Facts
Civil penalty amount: 23100
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the unannounced case management visit and documented findings |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Cyntia Drachenberg | Administrator | Facility Administrator met during the visit |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 144
Deficiencies: 0
Sep 28, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility was not following Covid-19 protocol.
Findings
The investigation found that the facility was following updated COVID-19 screening guidance from the CDC and California Department of Public Health, which no longer required visitor temperature checks or proof of vaccination, but the facility continued to encourage mask wearing. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that the facility was not following Covid-19 protocol. The investigation was unsubstantiated based on interviews and document review.
Report Facts
Capacity: 144
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the investigation |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 144
Deficiencies: 0
Sep 28, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff dispensed wrong medications not prescribed to residents and falsified resident medication logs.
Findings
The investigation found no substantial evidence or witnesses to support the allegations. Medication records for three residents were reviewed and found to be complete and accurate. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on review of medication records and interviews with staff. No evidence was found to support the allegations of medication errors or falsification of medication logs.
Report Facts
Capacity: 144
Census: 102
Number of residents reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Cyntia Drachenberg | Executive Director | Facility administrator met during the investigation |
| Nichelle Gillyard | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 144
Deficiencies: 0
Sep 17, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-01-03 regarding fecal smears and odor in a resident's room.
Findings
The investigation included a physical plant tour, staff interviews, and record reviews. The facility and randomly chosen resident rooms appeared clean and smelled fresh. Staff reported regular cleaning schedules and no complaints related to the allegations. Both allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, observations, and record reviews.
Report Facts
Capacity: 144
Census: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Funderberg | Administrator | Facility administrator named in the report |
| Cinthya Drachenberg | Executive Director | Met with Licensing Program Analyst during the investigation |
| Nichelle Gillyard | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Capacity: 144
Deficiencies: 1
Sep 14, 2022
Visit Reason
The visit was a Case Management visit conducted due to failure to timely submit several unusual incident/injury reports that occurred between 08/03/2022 and 08/22/2022.
Findings
The licensee failed to notify the Community Care Licensing Department regarding twelve incidents that occurred between 08/03/22 and 08/22/22 within the required seven days, posing a potential health and safety risk to persons in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit written reports to the licensing agency regarding twelve incidents occurring between 08/03/22 and 08/22/22 as required by Title 22 regulations. | Type B |
Report Facts
Incidents not reported timely: 12
Facility capacity: 144
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the Case Management visit and documented findings |
| Cyntia Drachenberg | Executive Director | Met with Licensing Program Analyst during the visit |
| Nichelle Gillyard | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 144
Deficiencies: 0
Sep 14, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not prevent a resident from physically abusing another resident.
Findings
The investigation found no evidence of resident-to-resident abuse; instead, it was determined that resident #1 was aggressive and abusive towards staff members. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff failed to prevent a resident from physically abusing another resident. After interviews with staff and residents and review of records, the allegation was found unsubstantiated.
Report Facts
Capacity: 144
Census: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation |
| Cynthia Drachenberg | Executive Director | Facility administrator met during investigation |
| Nichelle Gillyard | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 144
Deficiencies: 2
Sep 14, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not inform the responsible party of an unusual incident and did not prevent a resident from wandering away from the facility.
Findings
The investigation substantiated both allegations: staff failed to notify the responsible party in writing in a timely manner about the resident's elopement incidents, and staff failed to prevent the resident from wandering away from the facility, posing immediate health and safety risks.
Complaint Details
The complaint investigation was substantiated. The resident eloped from the Memory Care Unit on 08/04/2022 and was found minutes later. Staff did not notify the responsible party timely in writing, and another elopement incident was reported on 08/26/2022 with undetermined circumstances.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure the safety of a resident who wandered away from the facility, violating delayed egress device requirements and posing immediate health and safety risks. | Type A |
| Failure to notify the resident's responsible party in writing within seven days of the incident, violating reporting requirements. | Type B |
Report Facts
Capacity: 144
Census: 103
Deficiency count: 2
Plan of Correction Due Dates: Type A deficiency due 09/16/2022, Type B deficiency due 09/21/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
| Cynthia Drachenberg | Executive Director | Facility representative interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 144
Deficiencies: 2
Aug 10, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that Resident 1 sustained an unexplained injury for which staff failed to obtain timely medical care and that due to staff neglect Resident 1 sustained severe facial injuries.
Findings
The investigation found sufficient evidence to substantiate the allegations that staff failed to obtain timely medical care for Resident 1's unexplained injury and that neglect caused severe facial injuries. However, the allegation of questionable death was unsubstantiated based on death certificate review.
