Inspection Reports for
Palms Retirement Center
312 N ROOSEVELT AVE, FULLERTON, CA, 92832
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% better than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
72% occupied
Based on a February 2026 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Capacity: 144
Deficiencies: 0
Date: Feb 11, 2026
Visit Reason
Licensing Program Analyst Hanna Gough made an unannounced visit to conduct the required annual inspection of the facility.
Findings
The facility was observed to be clean, safe, and sanitary with all required components in resident bedrooms and common areas. No deficiencies were noted during the inspection per Title 22 Division 6 of the California Code of Regulations.
Report Facts
Fire inspection date: Dec 4, 2025
Last fire drill date: Dec 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Khatera Bahadory | Administrator | Met with Licensing Program Analyst during inspection. |
| Hanna Gough | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Armando J Lucero | Licensing Program Manager | Named in report header and narrative. |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 144
Deficiencies: 0
Date: Feb 4, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not keep the facility free of insects, specifically a cockroach sighting on January 30, 2026.
Complaint Details
The complaint alleged that staff did not keep the facility free of insects, citing a cockroach sighting. The investigation was unsubstantiated as no evidence confirmed the allegation despite resident reports. Pest control services were confirmed to be active and regular.
Findings
The investigation found no cockroaches during the inspection of ten units, hallways, and kitchen. Although two residents reported seeing cockroaches, staff denied such observations and pest control reports showed no signs of cockroach activity. The allegation was deemed unsubstantiated due to conflicting information and lack of preponderance of evidence.
Report Facts
Capacity: 144
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation |
| Khatera Bahadory | Administrator | Facility administrator present during the investigation and exit interview |
| Adriana Delgado | Wellness Director | Guided the investigator during the facility tour |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 144
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff inappropriately communicated with a resident and that staff did not tend to a resident's fall in a timely manner.
Complaint Details
The complaint investigation involved allegations that staff spoke inappropriately to Resident #1 after an unwitnessed fall and that staff did not attend to the fall in a timely manner. Eleven interviews were conducted, with six corroborating the inappropriate communication allegation, which was substantiated. The fall response allegation was unsubstantiated due to conflicting evidence.
Findings
The allegation that staff inappropriately communicated with a resident was substantiated based on interviews with residents and staff. The allegation that staff did not tend to a resident's fall in a timely manner was unsubstantiated due to conflicting information and insufficient evidence.
Deficiencies (1)
CCR 87468.1(a)(1) Personal Rights of Residents: The licensee did not ensure residents were spoken to appropriately by staff, violating residents' dignity in personal relationships. This poses a potential health, safety, and personal rights risk to persons in care.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kathleen Tamondong | Assistant Administrator | Assisted with the inspection and participated in exit interviews |
| Khatera Bahadory | Administrator | Facility administrator named in the report header |
Inspection Report
Census: 105
Capacity: 144
Deficiencies: 0
Date: Dec 29, 2025
Visit Reason
An unannounced case management visit was conducted to amend Complaint Control Number 22-AS-20250701132137.
Findings
The Licensing Program Analyst met with the assistant AD, explained the purpose of the visit, and conducted an exit interview. Copies of all reports were provided to the assistant AD at the conclusion of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Kathleen Tamondong | Assistant AD | Met with Licensing Program Analyst and granted entry to the facility. |
| Khatera Bahadory | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Capacity: 144
Deficiencies: 1
Date: Dec 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility failed to issue proper notification for a rate increase.
Complaint Details
The complaint was substantiated based on evidence that the facility did not provide the required 90-day written notice for a rate increase to Resident 1. The investigation included interviews, record reviews, and observations.
Findings
The investigation found that the facility provided only a 60-day written notice of a rate increase instead of the required 90 days. The allegation was substantiated as the notice did not meet the 90-day written notice requirement per California regulations.
Deficiencies (1)
CCR 1569.655(a) requires a licensee to provide no less than 90 days' prior written notice to residents for rate increases. The facility failed to ensure Resident 1 was given a 90-day notice, posing a potential health and safety risk.
