Inspection Reports for Pasadena Highlands
1575 E Washington Blvd, Pasadena, CA 91104, United States, CA, 91104
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated. The most recent report from September 20, 2025, was a complaint investigation that found no violations, although there was a minor delay in providing resident records that was ultimately resolved. Earlier reports show isolated issues, including one substantiated finding in August 2025 where staff failed to respond timely to a resident’s calls for assistance, resulting in emergency services being called. More serious deficiencies occurred in 2022 and earlier, involving staffing shortages, medication errors, and supervision failures, some leading to resident injury and elopement, but these issues have not recurred in recent years. Overall, the facility’s record shows improvement over time, with recent inspections reflecting compliance and resolution of prior concerns.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 215
Capacity: 245
Deficiencies: 0
Sep 20, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not provide resident records to the resident's authorized representative.
Findings
The investigation found that although there was a delay in providing the requested resident records, the facility did not deny the request and ultimately provided the records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff did not provide resident#1's authorized representative with resident records requested on 08/18/2025. Interviews with three staff members indicated the request was received but required verification of legitimacy before release. Records were sent by 09/18/2025. The allegation was unsubstantiated.
Report Facts
Capacity: 245
Census: 215
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Fernando Fierros | Licensing Program Manager | Named in report signature section |
| Cynthia Leon | Director of Marketing and Sales | Met with investigator during visit |
Inspection Report
Complaint Investigation
Census: 212
Capacity: 245
Deficiencies: 0
Sep 12, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not safeguard a resident's personal belongings, specifically a missing wedding ring.
Findings
The investigation included interviews with staff and residents, review of documentation, and a police report. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The allegation was that staff did not safeguard resident R-1's personal belongings, specifically a missing wedding ring. Interviews and documentation did not corroborate the allegation. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 245
Census: 212
Memory care unit census: 35
Number of interviewed residents: 3
Number of interviewed staff: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the complaint investigation |
| Kay Cano | Administrator | Facility administrator met during the investigation |
| Wei Siew Ho | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 215
Capacity: 245
Deficiencies: 1
Aug 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-07-17 regarding staff not timely responding to resident calls for assistance, resulting in hospitalization, and other related complaints.
Findings
The investigation substantiated that staff failed to respond timely to a resident's call for help, resulting in the resident having to call 911. Other allegations related to missed medications, failure to follow physician orders, failure to provide meals, and failure to check on the resident were found to be unsubstantiated based on interviews and record reviews.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not answer resident's calls for assistance timely, resulting in hospitalization. Other allegations including staff neglect related to missed medications, failure to follow physician orders, failure to provide meals, and failure to check on the resident were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff failed to respond to resident R1's repeated pull cord calls for assistance, resulting in R1 having to call 911 for emergency help. | Type A |
Report Facts
Facility capacity: 245
Census: 215
Deficiency count: 1
Plan of Correction due date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| David Sicairos | Licensing Program Manager | Oversaw the complaint investigation |
| Kay Cano | Administrator | Facility administrator notified and interviewed during investigation |
| Cherry Castro | Med-Tech | Met with Licensing Program Analyst during investigation and interviewed |
Inspection Report
Complaint Investigation
Census: 209
Capacity: 245
Deficiencies: 0
May 22, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including inadequate supervision resulting in resident falls and injuries, unsafe transfers, pressure injuries due to neglect, worsening resident condition, and isolation of a resident in her room.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations. Interviews with residents and staff, as well as review of medical and hospital documentation, indicated that incidents were either assist to ground rather than falls, injuries were minor and promptly addressed, and residents did not have pressure injuries or worsening conditions due to neglect. The allegation of isolation was also unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated for all allegations including inadequate supervision, unsafe transfers, pressure injuries, worsening condition, and isolation. Documentation and interviews did not support the claims, and the facility responded appropriately to incidents.
Report Facts
Residents present: 209
Licensed capacity: 245
Number of allegations: 5
Residents interviewed: 7
Staff interviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kay Cano | Administrator | Facility administrator met during investigation and provided information |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 223
Capacity: 245
Deficiencies: 0
Mar 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-02-19 regarding allegations that staff did not adequately address a change in a resident's condition and did not inform the resident's representative of incidents as required.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the claims, and documentation showed appropriate tracking and communication of residents' health conditions. The findings remain unsubstantiated.
