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 (last 5 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a April 2025 inspection.
Census over time
Inspection Report
Annual Inspection| 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| 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| 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| 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| 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| 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| 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| 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| 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| 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| 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| 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| 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| 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
| 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| 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| 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| 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| 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| 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| 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
| Name | Title | Context |
|---|---|---|
| Joan Gomez | Resident Care Director | Interviewed during the visit |
Inspection Report
Inspection Report
Complaint Investigation| 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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