Inspection Reports for Orchard Park Senior Living
675 W Alluvial Ave, Clovis, CA 93611, United States, CA, 93611
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with many complaint investigations unsubstantiated, indicating generally good compliance with regulations. However, there were some notable issues related to maintenance and medication management, including repeated findings of water damage and flooding in the dining area, as well as medication errors that resulted in citations and civil penalties. The facility received a citation and penalty for administering expired medications in October 2024, and another citation related to medication plans in May 2025. The most recent report from September 10, 2025, found a substantiated complaint about water damage discoloration on a ceiling but no severe enforcement actions were noted. Overall, while some maintenance and medication-related deficiencies occurred, recent inspections show the facility addressing these concerns without new severe violations.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
77% occupied
Based on a August 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Capacity: 148
Deficiencies: 1
Sep 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that staff do not ensure the facility is kept in good repair.
Findings
The investigation found a large spot of discoloration on the ceiling caused by water damage, which was substantiated as a violation of Title 22 regulations requiring the facility to be kept clean, safe, sanitary, and in good repair.
Complaint Details
The complaint alleging that staff do not ensure the facility is kept in good repair was substantiated based on observation and interviews during the unannounced visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The ceiling located in the back hallway on the first floor contained discoloration from water damage which poses a potential health, safety, or personal rights risk to residents in care. | Type B |
Report Facts
Capacity: 148
Plan of Correction Due Date: Sep 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Michelle Ramos | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 148
Deficiencies: 0
Aug 14, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff utilized bed rails for residents without a written physician's order and that staff were not properly safeguarding medications.
Findings
The investigation found that one resident had a physician's written order for bed rails and that two residents were capable of self-administering medications despite medications being accessible. There was insufficient evidence to substantiate the allegations, and no deficiencies were issued.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 148
Census: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Ramos | General Manager | Met with Licensing Program Analyst during complaint investigation |
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 148
Deficiencies: 0
Jun 5, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2025-06-02 regarding multiple allegations about staff conduct and resident care at the facility.
Findings
The investigation included interviews with staff, review of records, and observation of the facility. Although the allegations may have occurred, there was insufficient evidence to substantiate the claims. No deficiencies were issued and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint included allegations that staff did not provide requested records to a resident’s representative, prevented residents from receiving private phone calls, failed to meet residents' toileting needs, improperly stored personal hygiene items, improperly disposed of soiled briefs, did not treat residents with dignity or respect, and overcharged residents for services. The investigation found no preponderance of evidence to prove these violations.
Report Facts
Capacity: 148
Census: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit |
| Michelle Ramos | General Manager | Met with Licensing Program Analyst during investigation |
| Pamela Mazon | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 109
Capacity: 148
Deficiencies: 0
May 28, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted by Licensing Program Analyst J. Leffall to evaluate compliance with licensing requirements at the facility.
Findings
The facility was found to be clean, well-furnished, and safe with no passageway obstructions or fire hazards. Resident rooms and common areas were adequately furnished and maintained. Food storage and temperatures were appropriate, and medications were securely stored. No deficiencies were issued during this inspection.
Report Facts
Temperature - Refrigerator: 37
Temperature - Freezer: 0
Temperature - Hot Water: 113.1
Temperature - Hot Water: 118.4
Fire Extinguisher Service Date: Jan 8, 2025
Deficiency Count: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the annual inspection |
| Michelle Ramos | General Manager | Met with Licensing Program Analyst during inspection and received report |
Inspection Report
Follow-Up
Census: 109
Capacity: 148
Deficiencies: 1
May 28, 2025
Visit Reason
The visit was a case management follow-up to confirm details of an incident report regarding a medication error where a resident's medication was not given but signed off.
Findings
The inspection confirmed the medication error incident, noted that medication training was completed by staff, and a citation and civil penalty were issued related to the medication error.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a plan for incidental medical and dental care that encourages routine care and assists residents with self-administered medications as needed. | Type A |
Report Facts
Capacity: 148
Census: 109
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Michelle Ramos | General Manager | Met with Licensing Program Analyst during the visit |
| Pamela Mazon | Administrator/Director | Named as facility administrator/director |
Inspection Report
Follow-Up
Census: 109
Capacity: 148
Deficiencies: 1
May 28, 2025
Visit Reason
A case management visit was conducted to follow up and confirm details of an incident report regarding a medication error that occurred on 2025-05-15.