Report Facts
Facility Capacity: 144
Deficiency Plan of Correction Due Date: 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eleanor Barrientos | Administrator | Facility administrator named in the report |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
| Khatera Bahadory | Assistant Director | Greeted the investigator and granted entry during the visit |
Inspection Report
Census: 110
Capacity: 144
Deficiencies: 0
Date: Jul 24, 2025
Visit Reason
An unannounced case management visit was conducted to amend a prior complaint with control number 22-AS-20250701132137.
Findings
The visit involved reviewing and amending a prior complaint. An exit interview was conducted and a copy of the report and amended complaint reports were provided to the administrator.
Inspection Report
Complaint Investigation
Census: 109
Capacity: 144
Deficiencies: 1
Date: Jul 21, 2025
Visit Reason
This unannounced inspection was conducted to investigate a complaint alleging that the facility did not refund a resident their money.
Complaint Details
The complaint alleged that the facility did not refund a resident their money. The allegation was substantiated based on evidence including admission agreement, billing statements, and interviews.
Findings
The investigation substantiated that the facility overbilled Resident #1 by $22.58 due to incorrect prorating of fees based on the admission agreement. The resident is not entitled to a refund due to an outstanding balance but is entitled to a credit of $22.58 on that balance.
Deficiencies (1)
CCR 87507(f) Admission Agreements: The licensee did not comply with the admission agreement by overbilling Resident #1 by $22.58, posing a potential personal rights risk.
Report Facts
Resident overcharge amount: 22.58
Resident census: 109
Facility capacity: 144
Back payment amount: 2500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the complaint investigation |
| Khatera Bahadory | Administrator | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 144
Deficiencies: 0
Date: Jul 18, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that the facility failed to provide an appropriate bed and that a mattress provided had an odor.
Complaint Details
The complaint investigation was based on two allegations: failure to provide an appropriate bed and providing a mattress with an odor. The first allegation was found to be unfounded, meaning it was false or without reasonable basis. The second allegation was unsubstantiated, meaning there was insufficient evidence to prove or refute it.
Findings
The investigation found that mattresses and box springs were temporarily stacked in a resident's room due to construction, with no residents using the stacked beds. The allegation of failure to provide an appropriate bed was deemed unfounded. The allegation regarding a mattress odor was unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 144
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Khatera Bahadory | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Hanna Gough | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Census: 107
Capacity: 144
Deficiencies: 1
Date: Jul 18, 2025
Visit Reason
Licensing Program Analyst Hanna Gough made an unannounced visit to the facility for the purpose of conducting a case management deficiencies visit following a COVID outbreak report.
Findings
The facility had a COVID outbreak infecting 8 out of 107 residents. The licensee failed to report the COVID occurrences to the licensing agency within the required 24 hours, posing a potential health and safety risk.
Deficiencies (1)
CCR 87211(a)(2) Reporting Requirements: Licensee did not ensure to report the COVID occurrences to the licensing agency within 24 hours. This poses a potential health and safety risk to persons in care.
Report Facts
Residents infected: 8
Resident census: 107
Total capacity: 144
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Khatera Bahadory | Administrator | Met with Licensing Program Analyst during inspection and named in deficiency discussion |
| Hanna Gough | Licensing Program Analyst | Conducted the inspection and authored the report |
| Armando J Lucero | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 144
Deficiencies: 0
Date: Jul 15, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility issued an unlawful eviction to a resident.
Complaint Details
The complaint alleged that the facility issued an unlawful eviction to a resident. The investigation revealed the resident had received proper notice of a rate increase and a lawful eviction notice due to unpaid rent. The allegation was found to be unfounded.
Findings
The investigation found that the facility provided proper 60-day written notice of a rate increase and issued a lawful 30-day eviction notice due to nonpayment of rent. The allegation of unlawful eviction was deemed unfounded and the complaint was dismissed.
Report Facts
Capacity: 144
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation |
| Khatera Bahadory | Administrator | Facility representative who granted entry and was interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 144
Deficiencies: 0
Date: Jun 9, 2025
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that staff do not ensure residents receive their mail correspondence unopened in a timely manner.