Complaint Details
The complaint involved allegations that staff failed to adequately address changes in resident R1's condition and failed to inform R1's power of attorney (POA) of incidents. Interviews with staff and residents, as well as review of records, did not substantiate these allegations. The report notes that although the allegations may have happened or be valid, there was insufficient evidence to prove violations occurred.
Report Facts
Capacity: 245
Census: 223
Staff interviewed: 7
Residents interviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kay Cano | Administrator | Met during inspection and named in report |
| Sanjay Vaid | Licensing Program Analyst | Conducted the complaint investigation |
| Fernando Fierros | Licensing Program Manager | Named as Licensing Program Manager on report |
| Adrienne Hurd | Assistant Executive Director | Met during initial investigation visit |
Inspection Report
Census: 230
Capacity: 245
Deficiencies: 0
Mar 13, 2025
Visit Reason
Licensing Program Analyst Mary Flores conducted an unannounced collateral visit to conduct interviews regarding a recent incident at a different licensed facility.
Findings
Interviews were conducted with 7 residents regarding the incident that occurred at their previous facility. An exit interview was conducted with the administrator and a copy of the report was provided.
Report Facts
Number of residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the unannounced collateral visit and interviews |
| Kay Cano | Administrator | Met with Licensing Program Analyst and participated in exit interview |
| Marie Brooks | Wellness Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 230
Capacity: 245
Deficiencies: 0
Feb 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not adequately address a change in a resident's condition and did not inform the resident's representative of incidents as required.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the allegations, and documentation showed appropriate tracking and communication of residents' health conditions. The resident's POA was involved during behavioral episodes, and staff assisted the resident accordingly.
Complaint Details
The complaint involved two allegations: 1) staff did not adequately address a change in resident R1's condition related to dementia, and 2) staff did not inform R1's POA of incidents. Both allegations were unsubstantiated after interviews with staff, residents, and the resident's POA, and review of records.
Report Facts
Capacity: 245
Census: 230
Staff interviewed: 7
Residents interviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sanjay Vaid | Licensing Program Analyst | Conducted the complaint investigation |
| Fernando Fierros | Licensing Program Manager | Oversaw the complaint investigation |
| Adrienne Hurd | Assistant Executive Director | Facility representative met during investigation and exit interview |
| Kay Cano | Administrator | Facility administrator named in report |
Inspection Report
Annual Inspection
Census: 198
Capacity: 245
Deficiencies: 0
Dec 16, 2024
Visit Reason
The inspection was a required unannounced annual inspection to evaluate compliance with regulatory standards for the Pasadena Highlands facility.
Findings
The facility was found to be in compliance with all applicable regulations, with no deficiencies observed. The inspection covered infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, residents' rights, planned activities, food service, incidental medical and dental care, disaster preparedness, and residents with special health needs.
Report Facts
Residents on hospice: 30
Residents' bedrooms checked: 12
Food supply perishables: 2
Food supply non-perishables: 7
Resident files reviewed: 8
Staff files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kay Cano | Administrator | Met during inspection and named in exit interview |
| John Arbona | Maintenance Director | Assisted with facility tour during inspection |
| Adrienne Hurd | Executive Assistant | Assisted with facility tour during inspection |
| Sanjay Vaid | Licensing Evaluator | Conducted the inspection |
| Fernando Fierros | Supervisor | Supervised the inspection |
Inspection Report
Complaint Investigation
Census: 200
Capacity: 245
Deficiencies: 0
Oct 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations related to improper wound care, neglect, failure to note changes in medical condition, failure to seek timely medical attention, failure to provide wound care plan to family, and retaining a resident requiring a higher level of care.
Findings
The investigation found that although there were allegations of neglect and improper wound care resulting in worsening wounds, the resident was receiving hospice services and skilled care. Facility staff documented changes in condition and timely hospital transfers were made upon family request. There was insufficient evidence to substantiate any violations, and all allegations were determined to be unsubstantiated.
Complaint Details
The complaint involved multiple allegations including improper wound care handling, neglect leading to wound worsening, failure to note medical condition changes, failure to seek timely medical attention, failure to provide wound care plan to family, and retaining a resident needing higher level care. The investigation included interviews with staff, residents, family, hospice care, and review of medical and facility records. The complaint was found to be unsubstantiated.