Findings
The inspection confirmed that a resident was given incorrect medication. Medication training and corrective actions were planned for involved staff. A citation and civil penalty were issued related to the medication error.
Complaint Details
The visit was complaint-related, triggered by an incident report of a medication error involving resident R1 on 2025-05-15. The complaint was substantiated as corrective actions and penalties were issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a plan for incidental medical and dental care that encourages routine care and assists residents with self-administered medications as needed. | Type A |
Report Facts
Census: 109
Total Capacity: 148
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Michelle Ramos | General Manager | Met with Licensing Program Analyst during the visit |
Inspection Report
Plan of Correction
Capacity: 148
Deficiencies: 1
Apr 24, 2025
Visit Reason
The inspection was a Plan of Correction (POC) case management visit to obtain details for a repeat citation 87303(a) – Maintenance and Operations issued on 2025-04-11.
Findings
The facility has 9 sandbags placed to mitigate immediate rain and is adding additional weather stripping to a door. An independent agency was contacted for repairs, with details on assessment, quote, and repair timeline to be provided as part of the POC. A civil penalty form was completed and provided to the administrator.
Deficiencies (1)
| Description |
|---|
| Repeat citation 87303(a) – Maintenance and Operations |
Report Facts
Number of sandbags: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Ramos | Administrator | Met with Licensing Program Analyst and Manager during inspection |
| Eric | Maintenance staff confirming sandbags and weather stripping | |
| Jacques Leffall | Licensing Program Analyst | Conducted the inspection |
| See Moua | Licensing Program Manager | Conducted the inspection |
Inspection Report
Follow-Up
Census: 109
Capacity: 148
Deficiencies: 1
Apr 11, 2025
Visit Reason
The visit was a follow-up on a complaint regarding the food, but during interviews it was revealed that the dining room floor floods whenever it rains, posing a potential health, safety, or personal rights risk to residents.
Findings
The facility was found to have a deficiency related to maintenance and operation, specifically that the dining area flooring is wet from leaks through the double doors during heavy rains, which poses a potential risk to residents. A Plan of Correction is required.
Complaint Details
The visit was triggered by a complaint regarding the food, but the complaint interview revealed an issue with flooding in the dining room floor during rain.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility dining area flooring is wet from leaks through the double doors during heavy rains, posing a potential health, safety, or personal rights risk to residents. | Type B |
Report Facts
Census: 109
Total Capacity: 148
Plan of Correction Due Date: Apr 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted interviews and inspection |
| Michelle Ramos | General Manager | Met with during inspection and accepted Technical Support Services |
Inspection Report
Complaint Investigation
Capacity: 148
Deficiencies: 0
Apr 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2025-04-02 regarding personal rights allegations at the facility.
Findings
The investigation found no preponderance of evidence to substantiate the alleged violations; therefore, the complaint was unsubstantiated and no deficiencies were issued.
Complaint Details
The complaint involved allegations related to personal rights. The investigation was unsubstantiated as there was insufficient evidence to prove the alleged violation occurred.
Report Facts
Facility capacity: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Ramos | General Manager | Met with Licensing Program Analyst during complaint investigation |
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Capacity: 148
Deficiencies: 0
Apr 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff do not ensure food meals are adequately cooked and do not provide adequate food service.
Findings
The investigation included interviews with staff, residents, and the facility administrator, a review of records, a tour of the facility, and observation of food supply and meal service. Residents reported no issues with the food, and an adequate supply of food was observed. The allegation was found to be unsubstantiated and no deficiencies were issued.
Complaint Details
The complaint was unsubstantiated based on the investigation findings; there was no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Facility capacity: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Michelle Ramos | General Manager | Met with Licensing Program Analyst during the investigation |
| Pamela Mazon | Administrator | Facility administrator involved in interviews and report receipt |
Inspection Report
Complaint Investigation
Capacity: 148
Deficiencies: 0
Mar 26, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2025-03-19 alleging staff did not ensure the facility was free of hazards and were not following residents' care plans.
