Inspection Report Summary
The facility’s most recent inspection on July 17, 2025, was a complaint investigation that found no deficiencies, with all allegations unsubstantiated. Earlier reports showed some serious issues, including repeated failures to ensure adequate resident supervision that led to elopements and injuries, resulting in immediate civil penalties issued in 2023 and early 2024. Other notable deficiencies involved failure to meet residents’ care needs and timely reporting of incidents, which posed health and safety risks but did not lead to license suspensions or fines beyond civil penalties. Several complaint investigations over the past two years were unsubstantiated, indicating many concerns raised were not confirmed. The facility has shown improvement recently, with the last two annual inspections in 2024 and 2025 reporting no deficiencies and a clean, well-maintained environment.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
30% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 27
Capacity: 90
Deficiencies: 0
Jul 17, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not prevent a resident from harming another resident and did not provide adequate supervision resulting in falls.
Findings
Based on records reviewed and interviews with staff, the allegations that staff failed to prevent harm between residents and failed to provide adequate supervision resulting in falls were both deemed unsubstantiated due to insufficient evidence to prove the alleged violations.
Complaint Details
The complaint investigation addressed two allegations: 1) staff did not prevent resident from harming another resident, and 2) staff did not provide adequate supervision resulting in falls. Both allegations were found to be unsubstantiated after review of incident reports, interviews, and facility records.
Report Facts
Estimated Days of Completion: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Whiteley | Executive Director | Facility administrator met during investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 90
Deficiencies: 0
May 19, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding multiple allegations including rough handling of residents causing bruising, failure to ensure residents take medication, improper cleaning of the facility, residents not being able to eat or drink in the evening after dinner, and staff forcing residents to get up and dressed at 5 AM.
Findings
After reviewing facility records, interviewing staff and residents, and observing the facility, all allegations were found to be unsubstantiated due to lack of sufficient evidence to prove the violations occurred.
Complaint Details
The complaint investigation was triggered by allegations received on 12/20/2024. The investigation found all allegations unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Estimated Days of Completion: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Whiteley | Executive Director | Facility representative met during the investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 27
Capacity: 90
Deficiencies: 0
May 7, 2025
Visit Reason
The visit was an unannounced one-year annual/required inspection conducted by Licensing Program Analyst Jason Lund to evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, odor-free, and in good repair with sufficient furniture, lighting, and food supplies. Fire safety equipment was current and compliant. Medications and toxins were securely stored. Staff and resident files reviewed were in compliance. No deficiencies were observed or cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Whiteley | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour and inspection. |
| Jason Lund | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 90
Deficiencies: 1
Jan 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that a resident sustained multiple injuries due to lack of care from staff.
Findings
The investigation found that the resident sustained multiple injuries due to lack of care from staff, including failure to update needs and services plans and failure to report falls and hospital visits to licensing. The allegation was substantiated.
Complaint Details
The complaint was substantiated based on evidence that the resident sustained multiple injuries due to lack of care from staff. The facility failed to update the resident's needs and services plan and did not report falls or hospital visits to licensing. A civil penalty assessment is pending.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet the resident's needs as identified in the pre-admission appraisal, specifically inconsistent documentation of assistance required for bathing, grooming, feeding, and toileting, posing an immediate health and safety risk. | Type A |
Report Facts
Estimated Days of Completion: 90
Capacity: 90
Census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Whiteley | Administrator | Facility administrator met during the investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 90
Deficiencies: 1
Jan 29, 2025
Visit Reason
The visit was an unannounced case management visit to investigate a complaint regarding resident R1 who had multiple falls, including an incident on 09/18/2024 that resulted in injuries and a hospital visit which was not reported to licensing.
Findings
The facility failed to report the falls and hospital visit for resident R1 and did not submit an Unusual Incident/Injury Report (LIC624) for the fall on 09/18/2024. Deficiencies and an immediate civil penalty were issued for repeat violations.