Complaint Details
The complaint alleged that staff do not ensure residents receive their mail correspondence unopened in a timely manner. After interviews with 8 residents and 2 staff members, and observation of mail handling procedures, the allegation was determined to be unfounded.
Findings
The investigation included interviews with residents and staff, a tour of the facility, and document review. The allegation was found to be unfounded as all mail was observed unopened and residents reported timely receipt of mail.
Report Facts
Capacity: 144
Census: 107
Inspection Report
Complaint Investigation
Census: 107
Capacity: 144
Deficiencies: 0
Date: May 21, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that facility staff were not giving a resident's belongings to the resident after they left the facility.
Complaint Details
The complaint alleged that staff were not giving a resident's belongings to the resident after they left the facility. The allegation was determined to be unfounded after interviews, document review, and observations.
Findings
The investigation found the allegation to be unfounded. The facility had kept the resident's belongings past the required five-day removal period and made efforts to contact the responsible party. The belongings were left untouched and available for pickup, with no evidence that the facility withheld them.
Report Facts
Facility Capacity: 144
Resident Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation |
| Khatera Bahadory | Executive Director | Interviewed during investigation and exit interview |
| Kathleen Tamondong | Assistant Administrator | Interviewed during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 144
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by multiple allegations received on 2025-02-27 regarding medication administration, facility cleanliness, resident supervision, diet adherence, and facility disrepair.
Complaint Details
The complaint investigation was initiated based on allegations received on 2025-02-27. The allegations included failure to administer medications as prescribed, poor facility cleanliness, residents left unattended, failure to follow prescribed diets, and facility disrepair. The medication administration allegation was found unfounded. Cleanliness and supervision allegations were unsubstantiated. The diet and disrepair allegations were substantiated.
Findings
The investigation found the allegation that staff do not administer medications as prescribed to be unfounded. Allegations about facility cleanliness and residents being left unattended were unsubstantiated. However, allegations that staff do not follow physician prescribed diets and that the facility is in disrepair were substantiated, citing failure to provide prescribed diabetic diets and a non-operational telephone on the second floor.
Deficiencies (2)
CCR 87628(4): Licensee failed to ensure Resident 1 was provided a physician prescribed diabetic diet. This poses a potential health and safety risk to residents in care.
CCR 87303(a): Licensee failed to ensure the facility was in good repair. A non-operational telephone on the second floor poses a potential health and safety risk to residents.
Report Facts
Capacity: 144
Census: 95
Deficiency count: 2
Plan of Correction Due Date: Due date for correction is 2025-04-23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Eleanor Barrientos | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 144
Deficiencies: 1
Date: Mar 27, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation of unlawful eviction at Palms Retirement Center.
Complaint Details
The complaint alleging unlawful eviction was substantiated based on interviews and document review. One of six interviewed confirmed the allegation. The facility failed to provide the required 60 days' notice for rent increase before eviction.
Findings
The investigation substantiated that a resident received an unlawful eviction due to failure to provide the required 60 days' written notice for a rent increase. The facility issued only a 37-day notice, violating Health and Safety Code section 1569.655 and California Code of Regulations, Title 22, Division 6, Chapter 8.
Deficiencies (1)
CCR 87224(a)(1) Eviction Procedures require a 30-day written notice for eviction due to nonpayment within ten days of the due date. The licensee issued a 37-day notice for rent increase instead of the required 60 days, posing a risk to residents.
Report Facts
Census: 109
Total Capacity: 144
Deficiency count: 1
Rent increase notice days: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation |
| Eleanor Barrientos | Administrator | Facility administrator present during investigation |
| Kathleen Tamondong | Administrator Assistant | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 144
Deficiencies: 0
Date: Mar 26, 2025
Visit Reason
The visit was conducted as a complaint investigation following a complaint received on 2025-03-20 alleging mismanagement of residents' medication and failure to ensure residents were seen by their own physician.