Findings
The investigation included interviews with the General Manager and Health Services Director, a facility tour, and records review. The allegations were found to be unsubstantiated due to lack of preponderance of evidence, and no deficiencies were issued.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included hazards in the facility and non-compliance with residents' care plans, but no evidence was found to prove violations.
Report Facts
Facility capacity: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit |
| Michelle Ramos | General Manager | Interviewed during investigation and recipient of report |
| Lori Johnson | Health Services Director | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 148
Deficiencies: 1
Mar 18, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2025-03-13 regarding staff not preventing facility flooding and ensuring facility flooring is in good repair.
Findings
The allegation that staff does not prevent facility flooding was substantiated due to observed gaps and missing weather stripping allowing water intrusion during heavy rains. The allegation that staff does not ensure facility flooring is in good repair was unsubstantiated as the flooring was found to be in good repair despite flooding.
Complaint Details
The complaint was substantiated regarding failure to prevent flooding due to door gaps and missing weather stripping. The complaint regarding flooring repair was unsubstantiated. The investigation was conducted by Licensing Program Analyst Sarah Hurt with interviews including Administrator Shelly Ramos and Maintenance staff Eric Farley.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility dining area flooring is wet from leaks through the double doors during heavy rains, posing a potential health, safety, or personal rights risk to residents. | Type B |
Report Facts
Capacity: 148
Census: 102
Deficiency Type B: 1
Plan of Correction Due Date: Apr 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Shelly Ramos | Administrator | Facility administrator interviewed during investigation |
| Eric Farley | Maintenance Staff | Facility maintenance staff interviewed during exit interview |
Inspection Report
Complaint Investigation
Capacity: 148
Deficiencies: 0
Mar 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that facility staff did not ensure the facility was odorless at all times and that the facility carpet was not in good clean condition.
Findings
The investigation found no visible stains on the carpet and no abnormal odors. The General Manager confirmed that any stains were from a resident's incontinent dog, which has since moved out. Maintenance staff cleaned the spots promptly, and a housekeeping schedule was submitted. The allegations were unsubstantiated and no deficiencies were issued.
Complaint Details
The complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Facility capacity: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Michelle Ramos | General Manager | Met with Licensing Program Analyst during the investigation and provided information regarding the allegations |
| Pamela Mazon | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 148
Deficiencies: 4
Feb 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-09-26 regarding questionable death and other allegations at the facility.
Findings
The investigation found that the allegations were substantiated. Facility staff failed to seek timely medical care for a resident, did not report resident incidents to responsible parties, did not safeguard resident's personal belongings, and failed to ensure the resident was properly dressed. The facility is subject to citations and potential civil penalties.
Complaint Details
The complaint investigation was triggered by allegations including questionable death, failure to seek timely medical care, failure to report incidents to appropriate parties, failure to safeguard personal belongings, and failure to ensure proper dressing of a resident. The investigation substantiated these allegations based on interviews and record reviews.
Severity Breakdown
Type A: 2
Type B: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Staff did not seek medical care in a timely manner for resident in care. | Type A |
| Facility failed to ensure that resident was properly dressed. | Type A |
| Facility failed to notify resident's responsible parties of multiple falls. | Type B |
| Facility could not locate resident's bed sheets when requested by responsible parties. | Type B |
Report Facts
Capacity: 148
Census: 111
Deficiencies cited: 4
Plan of Correction Due Dates: Feb 26, 2025
Plan of Correction Due Dates: Mar 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Michelle Ramos | Administrator | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 148
Deficiencies: 0
Feb 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff yelled at a resident.
Findings
The investigation included record reviews and interviews with staff, residents, and the administrator. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, and no deficiencies were issued.
Complaint Details
The complaint alleged that staff yelled at a resident. After investigation, the allegation was determined to be unsubstantiated.
Report Facts
Capacity: 148
Census: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit |
| Michelle Ramos | General Manager | Met with Licensing Program Analyst during the investigation |
| Pamela Mazon | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 148
Deficiencies: 0
Feb 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-12-05 regarding resident care concerns including soiled diapers, call bell response, unmet resident needs, and inadequate food service.