Complaint Details
The complaint investigation was regarding resident R1 who had multiple falls. On 09/18/2024, R1 was transported to the Emergency Room with head and neck injuries. The facility failed to report the falls and hospital visit to licensing and did not complete the required Unusual Incident/Injury Report.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency and responsible person within seven days of the occurrence of the incident on 9/18/2024. | Type B |
Report Facts
Capacity: 90
Census: 32
Deficiencies cited: 1
Plan of Correction Due Date: Feb 12, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the unannounced case management visit and complaint investigation |
| Jennifer Whiteley | Administrator | Facility administrator met with Licensing Program Analyst during the visit |
| Lisa Rios | Licensing Program Manager / Supervisor | Named as supervisor and licensing program manager in the report |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 90
Deficiencies: 1
Dec 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident sustained multiple injuries due to lack of care from staff and that staff did not ensure that resident's hygiene needs were met.
Findings
The investigation substantiated that a resident sustained multiple injuries due to lack of care from staff, including failure to meet the resident's needs as identified in the pre-admission appraisal and failure to report falls and hospital visits. The allegation regarding unmet hygiene needs was found to be unsubstantiated after review of records, staff, and resident interviews.
Complaint Details
The complaint was substantiated regarding multiple injuries sustained by a resident due to lack of care from staff. The allegation that staff did not ensure the resident's hygiene needs were met was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet the resident's needs as identified in the pre-admission appraisal and provide other basic services, posing an immediate health and safety risk. | Type A |
Report Facts
Estimated Days of Completion: 90
Falls reported: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Jeanine Gaona | Resident Care Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 90
Deficiencies: 1
Oct 1, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted due to a complaint received on 2024-09-30 alleging that staff did not keep the facility free of cockroaches.
Findings
During the visit, the Licensing Program Analyst observed multiple small brown cockroaches in a resident bedroom and learned from staff interviews that cockroaches had been seen and reported previously. The facility was found not to be free of cockroaches, posing potential health, safety, and personal rights risks.
Complaint Details
The complaint was substantiated. The allegation was that staff did not keep the facility free of cockroaches. The investigation confirmed the presence of cockroaches and staff reports of sightings.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility did not ensure it was clean, safe, sanitary, and in good repair at all times, specifically failing to keep the facility free of cockroaches. | Type B |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Oct 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Whitely | Facility Designated Administrator | Met with Licensing Program Analyst during the complaint investigation and interviewed regarding the complaint |
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 33
Capacity: 90
Deficiencies: 0
Aug 26, 2024
Visit Reason
Licensing Program Analyst Jason Lund arrived unannounced to conduct a Case Management visit and met with the Executive Director to explain the reason for the visit.
Findings
The facility is working with the public guardianship to obtain conservatorship for a resident (R1) following a 30-day notice. The facility will keep the Licensing Program Analyst updated on any changes. An exit interview was conducted and the report was left.
Report Facts
Census: 33
Capacity: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Jennifer Whiteley | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Annual Inspection
Census: 38
Capacity: 90
Deficiencies: 0
Apr 18, 2024
Visit Reason
The visit was an unannounced annual/required inspection conducted by the Licensing Program Analyst to evaluate compliance with facility regulations.
Findings
The facility was found to be clean, odor-free, and in good repair with sufficient furniture, lighting, and food supplies. Fire safety equipment was current and medications and toxins were securely stored. Staff and resident files reviewed were in compliance. No deficiencies were observed or cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the annual inspection and reviewed staff and resident files. |
| Jennifer Whiteley | Executive Director | Met with Licensing Program Analyst during the inspection and exit interview. |
| Marie Arbios | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Plan of Correction
Census: 38
Capacity: 90
Deficiencies: 0
Apr 18, 2024
Visit Reason
The visit was an unannounced proof of correction (POC) inspection to verify that previously cited deficiencies from 04/03/2024 had been corrected.
Findings
Proper proof of correction documentation was received for the previously cited deficiency, and no new deficiencies were observed or cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the proof of correction visit and received POC documentation. |
| Jennifer Whiteley | Executive Director | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 90
Deficiencies: 0
Apr 3, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to an allegation that the licensee does not ensure the facility is in good repair at all times.
Findings
The investigation included review of facility records, staff and resident interviews. Repairs were documented on multiple dates and residents reported no impact on meals. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint allegation was unsubstantiated. Although the allegation may have happened or is valid, there was not sufficient evidence to prove the violation occurred.
Report Facts
Facility capacity: 90
Resident census: 39
Repair dates: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Whiteley | Executive Director | Met with Licensing Program Analyst during the investigation |
| Marie Arbios | Administrator | Facility administrator named in the report |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 90
Deficiencies: 1
Apr 3, 2024
Visit Reason
The visit was an unannounced case management inspection triggered by an unusual incident report stating that a resident eloped from the facility on 2024-03-23, despite being documented as unable to leave unassisted.
