Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated or unfounded. The facility had isolated issues related to cleanliness and failure to report a significant resident weight loss in an April 2, 2025 complaint investigation, and earlier concerns about staff qualifications and timely resident care in June 7, 2023, which included a finding of immediate health and safety risk due to unqualified personnel administering injections. Other deficiencies involved staff training and criminal record clearance noted in early 2024 but were minor and did not lead to enforcement actions or fines. The most recent inspection on October 16, 2025, was clean with no deficiencies cited, indicating improvement since prior findings. No fines, license suspensions, or severe enforcement actions were listed in the available reports.
Deficiencies (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a October 2025 inspection.
Census over time
Inspection Report
| Name | Title | Context |
|---|---|---|
| Barbara Fleck | Administrator | Met with Licensing Program Analyst during inspection. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Barbara Fleck | Executive Director | Met with Licensing Program Analyst and involved in investigation findings |
| Cassandra Mikkelson | Licensed Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Cassandra Mikkelson | Licensed Program Analyst | Conducted the complaint investigation and delivered findings. |
| Laura Munoz | Licensing Program Manager | Named in relation to the licensing program management and report. |
| Barbara Fleck | Administrator | Met with the investigator during the unannounced visit. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Cassandra Mikkelson | Licensed Program Analyst | Conducted the complaint investigation and authored the report |
| Barbara Fleck | Administrator | Met with the investigator and participated in interviews |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Barbara Fleck | Administrator | Met with during the inspection. |
| Cassandra Mikkelson | Licensing Program Analyst | Conducted the inspection. |
| Laura Munoz | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lisa Velasco | Health Services Director | Met with the Licensing Program Analyst during the inspection |
| Haley Thomas | Administrator | Facility administrator named in the report |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Haley Thomas | Administrator | Met with Licensing Program Analyst during inspection |
| Bethany Mirlohi | Licensing Program Analyst | Conducted complaint investigation |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Haley Thomas | Administrator | Met with Licensing Program Analyst during inspection |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Haley Thomas | Administrator | Met with Licensing Program Analyst during inspection and discussed incident report. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced case management visit and interview. |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Haley Thomas | Administrator | Met with Licensing Program Analyst during inspection and agreed to plan of correction |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Troy Ordonez | Licensing Program Manager | Named as supervisor and licensing program manager |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Haley Thomas | Administrator | Met with Licensing Program Analyst during inspection |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the annual inspection |
| Troy Ordonez | Licensing Program Manager | Named in report header |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Haley Thomas | Administrator | Met with Licensing Program Analysts during the visit and acknowledged the immediate exclusion order. |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Haley Thomas | Administrator | Met with Licensing Program Analysts during the visit |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced case management visit |
| Lavinia Muscan | Licensing Program Analyst | Conducted the unannounced case management visit |
| Troy Ordonez | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and facility tour. |
| Jessica Pryor | Administrator | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Antonette Edwards | Administrator | Met with Licensing Program Analyst during inspection and provided information regarding document release |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Troy Ordonez | Licensing Program Manager | Oversaw the complaint investigation |
| Lisa Velasco | Health Services Director | Met with Licensing Program Analyst during inspection |
| Antonette Edwards | Administrator | Facility administrator mentioned in relation to medication mishandling allegation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Antonette Edwards | Administrator | Met with Licensing Program Analyst during the visit |
| Troy Ordonez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Antonette Edwards | Administrator | Met with Licensing Program Analyst during the visit and acknowledged receipt of the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Antonette Edwards | Administrator | Met with Licensing Program Analyst during the inspection visit. |
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| Antonette Edwards | Executive Director | Met with Licensing Program Analyst during the pre-licensing visit. |
| Gabriel Morton | Maintenance Director | Participated in the facility tour during the pre-licensing visit. |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Antonette Edwards | Administrator | Participant in COMP II telephone call and facility administrator |
| Mirella Quaranta | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Stefania Fonteno | Licensing Program Analyst | Named as Licensing Program Analyst on the report |
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