Findings
After reviewing records and conducting interviews with staff, residents, and the facility administrator, no preponderance of evidence was found to substantiate the allegations. Residents reported their needs were met, staff responded to call pendants, and no concerns were found with food service. No deficiencies were issued.
Complaint Details
The complaint investigation was unsubstantiated based on the evidence reviewed and interviews conducted. Allegations included residents left in soiled diapers, untimely call bell response, unmet resident needs, and inadequate food service, none of which were substantiated.
Report Facts
Capacity: 148
Census: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Michelle Ramos | General Manager | Met with Licensing Program Analyst during investigation |
| Pamela Mazon | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 148
Deficiencies: 0
Feb 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility elevator is in disrepair.
Findings
The Department reviewed records, interviewed the General Manager, toured the facility, and checked the elevator status. The elevator repair service date was anticipated to be 2025-02-14. Residents used stairwells and evacuation chairs assisted by staff. The allegation was unsubstantiated and no deficiencies were issued.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.
Report Facts
Capacity: 148
Census: 111
Complaint Control Number: 24-AS-20250204085858
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit |
| Michelle Ramos | General Manager | Interviewed during the investigation |
| Pamela Mazon | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 148
Deficiencies: 0
Dec 4, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that staff do not treat residents with dignity or respect.
Findings
Based on records review and interviews with staff, residents, and the Administrator, all staff completed training on residents' personal rights and there was no preponderance of evidence to substantiate the allegation. The complaint was determined to be unsubstantiated and no deficiencies were issued.
Complaint Details
The complaint alleged that staff do not treat residents with dignity or respect. The investigation found no evidence to support this allegation, resulting in an unsubstantiated finding.
Report Facts
Complaint Control Number: 24-AS-20241101140610
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacques Leffall | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings. |
| Alex Den | Administrator | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 148
Deficiencies: 1
Oct 23, 2024
Visit Reason
A case management visit was conducted to follow up and confirm details of an incident report regarding a resident (R1) being given medications after their expiration dates multiple times.
Findings
The investigation found that R1 was given expired medications for 3 days, posing an immediate health and safety risk. The facility completed medication training with staff and submitted a completion sheet to the licensing department. A citation was issued related to this medication violation.
Complaint Details
The visit was complaint-related, triggered by an incident report received by the Department concerning expired medications given to resident R1. The citation was issued based on substantiated findings.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist resident R1 properly with medications as needed, resulting in administration of expired medications for 3 days, posing an immediate health and safety risk. | Type A |
Report Facts
Days expired medications given: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Mazon | Administrator | Met with Licensing Program Analyst during visit and provided information about medication training. |
| Jacques Leffall | Licensing Program Analyst | Conducted the case management visit and authored the report. |
Inspection Report
Capacity: 148
Deficiencies: 0
Oct 1, 2024
Visit Reason
The visit was conducted to return a resident's file that was obtained on 9/30/24 and to meet with the facility administrator for this purpose.
Findings
The Licensing Program Analyst returned the resident's file to the administrator and conducted an exit interview. No deficiencies or violations were noted in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Mazon | Administrator | Met with Licensing Program Analyst during file return visit. |
| Jacques Leffall | Licensing Program Analyst | Conducted the visit and returned the resident's file. |
Inspection Report
Complaint Investigation
Capacity: 148
Deficiencies: 0
Sep 30, 2024
Visit Reason
During a complaint visit, a Case Management Health & Safety check was conducted by Licensing Program Analyst K. McClurg with assistance from Administrator Pamela Mazon.
Findings
The facility was toured and found to have a comfortable temperature, sufficient furnishings, adequate lighting, and was clean with no unpleasant odors. Passageways were clear, fire extinguishers and detectors were present and operational, and residents appeared groomed and appropriately dressed. No health and safety concerns were observed during the visit.