Complaint Details
The complaint alleged that Resident 1 sustained an unexplained injury and staff failed to obtain timely medical care, and that due to staff neglect Resident 1 sustained severe facial injuries. The investigation was substantiated for these allegations. The allegation of questionable death was unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to immediately telephone emergency response (9-1-1) for emergencies not directly related to the resident's terminal illness. | Type A |
| Failure to meet resident's needs as identified in the pre-admission appraisal, specifically neglecting to put footrests on Resident 1's wheelchair causing a fall and severe facial injuries. | Type A |
Report Facts
Capacity: 144
Census: 99
Civil penalty: 500
Plan of Correction Due Date: Aug 12, 2022
Plan of Correction Completion Date: Sep 2, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Drachenberg | Executive Director | Met with Licensing Program Analyst during investigation and provided information about incidents |
| Stephanie Funderberg | Administrator | Named as facility administrator in report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 144
Deficiencies: 0
Feb 2, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations including insufficient staffing, failure to provide activities, hygiene needs, adequate food service, safe environment, and COVID-19 precautions.
Findings
All allegations were found to be unsubstantiated based on interviews with residents and staff, observations of the facility environment, activities, food service, hygiene care, and COVID-19 precautions.
Complaint Details
The complaint investigation was triggered by allegations of insufficient staffing, lack of activities, unmet hygiene needs, inadequate food service, unsafe environment, and failure to take COVID-19 precautions. After review and interviews, all allegations were deemed unsubstantiated.
Report Facts
Residents interviewed: 11
Staff interviewed: 3
Response time to pendant call: 8
Facility capacity: 144
Census: 90
Visit start time: 915
Visit end time: 1640
Residents observed in activity: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tom Park | Administrator | Facility administrator met with Licensing Program Analyst during visit |
| Stephanie Funderberg | Administrator | Named as facility administrator in report header |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 144
Deficiencies: 3
Feb 2, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-01-03 regarding medication administration, staff training, and facility signage.
Findings
The investigation substantiated that facility staff did not properly document medication administration, staff training was inadequate, and required signage was not properly posted. An allegation that the facility did not serve nutritious foods was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that facility staff did not give residents their medications correctly, staff were not adequately trained, and facility signage was not properly posted. The allegation that the facility does not serve nutritious foods was unsubstantiated.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR. | Type B |
| Staff were not provided the required 24 hours of initial training for assisting residents with self-administration of medication. | Type B |
| Ombudsman’s poster was not posted in the main entryway as required, but instead was placed on a second floor activity room. | Type B |
Report Facts
Census: 90
Total Capacity: 144
Deficiencies cited: 3
Plan of Correction Due Date: Feb 9, 2022
Plan of Correction Due Date: Feb 3, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tom Park | Administrator | Met with Licensing Program Analyst during the investigation and involved in findings discussion |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 144
Deficiencies: 1
Nov 3, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident was allowed to leave the facility without staff supervision.
Findings
The investigation substantiated the allegation that a resident exited the facility unsupervised and walked down the street before being returned by a family member of another resident. The facility failed to ensure the safety of the resident, posing an immediate health and safety risk.
Complaint Details
The complaint was substantiated based on the finding that a resident left the facility without staff supervision and was found outside by a family member of another resident.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the safety of a resident who wandered away from the facility, violating CCR 87705(k)(6) related to delayed egress devices and resident safety. | Type A |
Report Facts
Capacity: 144
Census: 91
Deficiency Type A: 1
Plan of Correction Due Date: Nov 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Funderburg | Administrator | Facility administrator interviewed during investigation |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Original Licensing
Capacity: 144
Deficiencies: 1
Sep 17, 2021
Visit Reason
An unannounced required pre-licensing visit was conducted due to a change in corporation for the facility.
Findings
The facility was found to be clean, sanitary, and in compliance with Title 22 Regulations with no health and safety hazards preventing license approval. Some staff files were missing employee rights documentation, and the administrator was instructed to update and complete these files.
Deficiencies (1)
| Description |
|---|
| Staff files missing employee rights documentation |
Report Facts
Facility capacity: 144
Water temperature: 107.7
Residents at one table: 4
Food restock frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderberg | Administrator | Informed about the visit and responsible for staff file corrections |
| Angelica Arambulo | Licensing Program Analyst | Conducted the pre-licensing visit and inspection |
| Susan Ralph | In house nurse | Accompanied the physical plant tour |
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