Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. However, some substantiated issues occurred, primarily involving medication management errors and a personal rights violation by staff, with the most recent substantiated deficiencies related to medication administration and falsification of records found in the April 17, 2025 complaint investigation. The facility did not have any fines, license suspensions, or enforcement actions listed in the available reports. The latest report from April 25, 2025, the annual inspection, had no deficiencies and found the facility clean, safe, and in good repair. This suggests improvement following earlier medication-related concerns, although isolated issues with medication practices and resident dignity were noted over time.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 108
Capacity: 123
Deficiencies: 0
Apr 25, 2025
Visit Reason
The inspection was an unannounced case management visit to complete the annual inspection originally scheduled for 04/17/2025.
Findings
The facility was found to be clean, safe, and in good repair with no pathway obstructions. All safety and health requirements were met, including proper storage of hazardous materials and medications, appropriate food supplies, and adequate resident and staff records. No deficiencies were cited during this inspection.
Report Facts
Facility internal temperature: 74
Facility internal temperature: 75
Facility internal temperature: 76
Refrigerator temperature: 40
Freezer temperature: 0
Licensed capacity: 123
Census: 108
Bedridden capacity: 10
Hospice waiver capacity: 20
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Met with Licensing Program Analyst during inspection and named as Administrator |
| Rebecca Borunda | Licensing Program Analyst | Conducted the unannounced case management annual inspection |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 123
Deficiencies: 2
Apr 17, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including staff not administering medications as prescribed, falsification of medication administration records, lack of supervision resulting in resident injuries, medication theft, failure to treat resident with dignity, and failure to keep resident's room clean.
Findings
The investigation substantiated that staff did not administer medications as prescribed and falsified medication administration records, posing a potential health risk to all 106 residents. It was found that a staff member administered medication prescribed to another resident. Other allegations including lack of supervision, medication theft, failure to treat resident with dignity, and failure to keep resident's room clean were deemed unsubstantiated based on interviews, records review, and observations.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not administer medications as prescribed and falsified medication administration records. The investigation found that Resident 1's anti-psychotic medication was not reordered and that medication from another resident was administered to Resident 1. Other allegations including lack of supervision, medication theft, failure to treat resident with dignity, and failure to keep resident's room clean were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility staff did not administer medications as prescribed by a physician, violating CCR 87465(c)(2). | Type B |
| Facility staff falsified resident’s medication administration record, violating CCR 87465(h)(6). | Type B |
Report Facts
Resident census: 106
Total capacity: 123
Medication supply missing: 9
Medication refill missed: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Met during investigation and named in findings related to medication administration and plan of correction |
| Dennis Prejusa | Resident Care Director | Met during investigation and involved in medication administration training |
| Rebecca A Borunda | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jennifer Lott | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 106
Capacity: 123
Deficiencies: 0
Apr 17, 2025
Visit Reason
The visit was an unannounced Required 1-Year annual inspection to evaluate compliance with licensing requirements at the assisted living and memory care facility.
Findings
No deficiencies were cited during the visit. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed.
Report Facts
Capacity: 123
Census: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Dennis Prejusa | Resident Care Director | Participated in exit interview confirming receipt of report and licensee appeal rights |
| Rebecca Borunda | Licensing Program Analyst | Conducted the unannounced Required 1-Year visit |
Inspection Report
Follow-Up
Census: 108
Capacity: 123
Deficiencies: 0
Mar 17, 2025
Visit Reason
The visit was an unannounced case management follow-up regarding an incident report involving a resident who complained of pain and was subsequently transported to the hospital.
Findings
No deficiencies were cited during the visit, and no immediate health or safety concerns were observed. The Licensing Program Analyst conducted a health and safety check, observed residents, and reviewed facility records.
Report Facts
Capacity: 123
Census: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Met with during the inspection and named in the report |
| Rebecca Borunda | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 123
Deficiencies: 0
Dec 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations including noncompliance with admission agreement terms, inadequate resident assessments, failure to update resident appraisals, insufficient staffing, and failure to follow appropriate fire clearance.
Findings
The investigation found no substantiated evidence supporting the allegations. Resident assessments and service plans were appropriately updated, staffing levels were generally sufficient, and the facility complied with admission agreement terms and fire clearance regulations. The allegations were deemed unsubstantiated or unfounded.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to comply with admission agreement terms, inadequate resident assessments, failure to update appraisals, insufficient staffing, and failure to follow fire clearance. The investigation included interviews, records review, and facility tour. Evidence did not support the allegations, and concerns about supervision were related to a third-party caregiver, not facility staff.