Findings
The facility was found deficient for failing to ensure resident supervision, resulting in a resident eloping from the facility. This deficiency posed an immediate health and safety risk and was cited as a repeat violation with an immediate civil penalty issued.
Complaint Details
The complaint was substantiated based on the investigation of the unusual incident report regarding resident elopement. Immediate civil penalty was issued for repeat violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident supervision resulting in resident elopement, violating Additional Personal Rights of Residents in Privately Operated Facilities. | Type A |
Report Facts
Capacity: 90
Census: 39
Deficiencies cited: 1
Plan of Correction Due Date: Apr 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the inspection and received the unusual incident report |
| Jennifer Whiteley | Executive Director | Met with Licensing Program Analyst during inspection |
| Lisa Rios | Licensing Program Manager / Supervisor | Supervisor and Licensing Program Manager named in report |
Inspection Report
Plan of Correction
Census: 37
Capacity: 90
Deficiencies: 0
Oct 30, 2023
Visit Reason
The visit was an unannounced proof of correction (POC) inspection to verify the facility's correction of two previously cited deficiencies related to case management visits dated 7/5/2023.
Findings
The Licensing Program Analyst reviewed documentation for the two deficiency plans of correction and conducted an exit interview. The report indicates the visit was completed with no further findings noted.
Report Facts
Deficiencies plans of correction: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the proof of correction visit and reviewed documentation. |
| Lacy Vincent | Administrator | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 90
Deficiencies: 0
Aug 7, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident's dietary needs were not being met.
Findings
Based on facility records, staff and resident interviews, and observation, it was unclear if the resident's dietary needs were unmet; therefore, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that a resident's dietary needs were not being met. The investigation found that residents have the choice of sugar free or regular creamer, and staff encourage but do not require sugar free creamer for diabetic residents. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Estimated Days of Completion: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeanine Gaona | Resident Care Director | Interviewed during the investigation and participated in exit interview |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 32
Capacity: 90
Deficiencies: 0
Jul 18, 2023
Visit Reason
The Non-Compliance Conference (NCC) was conducted to discuss the high volume of deficiencies and the facility's inability to remain in substantial compliance with regulations over the past 12 months.
Findings
No deficiencies were cited during this visit. The facility was advised on future non-compliance consequences and agreed to implement corrective actions including additional dementia training, quality assurance checks, monitoring improvements, and resident safety measures.
Report Facts
Elopements: 3
Fire Department Violations: 6
Training Hours: 1
Capacity: 90
Census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephenie Doub | Licensing Program Manager | Present at Non-Compliance Conference and named in report |
| Jason Lund | Licensing Program Analyst | Present at Non-Compliance Conference and named in report |
| Gregory Awrey | Regional Vice President of Operations | Present at Non-Compliance Conference and exit interview |
Inspection Report
Census: 33
Capacity: 90
Deficiencies: 2
Jul 5, 2023
Visit Reason
Unannounced case management visit to evaluate deficiencies related to fire safety and compliance with regulations following reports from the Modesto Fire Department.
Findings
The facility was found to have multiple fire safety violations including unapproved locking/latching devices on sliding glass doors of eight residents' rooms, obstructing emergency exits and posing immediate health and safety risks. Civil penalties were issued.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Unapproved locking/latching devices installed on sliding glass doors of residents' rooms (24, 25, 26, 27, 29, 30, 33, 34) preventing exit in case of fire. | Type A |
| Failure to maintain exit doors and door hardware operational at all times, exits and exit paths unobstructed, and removal of door stops and other obstructions to fire doors. | Type A |
Report Facts
Capacity: 90
Census: 33
Number of residents' rooms with locking devices: 8
Number of fire department violations reported on 2/13/2023: 5
Number of fire department regulations cited on 5/31/2023: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Eldridge | Resident Care Coordinator | Met with Licensing Program Analyst during visit and exit interview |
| Jason Lund | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Steven Richardson | Licensing Program Manager | Arrived with Licensing Program Analyst for the visit |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 33
Capacity: 90
Deficiencies: 1
Jul 5, 2023
Visit Reason
Unannounced case management visit conducted due to an unusual incident report of a resident eloping from the facility.