Complaint Details
Complaint visit with a Case Management Health & Safety check conducted; no health and safety concerns observed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly J. McClurg | Licensing Program Analyst | Conducted the Case Management Health & Safety check during the complaint visit. |
| Pamela Mazon | Administrator | Assisted with the complaint visit and exit interview. |
Inspection Report
Annual Inspection
Census: 90
Capacity: 148
Deficiencies: 3
Jul 12, 2024
Visit Reason
The visit was an unannounced annual inspection conducted by Licensing Program Analysts to evaluate compliance with regulations at the facility.
Findings
The facility was generally clean, well-furnished, and maintained at a comfortable temperature with no fire hazards observed. However, deficiencies were cited related to medication administration not following physician directions, unlocked medications accessible to residents, and unlocked tools and knives accessible to residents, all posing immediate health and safety risks.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Staff did not administer medications for memory care residents as directed by physician, posing an immediate health and safety risk. | Type A |
| Medications were found unlocked on a kitchen shelf accessible to residents, posing an immediate health and safety risk. | Type A |
| Tools and knives were found unlocked in kitchen drawers accessible to residents, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 148
Census: 90
POC Due Date: Jul 13, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Mazon | Administrator | Met with Licensing Program Analysts during inspection and signed receipt of report |
| Mai Yang | Licensing Program Analyst | Conducted inspection and signed report |
| See Moua | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Complaint Investigation
Capacity: 148
Deficiencies: 0
Jan 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2023-10-09 regarding staff not ensuring residents' rooms are free of malodors, overcharging residents for services not provided, and failure to remove soiled linens from residents' rooms.
Findings
The investigation found the allegations of malodors and overcharging to be unfounded, with evidence showing proper notification of rate changes and no malodors except during incontinence. The allegation regarding removal of soiled linens was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was conducted by Licensing Program Analyst Les Xiong. The allegations included staff not ensuring residents' rooms are free of malodors, overcharging residents for services not provided, and failure to remove soiled linens. The first two allegations were found to be unfounded, and the third was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Audie L Sherberg | Administrator | Facility administrator named in the report |
| Pamela Mazon | General Manager/Administrator | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 90
Capacity: 148
Deficiencies: 1
Jul 7, 2023
Visit Reason
The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to assess compliance with regulatory standards.
Findings
The facility was generally clean, well-maintained, and properly stocked with food and PPE supplies. However, multiple cleaning chemicals and knives were observed stored unlocked in areas accessible to residents, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Cleaning chemicals and knives were stored unlocked and accessible to residents in care, posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
POC Due Date: Jul 8, 2023
Rooms Observed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Mazon | General Manager | Met with Licensing Program Analyst during inspection and involved in observation of deficiencies |
| Mai Yang | Licensing Program Analyst | Conducted the inspection and authored the report |
| Robert Huntley | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 148
Deficiencies: 0
Jul 3, 2023
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2023-03-22 regarding multiple allegations about the facility's care and operations.
Findings
The investigation found all allegations unsubstantiated based on interviews, observations, and record reviews conducted on 2023-03-29. No citations were issued during this visit.
Complaint Details
The complaint included allegations that staff do not ensure residents' needs are met, facility food services are inadequate, staff do not keep residents' rooms clean, and the licensee did not provide a notice of fee increase with a general description of additional costs. All allegations were found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 148
Census: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Pamela Mazon | General Manager | Met with Licensing Program Analyst during the investigation |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 148
Deficiencies: 0
Oct 10, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to an allegation of neglect or lack of care and/or supervision resulting in injury to a resident.
Findings
The investigation found that it could not be proven or disproven that the facility's lack of care or neglect of supervision resulted in injury to the resident. The allegation was determined to be unsubstantiated and no deficiencies were issued.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.
Report Facts
Facility capacity: 148
Census: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation visit and delivered complaint findings |
| Robert Huntley | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 112
Capacity: 148
Deficiencies: 0
Jun 1, 2022
Visit Reason
The visit was an unannounced annual inspection focused on infection control conducted by the Licensing Program Analyst.
Findings
The facility was observed to maintain proper infection control measures including facial coverings, social distancing, and adequate PPE supplies. No deficiencies were issued during this inspection.