Complaint Details
The complaint alleged staff were mismanaging residents' medication and not ensuring residents were seen by their own physician. The investigation included interviews with 6 residents and 4 staff members, and review of records. The allegations were found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that staff provide medications as prescribed and residents are allowed to see a physician of their choosing based on insurance. The allegations were determined to be unsubstantiated with no deficiencies cited.
Report Facts
Capacity: 144
Census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation |
| John Garcia | Facility Manager | Met with during the investigation |
| Kathleen Tamondong | Assistant Administrator | Met with during the investigation |
Inspection Report
Annual Inspection
Census: 111
Capacity: 144
Deficiencies: 0
Date: Mar 3, 2025
Visit Reason
Licensing Program Analysts conducted an unannounced visit to perform a required annual inspection of the Residential Care Facility for the Elderly.
Findings
The inspection found the facility to be in compliance with all applicable regulations. No deficiencies were cited. The facility was clean, well-maintained, and all required documentation and safety systems were current and operational.
Report Facts
Food supply duration: 2
Food supply duration: 7
Resident records reviewed: 11
Employee records reviewed: 9
Inspection Report
Complaint Investigation
Census: 110
Capacity: 144
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that facility staff was not acting to prevent a bed bug infestation.
Complaint Details
The complaint alleged that facility staff was not acting to prevent a bed bug infestation. The allegation was unsubstantiated based on interviews, observations, and pest control records.
Findings
The investigation found no current evidence of bed bugs in the facility. Staff and residents reported effective pest control measures, and pest control records confirmed no bed bugs since December 2024. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 144
Census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eleanor Barrientos | Administrator | Assisted with the complaint investigation and participated in the exit interview |
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 144
Deficiencies: 1
Date: Jan 29, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that facility staff are mismanaging residents' medication.
Complaint Details
The complaint alleging mismanagement of residents' medication was substantiated based on staff interviews and medication record reviews. The preponderance of evidence standard was met.
Findings
The investigation found discrepancies in medication administration records for multiple residents, including missed doses and medications without refills. The allegation was substantiated, and a deficiency was cited for failure to comply with care and supervision regulations.
Deficiencies (1)
HSC 1569.2(c): The facility failed to provide ongoing assistance with activities of daily living, as residents' medications were mismanaged, posing an immediate health, safety, and personal rights risk.
Report Facts
Residents with medication discrepancies: 5
Medication administration records reviewed: 10
Estimated days of completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| John Garcia | Interim Administrator | Met with Licensing Program Analyst during investigation. |
| Kathleen Tamondong | Assistant Administrator | Interviewed during the investigation. |
Inspection Report
Annual Inspection
Census: 117
Capacity: 144
Deficiencies: 2
Date: May 8, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with licensing regulations using the CARE Inspection Tool.
Findings
The facility was generally found to be in compliance with medication administration and infection control practices, but staff personnel records were incomplete regarding training. One bedroom was observed missing a smoke detector, which was corrected during the visit.
Deficiencies (2)
CCR 87412C: Ten out of ten staff personnel files were missing required training hours and specific training topics, posing a potential health and safety risk.
CCR 87303A: One of ten bedrooms was observed missing a smoke detector, posing a potential health and safety risk. The facility corrected this during the visit.
Report Facts
Hospice residents present: 3
Fire extinguishers observed: 5
Staff files reviewed: 10
Resident files reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection |
| Edward Kim | Licensing Program Analyst | Conducted the inspection |
| Erin Rehbein | Administrator | Facility administrator present during inspection |
| Kathleen Tamondong | Assistant Administrator | Met with inspectors during the visit |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 144
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that the facility was refusing to accept a resident back to the facility.
Complaint Details
The complaint alleged the facility was refusing to accept the resident back. The investigation revealed the resident was hospitalized and returned to the facility on 03/26/2024. The allegation was unsubstantiated.
Findings
The investigation found that the resident was discharged to a hospital and returned to the facility without issues. The administrator denied refusing the resident but requested additional treatment time. The allegation was deemed unsubstantiated due to lack of evidence.