Findings
The facility was found deficient for failing to ensure resident supervision, resulting in a resident eloping. An immediate civil penalty was issued for this repeat violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident supervision resulting in resident elopement, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 90
Census: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the case management visit and received the unusual incident report |
| Stephen Richardson | Licensing Program Manager | Arrived unannounced for the case management visit |
| Andrea Eldridge | Resident Care Coordinator | Met with Licensing Program Analyst during the visit and involved in the incident explanation |
| Stephenie Doub | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Census: 31
Capacity: 90
Deficiencies: 1
Jun 5, 2023
Visit Reason
The visit was an unannounced case management inspection triggered by an unusual incident report regarding a resident who eloped from the facility.
Findings
The facility was found deficient for failing to ensure resident supervision, resulting in a resident eloping from the facility. An immediate civil penalty was issued for this repeat violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident supervision resulting in resident elopement, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 90
Census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Andrea Eldridge | Resident Care Coordinator | Met with Licensing Program Analyst during the visit |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Plan of Correction
Census: 31
Capacity: 90
Deficiencies: 0
Jun 5, 2023
Visit Reason
The visit was an unannounced proof of correction (POC) inspection to verify compliance with previously identified issues.
Findings
The Licensing Program Analyst received training meeting records for case management dated the day of the visit and conducted an exit interview with the facility representative.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the proof of correction visit and received training records. |
| Andrea Eldridge | Resident Care Coordinator | Met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 90
Deficiencies: 0
Apr 20, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff were not adhering to COVID protocols and that residents' needs were not being met due to insufficient staffing.
Findings
The investigation found that the facility had appropriate infection control policies and sufficient PPE, and staffing levels were adequate with the use of a staffing agency. Both allegations were found to be unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included non-adherence to COVID protocols and insufficient staffing to meet residents' needs. Evidence did not support these claims.
Report Facts
Estimated Days of Completion: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Andrea Eldridge | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation and participated in interviews |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 28
Capacity: 90
Deficiencies: 0
Apr 20, 2023
Visit Reason
The inspection was an unannounced annual/required visit to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in substantial compliance with no deficiencies observed or cited. The environment was clean, odor-free, and in good repair with adequate safety measures and supplies.
Report Facts
Staff files reviewed: 4
Resident files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Eldridge | Resident Care Coordinator | Met with Licensing Program Analyst during the inspection and participated in the exit interview |
| Jason Lund | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Capacity: 90
Deficiencies: 1
Apr 5, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that a resident sustained a serious injury due to inadequate staff supervision.
Findings
The investigation found that Resident R1 eloped from the facility and sustained serious injuries. Staff failed to follow elopement procedures and did not ensure adequate supervision, resulting in substantiated allegations and cited deficiencies.
Complaint Details
The complaint was substantiated. Resident R1 eloped from the facility on 01/21/2023 and sustained multiple serious injuries. Staff admitted to failing to follow elopement procedures. The allegation was found valid based on the preponderance of evidence.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident supervision while in care at the facility, resulting in resident elopement and serious injury. | Type A |
Report Facts
Estimated Days of Completion: 90
Capacity: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephenie Doub | Licensing Program Manager | Named in report as Licensing Program Manager |
| Alma Whitted | Executive Director | Met with Licensing Program Analyst during investigation and named in plan of correction |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 90
Deficiencies: 0
Jan 12, 2023
Visit Reason
An unannounced complaint investigation was conducted based on allegations that staff retained a resident who requires a higher level of care, did not seek medical attention for the resident in a timely manner, and were not following protocols to prevent the spread of illness.
Findings
The investigation found that the facility provided in-home support and hospice services to the resident and sought medical attention as needed. The resident's Power of Attorney, Resident Care Coordinator, and hospice agreed that the resident required a higher level of care. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff retaining a resident needing higher level of care, failure to seek timely medical attention, and not following illness prevention protocols. The facility records and interviews supported that medical care was sought and protocols were followed.
Report Facts
Estimated Days of Completion: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Eldridge | Resident Care Coordinator | Met with investigator and involved in findings |
| Stephenie Doub | Licensing Program Manager | Named in report header and signature |
Inspection Report
Annual Inspection
Census: 25
Capacity: 90
Deficiencies: 0
Apr 1, 2022
Visit Reason
The visit was a required, unannounced one-year post licensing and annual inspection to evaluate the facility's compliance with regulations.