Report Facts
Facility capacity: 245
Census: 200
Hospital visits: 3
Visit duration: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Cynthia Leon | Director Sales and Marketing | Met with Licensing Program Analyst during the investigation visit |
| Kay Cano | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Census: 197
Capacity: 245
Deficiencies: 0
Sep 27, 2024
Visit Reason
An unannounced Case Management visit was conducted to evaluate the third floor Memory Care unit for health and safety compliance.
Findings
The facility was found to be in full compliance with health and safety standards, including fire clearance and emergency systems. The memory care unit was ready and appropriately equipped to house residents with dementia needs.
Report Facts
Hospice residents: 28
Hospice waiver capacity: 30
Fire clearance date: Sep 11, 2024
Egress delay time: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kay Cano | Facility Executive Director | Met with licensing analyst during inspection and involved in facility tour |
| John Arbona | Maintenance Director | Explained and tested delayed egress doors on third floor |
| Sanjay Vaid | Licensing Evaluator | Conducted the inspection visit |
| Fernando Fierros | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 245
Deficiencies: 0
Jul 2, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not keep the facility free from pests.
Findings
The investigation found no evidence of pests in the facility. Interviews with staff and residents, inspection of the facility, and review of pest control documentation revealed no observations of roaches, rodents, or flies. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff do not keep the facility free from pests. The allegation was unsubstantiated based on interviews, inspections, and documentation review.
Report Facts
Capacity: 245
Census: 190
Pest control visits: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kay Cano | Administrator | Facility administrator met during the investigation |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 188
Capacity: 245
Deficiencies: 0
May 14, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-04-25 regarding pest control, sanitation of kitchen items, mildew presence, and food handling techniques at the facility.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations. Staff and residents denied the claims, observations and documentation supported proper pest control, sanitation, mildew cleaning, and food handling practices. The allegations were therefore determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not keeping the facility free from pests, improper sanitization of kitchen items, presence of mildew, and improper food handling techniques. Interviews with staff and residents, observations, and document reviews did not confirm these allegations.
Report Facts
Staff interviewed: 8
Residents interviewed: 10
Pest control visits: 7
Facility capacity: 245
Facility census: 188
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Villalobos | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Fernando Fierros | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Kay Cano | Administrator | Facility Administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 188
Capacity: 245
Deficiencies: 0
May 2, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-04-25 regarding pest control, sanitation, mildew, and food handling practices at the facility.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations. Staff and residents denied the claims, observations and documentation supported proper pest control, sanitation, mildew cleaning, and food handling practices. The allegations were therefore unsubstantiated.
Complaint Details
The complaint included allegations that staff did not keep the facility free from rodents, did not properly sanitize kitchen items, did not keep the facility free from mildew, and did not follow proper food handling techniques. All allegations were investigated and found to be unsubstantiated based on staff and resident interviews, observations, and documentation review.
Report Facts
Staff interviewed: 8
Residents interviewed: 10
Pest control visits: 7
Resident rooms inspected: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Villalobos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kay Cano | Administrator | Facility administrator met during investigation |
| Fernando Fierros | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 187
Capacity: 245
Deficiencies: 0
Mar 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of wrongful eviction of residents R1 and R2.
Findings
The investigation found no evidence of wrongful eviction. Staff and residents denied the allegation, and no eviction notices were found in the residents' files. The residents were moving out by choice, supported by a 30-day notice from the responsible party. The allegation was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged wrongful eviction of residents R1 and R2. The allegation was unsubstantiated after interviews with staff, residents, and review of documentation showed no eviction notices or wrongful eviction actions.
Report Facts
Capacity: 245
Census: 187
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Villalobos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
| Kay Cano | Administrator | Facility Administrator met during investigation |
Inspection Report
Annual Inspection
Census: 177
Capacity: 245
Deficiencies: 0
Jan 12, 2024
Visit Reason
The inspection was a required unannounced annual inspection to evaluate compliance with regulatory standards for the Pasadena Highlands facility.
Findings
The facility was found to be in compliance with all applicable regulations, including infection control, operational requirements, physical plant safety, staffing, personnel training, resident records, residents' rights, planned activities, food service, incidental medical and dental care, and disaster preparedness. No deficiencies were observed during the visit.