Report Facts
Capacity: 144
Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Eleanor Barrientos | Administrator | Facility administrator involved in the investigation |
Inspection Report
Follow-Up
Census: 118
Capacity: 144
Deficiencies: 0
Date: Mar 19, 2024
Visit Reason
The visit was an unannounced Case Management follow-up on an incident that occurred on March 14, 2024, involving two residents.
Findings
The facility reported an incident where one resident touched another inappropriately twice. Interviews and observations indicated no substantiated harm, and the involved resident was sent for a psychiatric evaluation and has not returned. The administrator contacted responsible parties and authorities regarding the incident.
Inspection Report
Complaint Investigation
Census: 131
Capacity: 144
Deficiencies: 1
Date: Feb 8, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in conjunction with a complaint investigation regarding a resident's room change without proper notice.
Complaint Details
The visit was triggered by complaint visit 22-AS-20240201121336. The complaint was substantiated based on interviews and observations regarding the lack of notice for a resident's room change.
Findings
The facility failed to provide a 30-day written notice to Resident 1 for a room change, which is required by regulation. This deficiency poses a potential health and safety risk to residents in care.
Deficiencies (1)
CCR 87468.2(a)(16): The licensee failed to provide Resident 1 with a 30-day written notice for a room change. This violates residents' personal rights and poses a potential health and safety risk.
Report Facts
Census: 131
Total Capacity: 144
Inspection Report
Complaint Investigation
Census: 131
Capacity: 144
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff did not provide adequate notice of a rate change.
Complaint Details
The complaint alleged that staff did not provide adequate notice of a rate change. The investigation revealed that the facility scanned and mailed notices to the responsible party, but there was no proof of receipt for the first notice. The allegation was deemed unsubstantiated.
Findings
The investigation included interviews, facility tour, and document review. The allegation was found to be unsubstantiated due to lack of sufficient evidence to prove the alleged violation occurred.
Report Facts
Facility Capacity: 144
Resident Census: 131
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Eleanor Barrientos | Administrator | Facility administrator involved in the investigation |
Inspection Report
Census: 113
Capacity: 144
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced collateral visit related to an open complaint investigation unrelated to the current licensee. The visit included interviews and record gathering concerning multiple open complaints.
Complaint Details
The visit was related to multiple open complaints with control numbers 22-AS-20200925103558, 22-AS-20231009110307, 22-AS-20230829083600, 22-AS-20230802135409, and 22-AS-20230727154102. The complaints are open and the visit was collateral in nature.
Findings
The Licensing Program Analyst conducted interviews and gathered records related to several open complaints at the facility. An exit interview was conducted with the Administrator and a copy of the report was provided to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the unannounced collateral visit and interviews. |
| Erin Rehbein | Administrator | Met with Licensing Program Analyst during the visit and exit interview. |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 144
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not following the infectious control plan.
Complaint Details
The complaint alleged that staff were not following the infectious control plan. The investigation determined the allegation was unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found the allegation to be unfounded based on interviews, observations, and documentation review. Staff were observed following infection control protocols including hand hygiene, PPE use, and cleaning procedures.
Report Facts
Capacity: 144
Census: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Rehbein | Administrator | Met with during investigation and exit interview |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 144
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 05/30/2023 regarding failure to provide residents with facility rules in a timely manner and presence of roaches in the facility.
Complaint Details
The complaint allegations were that staff did not provide residents with facility rules and regulations in a timely manner and that the facility had roaches. Both allegations were investigated and found to be unfounded.
Findings
The investigation found that residents did receive facility rules in a timely manner and pest control records showed no evidence of roaches. The allegations were deemed unfounded based on interviews, observations, and documentation review. No deficiencies were cited during the visit.
Report Facts
Capacity: 144
Census: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Rehbein | Administrator | Met with during the investigation and exit interview |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 144
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
The visit was an unannounced collateral visit to conduct investigations related to open complaints unrelated to the current licensee.
