Citations (last 6 years)
Citations (over 6 years)
2.2 citations/year
Citations are regulatory findings recorded during state inspections.
45% better than California average
California average: 4 citations/yearCitations per year
8
6
4
2
0
Occupancy
Latest occupancy rate
44% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 40
Capacity: 90
Citations: 0
Date: Feb 5, 2026
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2025-09-22 regarding facility cleanliness, staffing adequacy, resident care, and call button functionality.
Complaint Details
The complaint included allegations that staff did not ensure clean and orderly floors, facility odorlessness, adequate night staffing, timely changing of residents in soiled clothing, and proper working order of resident call buttons. All allegations were investigated and found unsubstantiated.
Findings
After reviewing records, interviewing staff and residents, and observing the facility, all allegations were deemed unsubstantiated due to lack of sufficient evidence to prove violations occurred.
Report Facts
Capacity: 90
Census: 40
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Stephany Issakhani | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 90
Citations: 0
Date: Dec 4, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff left a resident in soiled diapers/clothing, failed to notify an authorized representative of an incident, and that due to lack of supervision, a resident was missing a tooth.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff leaving a resident in soiled diapers/clothing, failure to notify the authorized representative of an incident, and lack of supervision resulting in a resident missing a tooth. The facility notified the resident's daughter of the missing tooth incident on 4/24/2025. No evidence supported the allegations.
Findings
The investigation found all allegations to be unsubstantiated based on facility records, staff interviews, and observations. No evidence was found 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 |
| Stephany Issakhani | Administrator | Met with Licensing Program Analyst during investigation |
| Jeanie Gaona | Resident Care Director | Observed resident missing a tooth and notified family |
| Lisa Rios | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 90
Citations: 0
Date: 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.
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.
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.
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
Citations: 0
Date: May 19, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations of rough handling of residents causing bruising, failure to ensure residents take medication, improper facility cleaning, 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.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included rough handling causing bruising, failure to ensure medication administration, improper cleaning, residents not able to eat/drink after dinner, and forcing residents to get up at 5 AM. All were found unsubstantiated after review of records, interviews, and observations.
Findings
Based on facility records, staff and resident interviews, and observations, all allegations were deemed unsubstantiated due to lack of sufficient evidence to prove the alleged violations occurred.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Whiteley | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Rios | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Annual Inspection
Census: 27
Capacity: 90
Citations: 0
Date: May 7, 2025
Visit Reason
The visit was a required one-year unannounced annual inspection conducted to evaluate the facility's 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 medications 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 compliance review. |
| Jason Lund | Licensing Program Analyst | Conducted the inspection visit and compliance evaluation. |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 90
Citations: 1
Date: 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.
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.
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.
Citations (1)
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.
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
Citations: 1
Date: 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.
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.
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.
Citations (1)
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.
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
Citations: 1
Date: Oct 1, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted due to a complaint alleging that staff did not keep the facility free of cockroaches.
Complaint Details
The complaint was substantiated. The allegation was that staff did not keep the facility free of cockroaches.
Findings
The Licensing Program Analyst observed multiple small brown cockroaches in a resident bedroom and learned from staff interviews that cockroaches had been reported to maintenance about two weeks prior. The facility was found not to be free of cockroaches, posing potential health, safety, and personal rights risks.
Citations (1)
The facility did not ensure that the facility was free of cockroaches, with 4 small cockroaches observed in a resident room.
Report Facts
Capacity: 90
Census: 35
Deficiencies cited: 1
Plan of Correction Due Date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Whitely | Facility Designated Administrator | Met with Licensing Program Analyst during the complaint investigation and interviewed regarding facility conditions |
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lisa Rios | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Census: 33
Capacity: 90
Citations: 0
Date: 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
Citations: 0
Date: 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
Citations: 0
Date: Apr 18, 2024
Visit Reason
Licensing Program Analyst Jason Lund conducted an unannounced proof of correction (POC) visit to verify correction of a previously cited deficiency from 04/03/2024.
Findings
Proper proof of correction documentation was received and no deficiencies were observed or cited during this visit.
Report Facts
Capacity: 90
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the proof of correction visit |
| Jennifer Whiteley | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 90
Citations: 1
Date: 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.
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.
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.
Citations (1)
Failure to ensure resident supervision resulting in resident elopement, violating Additional Personal Rights of Residents in Privately Operated Facilities.
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
Citations: 0
Date: 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
Citations: 0
Date: 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.
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.
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.
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
Citations: 0
Date: Jul 18, 2023
Visit Reason
The visit was a Non-Compliance Conference 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 conference addressed multiple issues including resident elopements and fire department violations, and outlined corrective actions the licensee agreed to implement by 07/28/2023.
Report Facts
Facility elopement dates: Elopements occurred on 1/21/23, 5/17/23, and 6/15/23
Fire department violations: 6
Training hours: 1
Training hours: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephenie Doub | Regional Manager | Present at Non-Compliance Conference and named as supervisor |
| Stephen Richardson | Licensing Program Manager | Present at Non-Compliance Conference |
| Jason Lund | Licensing Program Analyst | Licensing Evaluator and present at Non-Compliance Conference |
| Joel Goldman | Lawyer | Present at Non-Compliance Conference |
| Chris Coulter | Licensee | Present at Non-Compliance Conference |
| Andrea Eldridge | Resident Care Coordinator | Present at Non-Compliance Conference |
| Jeanine Gaona | RCD | Present at Non-Compliance Conference |
| Gregory Awrey | Regional Vice President of Operations | Present at Non-Compliance Conference and exit interview |
| Rhonda Dolcater | Novellus Specialist | Present at Non-Compliance Conference |
Inspection Report
Monitoring
Census: 33
Capacity: 90
Citations: 3
Date: Jul 5, 2023
Visit Reason
The visit was an unannounced case management inspection to evaluate deficiencies related to fire safety and compliance 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. Civil penalties were issued due to noncompliance with California Code of Regulations, Title 22 and Title 19.