Report Facts
Capacity: 123
Census: 110
Staff scheduled per shift: 4
Staff scheduled per shift: 5
Staff scheduled overnight shift: 2
Staff scheduled overnight shift: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Sheryl Johnston | Executive Director | Facility representative met during the investigation and named in findings |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 123
Deficiencies: 0
Apr 24, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations including failure to assist resident with toileting needs, medication mismanagement, improper transfer techniques, leaving residents in soiled clothing, poor food quality, and facility cleanliness issues.
Findings
The investigation included interviews, records review, and facility tour. Conflicting information was found regarding some allegations, but no specific medication errors were identified. Pest control was ongoing despite some limitations due to the COVID-19 pandemic. The allegations were ultimately deemed unsubstantiated based on the evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to assist resident with toileting needs, medication mismanagement, improper transfer technique causing bruising, leaving resident in soiled clothing, poor food quality, and facility cleanliness issues. The investigation found conflicting information and no evidence to substantiate the allegations.
Report Facts
Capacity: 123
Census: 113
Complaint Control Number: 08-AS-20200611092333
Visit start time: 10:00 AM
Visit end time: 03:15 PM
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kristin Mulligan | Business Office Manager | Met with Licensing Program Analyst during the visit |
| Kurt Norden | Administrator | Facility administrator named in report header |
| Sheryl Johnston | Executive Director | Participated in exit interview and acknowledged report receipt |
Inspection Report
Annual Inspection
Census: 116
Capacity: 123
Deficiencies: 0
Feb 27, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing regulations at Ocean Hills Assisted Living & Memory Care.
Findings
The facility was found to be in full compliance with no deficiencies observed or cited. The environment was safe, clean, and well-equipped, with all required safety and licensing measures in place.
Report Facts
Days supply of perishable food: 2
Days supply of non-perishable food: 7
Facility capacity: 123
Resident census: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Participated in the inspection and exit interview |
| Jiovani Anderson Diaz | Assistant Director | Participated in the inspection and exit interview |
| Jamie Colon | Business Office Manager | Participated in the inspection |
| Juliana Barfield | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 123
Deficiencies: 0
Dec 4, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation of lack of supervision resulting in sexual abuse involving two residents.
Findings
The investigation included interviews, records review, and facility tour. The allegation was found unsubstantiated based on the preponderance of evidence, with no history of inappropriate or aggressive behaviors by the involved residents and no prior knowledge of the alleged incident by facility staff.
Complaint Details
The complaint alleged lack of supervision resulting in sexual abuse involving Resident 1 and Resident 2. The allegation was investigated and deemed unsubstantiated.
Report Facts
Complaint Control Number: 8
Capacity: 123
Census: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sheryl Johnston | Executive Director | Facility representative met during the investigation |
| Dennis Prejusa | Director of Resident Care | Facility staff involved in the investigation |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 123
Deficiencies: 0
Nov 9, 2023
Visit Reason
The visit was conducted in response to a Report of Suspected Dependent Adult/Elder Abuse involving Resident #1, which the licensee self-submitted to the licensing office.
Findings
During the unannounced case management incident visit, no deficiencies were observed or cited. The Licensing Program Analyst performed a facility tour, welfare check, collected records, and interviewed the resident and relevant staff.
Complaint Details
The visit was triggered by an SOC341 Report of Suspected Dependent Adult/Elder Abuse involving Resident #1. The complaint was investigated through interviews and record review, with no deficiencies found.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced case management incident visit. |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 123
Deficiencies: 0
Oct 24, 2023
Visit Reason
The visit was an unannounced case management follow-up on an incident report regarding a resident who eloped from the facility and sustained an injury requiring hospitalization.
Findings
During the visit, the Licensing Program Analyst toured the facility, conducted a health and safety check, observed residents, and reviewed facility records. No deficiencies were cited or observed.
Complaint Details
The complaint involved a resident who eloped from the facility on 10/16/2023 and was hospitalized due to injury. The visit was to follow up on this incident report received on 10/20/2023.
Report Facts
Capacity: 123
Census: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Colon | Business Office Manager | Met during the visit and involved in the exit interview |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 123
Deficiencies: 1
Sep 6, 2023
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that a resident was left unattended for an extended period of time resulting in hospitalization.
Findings
The investigation substantiated the allegation that Resident 1 was left unattended for an extended period, leading to hospitalization. The facility failed to provide adequate care and supervision, posing a potential health or safety risk.
Complaint Details
The complaint was substantiated based on evidence that Resident 1 was left unattended from approximately 2:30 PM until found unresponsive between 6:00 PM and 7:10 PM on September 7, 2020. Staff member S1 failed to check on the resident as required and was terminated on September 15, 2020.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care, supervision, and services that meet individual needs, resulting in a potential health or safety risk to one resident. | Type B |
Report Facts
Resident count: 116
Facility capacity: 123
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Miller | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation |
| Sheryl Johnston | Executive Director | Facility representative who met with the Licensing Program Analyst during the investigation |
| Kurt Norden | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 123
Deficiencies: 1
Aug 29, 2023
Visit Reason
The visit was conducted in response to a self-submitted LIC624 Incident Report regarding a medication error where a resident received medications prescribed to another resident.