Report Facts
Residents on hospice: 24
Staff files reviewed: 10
Resident files reviewed: 10
Food supply - perishables: 2
Food supply - non-perishables: 7
Floors in facility: 8
Rooms checked: 20
Oxygen rooms observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kay Cano | Administrator | Facility Administrator present during inspection and named in report |
| John Arbona | Maintenance Director | Assisted with facility tour during inspection |
| Tena Herrera | Licensing Program Analyst | Conducted the inspection |
| David Sicairos | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 245
Deficiencies: 0
Jul 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff was not providing adequate care and supervision to a resident.
Findings
The investigation found insufficient evidence to substantiate the allegation. Interviews with staff and residents, as well as file reviews, indicated that the resident received proper care and medication management was appropriately handled by certified staff.
Complaint Details
The allegation was that staff was not providing adequate care and supervision to a resident, specifically that the resident was denied care and the private caregiver was not allowed to administer medication. The allegation was unsubstantiated based on interviews and documentation reviewed.
Report Facts
Capacity: 245
Census: 164
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kay Cano | Administrator | Met with during the investigation and named in findings |
| Tena Herrera | Licensing Program Analyst | Conducted the complaint investigation |
| David Sicairos | Licensing Program Manager | Named in report as Licensing Program Manager |
| Brodey De Borde | Executive Director | Interviewed during investigation |
| Laura Sanchez | Health and Wellness Director | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 245
Deficiencies: 0
Jan 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not provide adequate supervision to a resident while in care.
Findings
The investigation found insufficient evidence to substantiate the allegation. Staff and residents interviewed denied the claim, and records showed adequate supervision and staffing. The resident in question was reported missing briefly but was not found after a search and police notification. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged inadequate supervision of a resident who went missing on 01/21/2023. The investigation included interviews with staff and residents, review of resident files, and facility policies. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 245
Resident census: 59
Staff interviewed: 6
Residents interviewed: 6
Time missing: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation |
| Kay Cano | Executive Director | Facility representative interviewed during investigation |
| David Sicairos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 154
Capacity: 245
Deficiencies: 0
Dec 16, 2022
Visit Reason
The visit was an unannounced Case Management site visit focused on COVID-19 to assist the facility in reducing their COVID-19 positive cases.
Findings
The facility was closed for new admissions and conducting twice-weekly COVID-19 testing. Communal areas were closed due to the outbreak, and residents isolated in their rooms. Infection control measures including hand sanitizers, PPE availability, cleaning protocols, and mask usage were observed and enforced throughout the facility.
Report Facts
COVID-19 positive residents: 4
Medtechs per shift: 2
Memory Care staff: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the unannounced site visit. |
| Kay Cano | Executive Director | Met with the licensing team during the visit. |
| Sanda Lee | Assisted Living Director | Assisted with the tour of the facility. |
| John Arbona | Director of Plant Operations | Assisted with the tour of the facility. |
| David Sicairos | Supervisor | Named as supervisor in the report. |
| Casey Cortes | Public Health Nurse | Participated in the joint visit. |
| Sandy Gesell | Public Health Nurse | Participated in the joint visit. |
| Britany Bruner | Wellness Director | Called by Medtechs to perform assessments in emergencies. |
Inspection Report
Annual Inspection
Census: 154
Capacity: 245
Deficiencies: 0
Dec 16, 2022
Visit Reason
An unannounced required 1-year visit focusing on the Infection Control Domain was conducted to evaluate compliance with health and safety regulations.
Findings
The facility was found to be in compliance with infection control and safety standards, including adequate PPE supplies, proper signage, mask usage, and safe medication storage. No deficiencies were cited during the visit.
Report Facts
Hospice waivers: 25
Resident rooms inspected: 15
Fire extinguishers per floor: 4
Perishable food supply: 2
Non-perishable food supply: 7
Medication supply: 30
Facility floors: 8
Bedrooms: 245
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kay Cano | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Bennette Pena | Licensing Program Analyst | Conducted the inspection visit |
| David Sicairos | Supervisor | Supervisor overseeing the inspection |
| Wayne Scott | Director of Dining Services | Met with Licensing Program Analyst during kitchen inspection |
| Sanda Lee | Assisted Living Director | Assisted with the tour of the facility |
| John Arbona | Director of Plant Operations | Assisted with the tour of the facility |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 245
Deficiencies: 0
Aug 31, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff did not provide a resident's records to the authorized representative upon written request.