Complaint Details
The visit was related to complaint control numbers 22-AS-20200604111128 and 22-AS-20200720143243. No substantiation status is provided.
Findings
The Licensing Program Analyst conducted interviews and gathered pertinent records related to two complaint control numbers. An exit interview was conducted with the Administrator and a copy of the report was provided to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eleanor Barrientos | Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Jenifer Tirre | Licensing Program Analyst | Conducted the unannounced collateral visit and gathered records related to complaint investigations. |
| Luz Adams | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 144
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2022-04-05 regarding sexual abuse, inadequate staff supervision, and vermin presence at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a resident being raped by another resident, inadequate staff supervision, and vermin presence. Interviews and medical records did not support these allegations, and the facility was found to be providing adequate care and supervision.
Findings
The investigation found no preponderance of evidence to substantiate the allegations of sexual abuse, inadequate supervision, or vermin presence. Medical records and interviews did not support the claims, and facility inspections found no vermin.
Report Facts
Capacity: 144
Census: 109
Residents interviewed: 9
Residents confirming vermin: 6
Residents confirming adequate supervision: 6
Residents confirming monitoring at exit: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation |
| Kathleen Tamondong | Assistant Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 144
Deficiencies: 1
Date: Nov 8, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2022-07-06 regarding inadequate supervision of a resident.
Complaint Details
The complaint alleging inadequate supervision of a resident was substantiated based on interviews, records, and police reports confirming the resident eloped and was found outside the facility.
Findings
The investigation substantiated that staff did not adequately supervise a resident who eloped from the facility and was found in another city, posing an immediate health and safety risk.
Deficiencies (1)
CCR 87464(f)(1) Basic services shall include care and supervision as defined by regulations. Licensee failed to ensure care and supervision were provided to resident R1 who eloped from the facility on 6/28/22 and was found in another city, posing an immediate health and safety risk.
Report Facts
Capacity: 144
Census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kathleen Tamondong | Assistant Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Follow-Up
Census: 111
Capacity: 144
Deficiencies: 0
Date: Jul 12, 2022
Visit Reason
This was an unannounced Case Management visit to follow up on concerns related to a recent complaint investigation about resident altercations and bullying.
Complaint Details
The complaint alleged residents engaged in an altercation while in care. The investigation found the complaint unsubstantiated due to conflicting reports. Some residents expressed feeling unsafe due to bullying by other residents.
Findings
The complaint alleging resident altercations was found unsubstantiated due to conflicting reports. The facility is addressing resident safety concerns by increasing one-on-one visits, updating staff training on personal rights, and holding resident meetings every other week.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation. |
| Katherine Trevino | Administrator | Met with Licensing Program Analyst to discuss visit and facility measures. |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 144
Deficiencies: 0
Date: Jul 5, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that residents engaged in an altercation while in care.
Complaint Details
The complaint alleged residents engaged in an altercation while in care. The allegation was found unsubstantiated.
Findings
The investigation found the allegation unsubstantiated due to lack of corroborating evidence and witnesses. The department concluded there was no preponderance of evidence to prove the alleged violation occurred.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit. |
| Kathleen Tamondong | Business Office Coordinator | Met with the Licensing Program Analyst during the investigation. |
| Eleanor Barrientos | Administrator | Named as facility administrator. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 144
Deficiencies: 0
Date: May 24, 2022
Visit Reason
The visit was an unannounced case management incident inspection conducted to interview a resident in conjunction with a complaint investigation regarding a resident who left the facility and had not returned.
Complaint Details
The investigation was triggered by a complaint related to a resident leaving the facility unassisted and not returning. The resident is able to leave unassisted per physician's report. The resident has not returned to the facility to date.
Findings
The Licensing Program Analyst interviewed the administrator and a resident. The facility reported that a resident left on 5/12/22 without signing out and had not returned as of the inspection date. The administrator is working with local law enforcement regarding the missing resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the unannounced visit and interviews. |
| Katherine Trevino | Administrator | Interviewed during the visit and involved in follow-up regarding the incident. |
Inspection Report
Census: 108
Capacity: 144
Deficiencies: 0
Date: Apr 18, 2022
Visit Reason
Licensing Program Analyst Jenifer Tirre made an unannounced case management visit to follow up on an incident involving a resident's aggressive behavior towards a staff member on 2022-03-30.