Findings
The investigation found that a medication technician (S1) gave Resident #1 six medications prescribed to Resident #2 due to mistaken identity. The resident did not suffer observable injury, and the facility took corrective actions including retraining staff and monitoring the resident's vital signs.
Complaint Details
The visit was complaint-related, triggered by an incident report of medication error. The deficiency was substantiated with one deficiency cited and one technical violation issued.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not assist 1 of 113 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care. | Type B |
Report Facts
Medications given in error: 6
Vital signs measurements: 14
Residents present: 113
Facility capacity: 123
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Prejusa | Resident Services Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced case management incident visit and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 123
Deficiencies: 1
Apr 11, 2023
Visit Reason
The visit was conducted in response to a self-submitted SOC341 Report of Suspected Dependent Adult/Elder Abuse involving an incident where staff member S1 yelled at and pointed disrespectfully at Resident #1 on 01-01-2023.
Findings
The investigation confirmed that S1 did not treat Resident #1 with dignity, posing an immediate personal rights risk. The facility took disciplinary action against S1 and retrained staff on resident rights and abuse reporting. One deficiency was cited related to personal rights violations.
Complaint Details
The complaint was substantiated based on the investigation of the incident where staff member S1 yelled at Resident #1 and called them a liar multiple times. There was no physical injury. Facility management placed S1 on administrative leave and later formally disciplined S1. Retraining was conducted for staff on personal rights and mandated abuse reporting.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Based on records and interviews, licensee’s staff (S1) did not treat 1 of 107 residents (R1) with dignity, which posed an immediate personal rights risk to persons in care. | Type A |
Report Facts
Deficiencies cited: 1
Census: 107
Total Capacity: 123
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Met during inspection and involved in exit interview |
| Dennis Prejusa | Resident Services Director | Met during inspection and involved in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor of the Licensing Program Analyst |
Inspection Report
Annual Inspection
Census: 104
Capacity: 140
Deficiencies: 0
Feb 10, 2023
Visit Reason
Licensing Program Analyst Dang Nguyen conducted an unannounced Required 1-Year Visit to evaluate the facility's compliance, including infection control measures related to COVID-19.
Findings
No deficiencies were cited during the inspection. The facility's COVID-19 Mitigation Plan, including disinfection, screening protocols, and use of personal protective equipment, was observed and evaluated with technical assistance provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Prejusa | Resident Care Director | Met with Licensing Program Analyst during the inspection and exit interview. |
| Sheryl Johnston | Executive Director | Met with Licensing Program Analyst during the inspection and exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Required 1-Year Visit. |
| Lizzette Tellez | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 104
Capacity: 140
Deficiencies: 0
Feb 10, 2023
Visit Reason
An unannounced Case Management Visit was conducted to observe the physical plant and review the facility's application to change its licensed capacity and bedridden resident capacity.
Findings
No immediate health or safety issues were observed during the tour, and no deficiencies were cited. The facility's floor plan was consistent with the current layout.
Report Facts
Licensed capacity change: 123
Bedridden resident capacity: 10
Non-ambulatory resident capacity: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Prejusa | Resident Care Director | Met during the visit and discussed the purpose of the visit |
| Sheryl Johnston | Executive Director | On-site during the visit and participated in the exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management Visit |
| Lizzette Tellez | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 140
Deficiencies: 0
Oct 14, 2022
Visit Reason
The visit was an unannounced case management follow-up on an incident report regarding a resident who had eloped from the facility on 2022-10-02.
Findings
During the visit, the Licensing Program Analyst toured the facility, observed residents, interviewed staff, and reviewed records. No deficiencies were cited on this date.
Complaint Details
The complaint involved a resident who eloped from the facility on 2022-10-02. The resident was located outside the facility and returned without injury. The visit was to follow up on this incident report.
Report Facts
Capacity: 140
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Met during the visit and involved in the incident report follow-up |
| Joan Gomez | Resident Care Director | Met during the visit and involved in the incident report follow-up |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 140
Deficiencies: 0
Jun 9, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report regarding a resident experiencing increased pain not well managed by pain medications, who was subsequently diagnosed with a compression fracture at the hospital.
Findings
During the visit, the Licensing Program Analyst toured the facility, observed residents, reviewed records, and interviewed staff and residents. No deficiencies were cited or observed on this date.