Report Facts
Percentage of rooms toured: 10
Percentage of bathrooms observed: 10
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rob Huntley | Administrator | Met with Licensing Program Analyst during inspection. |
| Mai Yang | Licensing Program Analyst | Conducted the annual inspection. |
| Melinda Hoffmann | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 148
Deficiencies: 0
May 20, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility failed to seek timely medical attention for a resident resulting in serious injury and failed to report a change in resident condition to the responsible party.
Findings
The investigation found that it could not be proven or disproven that the facility failed to seek medical attention or notify the responsible party regarding the resident's condition change. Staff did seek immediate medical attention and notified the responsible party when a strong odor in the resident's urine was observed. The allegations were unsubstantiated and no deficiencies were issued.
Complaint Details
The complaint was unsubstantiated based on interviews and medical record reviews. There was no preponderance of evidence to prove or disprove the alleged violations.
Report Facts
Facility capacity: 148
Census: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rob Huntley | Administrator | Met with Licensing Program Analyst during investigation |
| Laurie Johnson | Health Services Director | Met with Licensing Program Analyst during investigation |
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 148
Deficiencies: 0
Nov 17, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident sustained a fall while in care.
Findings
The investigation found that the resident fell but did not report it to facility staff, and there were no reported falls in October 2021. The resident was admitted to the hospital for cellulitis unrelated to a fall. The complaint was determined to be unfounded and dismissed.
Complaint Details
Complaint was regarding a resident sustaining a fall while in care. The complaint was found to be unfounded after investigation including interviews and record review.
Report Facts
Capacity: 148
Census: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lady Cabrera | Licensing Program Analyst | Conducted the complaint investigation |
| Tracy Flaherty | Administrator | Facility administrator, not present during visit but involved in findings discussion |
| Jeremy Salas | Memory Care Director | Met with investigator and designated to sign the report |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 117
Capacity: 148
Deficiencies: 0
Jul 16, 2021
Visit Reason
An Annual Inspection was conducted as a required 1-year unannounced visit to evaluate the facility's compliance and conditions.
Findings
The facility was found clean with no obstructions or fire clearance issues. COVID-19 guidelines were observed, including visitor screening and mask use. Medication, food, cleaning, and PPE supplies were adequate. Ten percent of bedrooms and staff records were reviewed. No deficiencies were observed, but technical advisory notes were provided regarding COVID-19 precautions.
Report Facts
Percentage of bedrooms checked: 10
Percentage of staff records reviewed: 10
Medication supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Flaherty | Administrator | Met with Licensing Program Analyst during the inspection and provided facility information. |
| Lady Cabrera | Licensing Program Analyst | Conducted the Annual Inspection. |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 117
Capacity: 148
Deficiencies: 0
Jul 16, 2021
Visit Reason
An Annual Inspection was conducted as a required 1-year unannounced visit to evaluate compliance with licensing regulations and COVID-19 guidelines.
Findings
The facility was found clean with no obstructions or fire clearance issues. Infection control measures including mask use, social distancing, and hand hygiene were observed. No deficiencies were noted during the inspection, though technical advisory notes were provided regarding COVID-19 precautions and N95 respirator fit testing.
Report Facts
Percentage of bedrooms checked: 10
Percentage of staff records reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Flaherty | Administrator | Met with Licensing Program Analyst during the inspection. |
| Lady Cabrera | Licensing Program Analyst | Conducted the Annual Inspection. |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report header. |
Inspection Report
Follow-Up
Census: 106
Capacity: 148
Deficiencies: 0
Mar 30, 2021
Visit Reason
The visit was conducted as a Case Management follow-up on an incident report submitted regarding a theft of money from a resident's apartment by facility staff.
Findings
No deficiencies were issued during this unannounced telephone visit. The Licensing Program Analyst requested submission of resident records and video evidence related to the incident.
Complaint Details
The visit was triggered by a complaint of money stolen from resident R1's apartment by facility staff on 03/24/2021.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Flaherty | Administrator | Contacted during the Case Management visit and involved in the incident follow-up. |
| Alexandria Walton | Licensing Program Analyst | Conducted the Case Management visit and requested documents related to the incident. |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report. |
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