Findings
The facility was observed to be clean, odor-free, in good repair, and compliant with safety and medication storage regulations. No deficiencies were cited during this visit, and the facility was found to be in substantial compliance.
Report Facts
Census: 25
Total Capacity: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Met with Licensing Program Analyst during the inspection and participated in the facility tour and exit interview |
| Jason Lund | Licensing Program Analyst | Conducted the post licensing and annual required visit |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 25
Capacity: 90
Deficiencies: 0
Apr 1, 2022
Visit Reason
The visit was a post licensing and annual required visit conducted by Licensing Program Analyst Jason Lund to evaluate the facility's compliance with regulations.
Findings
The facility was observed to be clean, odor-free, and in good repair with sufficient furniture, lighting, and safety equipment. No deficiencies were observed or cited, and the facility was found to be in substantial compliance on the date of the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the post licensing and annual required visit and observed facility compliance. |
| Alma Whitted | Administrator | Met with Licensing Program Analyst during the visit and participated in the facility tour and exit interview. |
Inspection Report
Follow-Up
Census: 25
Capacity: 90
Deficiencies: 0
Apr 1, 2022
Visit Reason
Unannounced proof of correction (POC) visit to verify correction of a previously cited deficiency related to a complaint received on 12/17/2021.
Findings
No deficiencies were observed or cited during this visit. The facility was found to be in substantial compliance on the date of the visit.
Complaint Details
The visit was related to a complaint deficiency received on 12/17/2021. Administrator Alma Whitted acknowledged understanding the regulation and submitted a corrective email. The complaint deficiency was addressed and no further deficiencies were cited.
Report Facts
Capacity: 90
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Whitted | Administrator | Met with Licensing Program Analyst during the POC visit and involved in corrective action |
| Jason Lund | Licensing Program Analyst | Conducted the unannounced proof of correction visit |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 90
Deficiencies: 1
Dec 17, 2021
Visit Reason
The inspection was an unannounced complaint investigation regarding allegations that the facility refused to accept a resident back with COVID.
Findings
The investigation substantiated the allegation that the facility refused to accept resident R1 back from the hospital after discharge on 12/17/2021, violating eviction procedures and posing a potential health and safety risk to residents.
Complaint Details
The complaint was substantiated based on evidence that the facility refused to accept resident R1 back after hospital discharge, violating eviction procedures.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet eviction procedures by not providing a 30 day notice to resident R1 and refusing to accept R1 back from the hospital. | Type B |
Report Facts
Estimated Days of Completion: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Marie Arbios | Administrator | Facility administrator met during investigation and named in findings |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 90
Deficiencies: 0
Sep 2, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that a resident sustained a fracture while in care, facility staff did not seek medical attention in a timely manner, did not accept resident back from a hospital stay, and did not allow the resident to have visitors.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Records and interviews showed the resident was taken to the Emergency Room the same day for shortness of breath and dizziness, had a contusion possibly from a mechanical fall, and visitors were allowed in designated areas with COVID-19 visitation restrictions. No deficiencies were cited.
Complaint Details
The complaint was unsubstantiated based on interviews, record reviews, and documentation. Allegations included resident fracture, delayed medical attention, refusal to accept resident back from hospital, and denial of visitors. The facility was found to have complied with medical and visitation protocols.
Report Facts
Facility capacity: 90
Resident census: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Arlene D Garcia | Licensing Program Analyst | Conducted the complaint investigation visit |
| Marie Arbios | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Stephenie Doub | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 26
Capacity: 90
Deficiencies: 1
Apr 26, 2021
Visit Reason
The inspection was a prelicensing visit conducted to evaluate the facility for licensing approval.
Findings
The facility was inspected indoors and outdoors, found clean and in good repair with adequate safety measures. Medication errors were observed but were technical in nature and an advisory was given.
Deficiencies (1)
| Description |
|---|
| Medication errors observed during inspection of medication room and files |
Report Facts
Fire clearance capacity: 80
Hot water temperature: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the prelicensing inspection and observed medication errors |
| Marie Arbios | Administrator | Met with Licensing Program Analyst during inspection |
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