Complaint Details
The visit was triggered by an incident report received on 2022-05-13 concerning Resident 1's increased pain and hospital diagnosis of a compression fracture.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joan Gomez | Resident Services Director | Met during the visit and participated in the exit interview. |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 140
Deficiencies: 0
Jun 9, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report regarding a resident who complained of pain and was later diagnosed with a fractured foot.
Findings
No deficiencies were cited or observed during the visit. The Licensing Program Analyst toured the facility, observed residents, reviewed records, and interviewed staff.
Complaint Details
The visit was triggered by an incident report received on 2022-05-13 about Resident 2 who complained of pain and had swelling and a bruise on the foot. The resident was sent to the hospital and diagnosed with a fractured foot.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joan Gomez | Resident Services Director | Met during the visit and involved in the incident report follow-up |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 103
Capacity: 140
Deficiencies: 0
Apr 26, 2022
Visit Reason
An unannounced Required 1-Year Visit was conducted to evaluate the facility's compliance with licensing requirements and infection control protocols.
Findings
No deficiencies were cited or observed during the inspection. The Licensing Program Analyst provided technical assistance and evaluated the facility's COVID-19 Mitigation Plan including disinfection, testing, vaccination, screening protocols, and PPE use.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Met with Licensing Program Analyst during the inspection and participated in the exit interview. |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the unannounced Required 1-Year Visit and evaluation. |
Inspection Report
Follow-Up
Census: 102
Capacity: 140
Deficiencies: 1
Dec 8, 2021
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report received on December 7, 2021, regarding a resident's witnessed fall on October 5, 2021.
Findings
The licensee did not submit an incident report within seven days of a serious injury of a resident to the licensing agency, resulting in a cited deficiency pursuant to Title 22, Division 6, Chapter 8 of the California Code of Regulations.
Deficiencies (1)
| Description |
|---|
| Failure to submit an incident report within seven days of a serious injury of a resident to the licensing agency. |
Report Facts
Residents in care: 102
Total capacity: 140
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Met during the inspection and involved in the visit |
| Joan Gomez | Resident Care Director | Met during the inspection and involved in the visit |
| Kristina Ryan | Licensing Program Analyst | Conducted the inspection visit |
| Simon Jacob | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 140
Deficiencies: 1
Nov 19, 2021
Visit Reason
An unannounced case management visit was conducted to follow up on incident reports received regarding medication errors involving three residents at the facility.
Findings
The facility staff did not administer medications as prescribed for 3 out of 95 residents, posing a potential health risk. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations.
Complaint Details
The visit was triggered by incident reports received on November 4 and November 12, 2021, regarding medication errors involving Resident 1, Resident 2, and Resident 3. The facility self-reported these incidents to Community Care Licensing.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not administer medications as prescribed for 3 out of 95 residents, violating medication administration requirements. | Type B |
Report Facts
Residents affected by medication errors: 3
Census: 95
Total capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Johnston | Executive Director | Met during the visit and involved in exit interview |
| Joan Gomez | Resident Care Director | Met during the visit and involved in exit interview |
| Kristina Ryan | Licensing Program Analyst | Conducted the unannounced case management visit |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 95
Capacity: 140
Deficiencies: 0
Aug 18, 2021
Visit Reason
An unannounced case management visit was conducted to perform a health and safety check and review COVID-19 mitigation strategies via a virtual FaceTime visit due to COVID-19 restrictions.
Findings
During the visit, the Licensing Program Analyst toured the facility and interviewed the Resident Care Director. No deficiencies were issued during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joan Gomez | Resident Care Director | Interviewed during the visit |
Inspection Report
Census: 100
Capacity: 140
Deficiencies: 0
Jul 27, 2021
Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment.
Findings
During the visit, no deficiencies were issued. The team interviewed facility leadership and conducted a walk-through of the facility, concluding with a debriefing and exit interview.
Inspection Report
Complaint Investigation
Census: 82
Capacity: 140
Deficiencies: 0
Jan 23, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility did not honor the admission agreement, did not provide a resident with comfortable accommodations, and did not offer a variety of food specific to a resident's prescribed diet.
Findings
Based on observations, interviews, and record reviews, the allegations were determined to be unsubstantiated. The facility provided a revised billing statement to the resident, addressed accommodation concerns including construction noise, and demonstrated willingness to accommodate dietary needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to honor admission agreement, uncomfortable accommodations due to construction noise, and lack of dietary variety. The facility addressed billing issues, offered alternative rooms, and confirmed ability to accommodate dietary requests.
Report Facts
Monthly fee: 7300
Credit amount: 3100
Credit amount: 2200
Remaining balance: 2000
Complaint control number: 08-AS-20200604110036
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan C Pineda | Licensing Program Analyst | Conducted the complaint investigation and tele-visit |
| Sheryl Johnston | Executive Director | Interviewed during investigation and involved in findings |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
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