Findings
The investigation found that the initial document request lacked proper authorization or power of attorney, making it a HIPAA violation to provide the documents. An updated request with proper authorization was provided on 08/31/2022, and the facility agreed to provide the requested documents accordingly. Therefore, the allegation was unsubstantiated.
Complaint Details
The complaint alleged that facility staff did not provide resident's records to the authorized representative upon written request. The allegation was unsubstantiated due to lack of evidence and proper authorization in the initial request.
Report Facts
Facility capacity: 245
Census: 162
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brodey DeBorde | Administrator | Met with Licensing Program Analyst during investigation |
| Bonnie Tao | Licensing Program Analyst | Conducted the complaint investigation |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 245
Deficiencies: 4
Feb 3, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-11 regarding multiple allegations including resident injury from a fall, staffing shortages, care plan non-adherence, inadequate food services, and medication administration errors.
Findings
The investigation substantiated all allegations, finding that a resident fell resulting in brain injury, staffing shortages led to missed care such as repositioning and feeding, the resident's care plan was not consistently followed or updated, food services were delayed due to staff shortages, and medications were not administered according to physician orders including medication errors.
Complaint Details
The complaint investigation was substantiated based on evidence including interviews, record reviews, and video surveillance. Allegations included a resident fall causing injury, insufficient staffing, failure to follow care plans, inadequate food services, and medication administration errors.
Severity Breakdown
Type B: 3
Type A: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, including activities of daily living and medication assistance. | Type B |
| Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers and competent to meet resident needs. | Type B |
| Incidental Medical and Dental Care Services. Licensee shall assist residents with self-administered medications when needed; medication errors occurred including late administration, failure to crush medications, and wrong inhaler brought to resident. | Type A |
| Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have care and supervision delivered by sufficient and competent staff; resident fell without required escort assistance. | Type B |
Report Facts
Capacity: 245
Census: 154
Staffing shortage: 3
Plan of Correction Due Date: Feb 17, 2022
Plan of Correction Due Date: Feb 17, 2022
Plan of Correction Due Date: Feb 17, 2022
Plan of Correction Due Date: Feb 4, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brodey DeBorde | Executive Director | Met with during investigation and named in findings related to resident fall and staffing |
| Noemi Galarza | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
| S6 | Staff member interviewed who confirmed medication errors |
Inspection Report
Annual Inspection
Census: 154
Capacity: 245
Deficiencies: 2
Feb 3, 2022
Visit Reason
An unannounced required 1-year visit focusing on COVID-19 Infection Control Practices was conducted to evaluate compliance with health and safety regulations.
Findings
The inspection found deficiencies related to failure to screen visitors for COVID-19 symptoms and temperature checks, and improper medication storage in a resident's room. Infection control signage and PPE were observed, and staff were wearing masks. The facility removed medications from the resident's room during the visit and planned staff training on medication handling.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Front desk staff did not screen for COVID-19 symptoms or check temperature of Licensing Program Analysts upon arrival, posing immediate health and safety risks. | Type A |
| Facility did not comply with assisting a resident with self-administered medications as medications were improperly stored in resident's room #223, posing immediate health and safety risks. | Type A |
Report Facts
Hospice residents: 23
Hospice waivers: 25
Client rooms inspected: 36
Client rooms lacking hand sanitizer: 9
Medication records reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brodie Deborde | Administrator | Met with Licensing Program Analysts during inspection and involved in medication deficiency observation |
| Laura | Nurse | Observed medications in resident's room during inspection |
| Christine Yee | Supervisor | Supervisor overseeing the inspection |
| Alberto Lopez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lara P. Morris | Assistant Administrator | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 245
Deficiencies: 0
Feb 2, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not follow a resident's Care Plan, did not aid a resident with incontinence needs, and did not ensure a resident's room was not malodorous.
Findings
The investigation found that the alleged resident (R1) was not and has never been a resident of the facility. Interviews with multiple facility directors and observations of resident rooms showed no evidence supporting the allegations. The complaint was determined to be unfounded and dismissed.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, and/or were without reasonable basis.