Findings
The incident involved a resident placing hands on a staff member's throat, police were called but no charges were pressed. The resident was later transferred to hospital for psychiatric evaluation. The facility is conducting staff training on de-escalation techniques as a result.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| Katherine Trevino | Administrator | Met with Licensing Program Analyst during visit and involved in incident follow-up. |
| Eleanor Barrientos | Administrator | Named as facility administrator in report header. |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 144
Deficiencies: 0
Date: Apr 7, 2022
Visit Reason
Unannounced health and safety visit conducted in conjunction with complaint visit 22-AS-20220405132859 to investigate allegations at the facility.
Complaint Details
Complaint visit 22-AS-20220405132859 was the basis for this investigation. No deficiencies or concerns were found.
Findings
No health and safety concerns were noted during the visit. Residents appeared clean and well cared for.
Inspection Report
Original Licensing
Census: 110
Capacity: 144
Deficiencies: 0
Date: Feb 9, 2022
Visit Reason
An announced prelicensing visit was conducted to follow up on corrections identified during a prior visit and to evaluate readiness for licensing of a Residential Facility Care for the Elderly.
Findings
All noted corrections from the previous visit were addressed, including repairs to sinks, bathroom doors, and grab bars, as well as compliance with COVID precaution guidelines. The facility was found ready to be licensed.
Inspection Report
Original Licensing
Census: 117
Capacity: 144
Deficiencies: 8
Date: Jan 10, 2022
Visit Reason
An announced pre-licensing visit was conducted to evaluate the facility's readiness to operate as a Residential Facility Care for the Elderly following an initial application submitted on 2021-12-03.
Findings
The facility was observed to be generally compliant with COVID-19 precautions and had adequate amenities and safety features. However, several maintenance and compliance issues were identified, including water temperature out of compliance in multiple rooms, soiled bathtubs, plumbing repairs needed, and an improperly sized regulatory poster. The facility was deemed not ready to be licensed pending correction of these issues.
Deficiencies (8)
Water temperature is out of compliance in rooms 104, 109, 203, 217, 220, and 221. The water temperature must be adjusted to comply with regulations.
Bathtubs in rooms 113, 115, 122, and 210 were soiled and require cleaning. Cleanliness must be maintained in resident bathing areas.
The sink in room 127 is separating from the wall and needs repair. Structural repairs are required to maintain safety.
The sink in room 122 is backing up and must be unclogged to ensure proper plumbing function.
The sink in room 113 is supported by a wooden beam and requires proper repair. Unsafe temporary supports must be corrected.
The bathroom door in room 210 needs repairs to maintain functionality and safety.
The grab bar in restroom 128 needs proper repair and holes in the wall must be fixed. Safety equipment must be maintained.
The 'Let Us Know' poster near the entrance is not regulation size and must be replaced with a proper 20x26 inch poster.
Report Facts
Residents in care: 117
Licensed capacity: 144
Fire clearance approval: 112
Fire clearance approval: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eleanor Barrientos | Administrator | Facility Administrator present during the inspection and involved in the visit |
| Sona Bhatia | Licensee | Licensee present during the inspection and involved in the visit |
| Katherine Trevino | Assistant Administrator | Assistant Administrator present during the facility tour |
| Jenifer Tirre | Licensing Program Analyst | Licensing evaluator conducting the inspection |
| Kimberly Lyman | Licensing Program Analyst | Licensing evaluator conducting the inspection |
Inspection Report
Census: 107
Capacity: 144
Deficiencies: 0
Date: Dec 14, 2021
Visit Reason
The visit was conducted as an office evaluation related to a change of ownership application for the Residential Care Facility for the Elderly.
Findings
The applicant and administrator participated in a telephone interview to confirm understanding of California Code Title 22 regulations, covering facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.
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