Citations (3)
Failure to maintain exit doors and door hardware operational at all times, exits and exit paths not obstructed or obscured, and removal of unapproved locking/latching devices.
Facility put screws in sliding glass doors of eight residents' rooms preventing exit in case of fire.
Failure to ensure nonambulatory fire clearance for residents with dementia as required by CCR 87705(c)(1).
Report Facts
Residents with sliding glass doors obstructed: 8
Capacity: 90
Census: 33
Fire Department reports: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Steven Richardson | Licensing Program Manager | Arrived with LPA to conduct case management visit |
| Andrea Eldridge | Resident Care Coordinator | Met with evaluators during inspection and exit interview |
Inspection Report
Census: 33
Capacity: 90
Citations: 2
Date: 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.
Citations (2)
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.
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.
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
Plan of Correction
Census: 31
Capacity: 90
Citations: 0
Date: 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
Census: 31
Capacity: 90
Citations: 1
Date: Jun 5, 2023
Visit Reason
Licensing Program Analyst Jason Lund conducted an unannounced case management visit following receipt of an Unusual Incident/Injury Report stating that a resident eloped from the facility, which violated the resident's care plan.
Complaint Details
The visit was triggered by a complaint in the form of an Unusual Incident/Injury Report (LIC 624) received on 5/19/2023 regarding a resident eloping on 5/17/2023. The resident's care plan (LIC 602) dated 5/8/2023 stated the resident cannot leave unassisted.
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.
Citations (1)
Failure to ensure resident supervision, resulting in a resident eloping from the facility, violating Additional Personal Rights of Residents in Privately Operated Facilities (CCR 87468.(2)(a)(4)).
Report Facts
Capacity: 90
Census: 31
Deficiencies cited: 1
Plan of Correction Due Date: Jun 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the case management visit and issued the deficiency |
| Andrea Eldridge | Resident Care Coordinator | Met with Licensing Program Analyst during the visit and responsible for staff training as part of plan of correction |
| Stephenie Doub | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 28
Capacity: 90
Citations: 0
Date: 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
Census: 28
Capacity: 90
Citations: 0
Date: Apr 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2023-01-10 regarding non-adherence to COVID protocols and insufficient staffing affecting resident care.
Complaint Details
The complaint allegations were unsubstantiated based on records review, staff interviews, and observations. The allegations included failure to adhere to COVID protocols and insufficient staffing impacting resident care. The facility was found to have sufficient staffing and proper infection control measures in place.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Facility staff adhered to COVID protocols with proper infection control policies and sufficient PPE. Staffing levels were adequate, supported by a staffing agency since 03/04/2023, and resident needs were met during the visit.
Report Facts
Estimated Days of Completion: 90
Capacity: 90
Census: 28
Staffing agency start date: Mar 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Eldridge | Resident Care Coordinator | Met with Licensing Program Analyst during investigation and provided information |
Inspection Report
Complaint Investigation
Capacity: 90
Citations: 1
Date: Apr 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-01-27 regarding a resident sustaining a serious injury due to inadequate staff supervision.
Complaint Details
The complaint was substantiated. Resident R1 eloped from the facility and sustained serious injuries including basilar skull fracture, distal left radius/ulna fracture, LI compression fracture, scalp laceration requiring staples, and subdural hematoma. Staff failed to follow elopement procedures and did not confirm resident exit after door alarms sounded.
Findings
The investigation substantiated that Resident R1 eloped from the facility on 2023-01-21 and sustained serious injuries. Staff failed to follow elopement procedures and did not ensure adequate supervision, resulting in an immediate health and safety risk. Deficiencies were cited under California Code of Regulations, Title 22.
Citations (1)
Failure to ensure resident supervision resulting in resident elopement and serious injury.
Report Facts
Capacity: 90
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| 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
Citations: 0
Date: 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.
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.
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.
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
Citations: 0
Date: 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
Citations: 0
Date: 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
Citations: 0
Date: 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.
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.
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.
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
Citations: 1
Date: Dec 17, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that the facility refused to accept a resident back with COVID after discharge from the hospital.
Complaint Details
The complaint was substantiated based on evidence that the facility refused to accept resident R1 back from the hospital after discharge on 12/17/2021.
Findings
The investigation substantiated the allegation that the facility refused to accept the resident back, which posed a potential health and safety risk. The licensee failed to provide a 30-day notice as required by eviction procedures.
Citations (1)
Failure to meet eviction procedures by not providing a 30 day notice with specific facts permitting determination of date, place, witnesses, and circumstances.
Report Facts
Capacity: 90
Census: 25
Estimated Days of Completion: 90
Plan of Correction Due Date: Dec 31, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation |
| Marie Arbios | Administrator | Facility administrator involved in investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 90
Citations: 0
Date: 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.
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.
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.
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
Citations: 1
Date: 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.
Citations (1)
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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