Report Facts
Monthly rate: 4000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Gonzalez | Licensing Program Analyst | Conducted the complaint investigation |
| Brodey De Borde | Executive Director | Interviewed during investigation and provided information about the allegations |
| Laura Sanchez | Health and Wellness Director | Interviewed during investigation and provided information about the allegations |
| Sanda Lee | Assisted Living Director | Interviewed during investigation and provided information about the allegations |
| Kay Cano | Corporate Health and Wellness Director | Interviewed during investigation and provided information about the allegations |
Inspection Report
Census: 154
Capacity: 245
Deficiencies: 1
Jan 12, 2022
Visit Reason
The visit was a Case Management - Other type, conducted to address the facility's failure to report a Covid-19 outbreak in a timely manner.
Findings
The facility had an outbreak of Covid-19 involving 12 individuals starting on 2021-12-25 but failed to report the outbreak to the licensing agency and local health officer within the required 24 hours. A citation was issued for this failure to report.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the licensing agency and local health officer within 24 hours of an epidemic outbreak of Covid-19 involving 12 individuals. | Type A |
Report Facts
Covid-19 positive individuals: 12
Plan of Correction Due Date: Feb 4, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensed Program Analyst | Conducted the inspection and spoke with the Administrator regarding the Covid-19 outbreak reporting |
| Christine Yee | Supervisor | Supervisor overseeing the inspection |
| Bordie Deborde | Administrator | Facility Administrator who was spoken to about the failure to report the Covid-19 outbreak |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 245
Deficiencies: 2
Jun 9, 2021
Visit Reason
Licensing Program Analyst conducted a Case Management-Deficiencies visit due to observations made during a complaint investigation (control #: 28-AS-20210607141758).
Findings
The inspection found that the right delayed egress door in the memory care unit did not open after the 15-second delay and the alarm did not sound, posing an immediate health and safety risk. Additionally, the required complaint poster was not displayed in the main entryway of the facility.
Complaint Details
The visit was triggered by a complaint investigation under control number 28-AS-20210607141758.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Delayed egress door in the memory care unit did not open after 15 seconds and alarm did not sound. | Type A |
| Complaint poster with DSS/CCLD complaint phone number was not displayed in the main entryway. | Type B |
Report Facts
Capacity: 245
Census: 147
Deficiencies cited: 2
POC Due Date: Jun 10, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brodey DeBorde | Executive Director | Met with Licensing Program Analyst during the visit and involved in exit interview. |
| Noemi Galarza | Licensing Evaluator | Conducted the inspection and authored the report. |
| Lisa Hicks | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 245
Deficiencies: 1
Jun 9, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation of lack of supervision resulting in a resident eloping from the facility.
Findings
The investigation substantiated the allegation that a memory care resident eloped from the facility due to staff failing to supervise and ensure the delayed egress door closed properly. The resident was found safe after being missing for approximately 20 minutes. No injuries were observed upon return.
Complaint Details
The complaint was substantiated. The resident eloped on June 4, 2021, from the memory care unit. Staff failed to supervise and ensure the door closed after exiting. The resident was found safe approximately 1.5 miles away after a search and police involvement. The resident has a history of elopement and dementia diagnosis.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of failure to supervise resident (R1) who eloped through a delayed egress door that staff did not ensure closed properly. | Type A |
Report Facts
Staff to resident ratio: 10
Number of staff working during incident: 4
Deficiency count: 1
Plan of Correction due date: Jun 11, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brodey DeBorde | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 245
Deficiencies: 1
May 3, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that residents were not being changed timely due to lack of staff.
Findings
The investigation found that the facility was short-staffed, with residents waiting 25 minutes to an hour for assistance. Staff reported being overwhelmed and that management had not improved staffing levels. The allegation was substantiated based on interviews and evidence.
Complaint Details
The complaint was substantiated. Residents and staff reported short staffing causing delays in care. The assisted living floor had reduced caregivers from 4-5 to 1-2, posing a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers to provide necessary services to meet resident needs, resulting in residents waiting 25 minutes to an hour for assistance. | Type B |
Report Facts
Deficiencies cited: 1
Capacity: 245
Census: 129
Plan of Correction Due Date: May 17, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christine Wong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Christine Yee | Licensing Program Manager | Oversaw the complaint investigation |
| Maria Alarcon | Business Office Director | Interviewed during investigation and participated in exit interview |
| Kay Cano | Administrator | Facility administrator mentioned in relation to investigation |
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