Inspection Report Summary
Most inspections found no deficiencies, showing the facility generally meets regulatory standards and maintains a safe environment. Several complaint investigations were unsubstantiated, indicating that many concerns raised by residents or others were not confirmed. However, there have been repeated deficiencies related to residents’ personal rights, including unlawful eviction procedures, denial of access to personal belongings or communication devices, and resident-on-resident harassment. The most recent inspection on September 4, 2025, still cited a personal rights violation, suggesting this remains an area needing improvement. Other issues over time included safety risks from wandering residents and occasional lapses in medical care, but recent reports show some improvement in these areas.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
99% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Census: 107
Capacity: 108
Deficiencies: 1
Date: Sep 4, 2025
Visit Reason
The visit was an unannounced Proof of Correction (POC) inspection to verify compliance with a previously cited deficiency related to personal rights under Section 87468.1(a)(2).
Findings
The facility was still not in compliance with the cited Type B deficiency regarding personal rights as of the inspection date. An exit interview was conducted and a copy of the report was provided to the administrator.
Deficiencies (1)
Type B Section 87468.1(a)(2) Personal rights violation
Report Facts
Correction due date: Sep 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the unannounced Proof of Correction visit |
| Susana Fuentes | Administrator | Facility administrator met during the inspection and received the report |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 108
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff unlawfully evicted a resident.
Complaint Details
The complaint alleged that staff unlawfully evicted a resident who was placed on a 51/50 hold at Harbor UCLA Psychiatric Emergency Room. The facility refused to accept the resident back, which was substantiated by interviews and record reviews.
Findings
The investigation substantiated the allegation that the facility did not permit the resident to return after a psychiatric emergency hold, violating the requirement to provide 30 days' written notice before changes. Deficiencies were issued related to residents' personal rights.
Deficiencies (1)
(a) Residents in all residential care facilities for the elderly shall have all the following personal rights: (2) to be accorded safe, healthful and comfortable accommodations. This requirement was not met as evidence by the facility not permitting resident R1 to return, posing a potential personal rights risk.
Report Facts
Capacity: 108
Census: 81
Plan of Correction Due Date: Sep 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator interviewed regarding the complaint |
| Christina Novoa | Facility staff met with during the investigation and present at exit interview |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 108
Deficiencies: 1
Date: Aug 25, 2025
Visit Reason
An unannounced complaint investigation was conducted to address the allegation that staff unlawfully evicted a resident.
Complaint Details
The complaint alleged that staff unlawfully evicted a resident who was placed on a 51/50 hold at Harbor UCLA Psychiatric Emergency Room. The facility refused to accept the resident back after hospitalization, violating eviction notice requirements. The allegation was substantiated based on interviews and record reviews.
Findings
The investigation found that the facility did not provide the required 30 days' written notice before eviction and refused to accept the resident back after hospitalization, substantiating the allegation. Deficiencies were issued and plans for correction were developed.
Deficiencies (1)
Failure to comply with eviction procedures requiring 30 days' written notice before eviction, posing a potential health and safety risk to residents.
Report Facts
Capacity: 108
Census: 85
Deficiency count: 1
Plan of Correction Due Date: Aug 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susana Fuentes | Administrator | Facility administrator interviewed regarding the eviction allegation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 83
Capacity: 108
Deficiencies: 0
Date: Apr 7, 2025
Visit Reason
An unannounced required annual inspection was conducted using the full CAREs Inspection Tool to evaluate compliance with licensing requirements for the facility serving elderly developmentally disabled adults ages 60 and above.
Findings
The inspection found the facility to be in good condition with no deficiencies issued. Resident rooms, common areas, and safety equipment were all compliant with regulations, and all required documentation was maintained and in order.
Report Facts
Resident bedrooms: 54
Staff files reviewed: 5
Resident files reviewed: 5
Bedrooms inspected: 10
Fire extinguishers: 24
Water temperature range (F): 111.9-113.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the inspection and authored the report |
| Susana Fuentes | Administrator | Facility administrator met with the Licensing Program Analyst during the inspection |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 108
Deficiencies: 0
Date: Feb 14, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident sustained multiple unexplained bruises.
Complaint Details
The allegation was that a resident sustained multiple unexplained bruises. The investigation found bruises on the resident's arms, but the resident denied knowledge of the cause. Medication side effects and family member actions were noted as possible factors. Staff and resident interviews were inconclusive. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews, record reviews, and observations. Although bruises were noted on the resident, there was insufficient evidence to substantiate the allegation, and no deficiencies were cited.
Report Facts
Facility capacity: 108
Resident census: 87
Staff interviewed: 5
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susana Fuentes | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 108
Deficiencies: 0
Date: Jan 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not permitting residents to have visitors, receive phone calls, and were not safeguarding residents' belongings.
Complaint Details
The complaint alleged that staff were not permitting residents to have visitors or receive phone calls, and were not safeguarding residents' belongings. The investigation included interviews with staff and residents, review of records, and observation. All allegations were found to be unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with staff and residents indicated that residents were allowed visitors and phone calls, and staff generally safeguarded residents' belongings. The allegations were determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Facility capacity: 108
Census: 88
Staff interviewed: 5
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Susana Fuentes | Administrator | Facility Administrator interviewed during the investigation |
| Xiomara Mejia | Staff who signed the exit interview report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 108
Deficiencies: 3
Date: Nov 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that a resident developed pressure injuries while in care and that staff did not seek medical attention for the resident.
Complaint Details
The complaint was substantiated based on evidence including medical records, interviews with staff and residents, and facility documentation. The allegations involved neglect resulting in pressure injuries and failure to seek medical care for Resident 1.
Findings
The investigation substantiated that due to facility staff neglect, Resident 1 developed stage 2 and stage 3 pressure injuries which were not properly treated or assessed by medical professionals. Staff failed to ensure timely medical attention for the resident, posing a potential health and safety risk to all residents in care.
Deficiencies (3)
Facility staff neglect led to pressure injuries in Resident 1, violating residents' rights to be free from neglect and abuse.
Facility staff failed to ensure Resident 1 received timely medical attention.
Facility failed to develop and implement a plan for incidental medical and dental care appropriate to residents' needs.
Report Facts
Civil Penalty: 500
Capacity: 108
Census: 87
Plan of Correction Due Date: Nov 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susana Fuentes | Administrator | Facility Administrator interviewed during investigation and participated in exit interview. |
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 108
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-06-24 regarding visitor restrictions, lack of hygiene products, food provision, staff hitting residents, and assistance with showers.
Complaint Details
The complaint investigation addressed multiple allegations including staff not allowing visitors, not supplying hygiene products, not providing food, staff hitting residents, and not assisting residents in the shower. All allegations were found unsubstantiated due to lack of sufficient evidence.
Findings
After interviews with staff, residents, and the administrator, as well as record reviews and observations, there was insufficient evidence to substantiate any of the allegations. All allegations were deemed unsubstantiated.
Report Facts
Number of residents interviewed: 8
Number of staff interviewed: 6
Meals provided daily: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susana Fuentes | Administrator | Interviewed and denied allegations during complaint investigation |
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation visits |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 108
Deficiencies: 1
Date: Jun 5, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 04/18/2024 alleging that facility staff did not treat a resident with dignity.
Complaint Details
The complaint alleged that staff were disrespectful, bullied a resident after a police report request, failed to maintain confidentiality, and caused the resident to request transfer due to safety concerns. The allegation was substantiated based on interviews and record review.
Findings
The investigation substantiated the allegation that staff did not treat a resident with dignity and respect, including bullying and lack of confidentiality. Interviews with staff and residents showed a majority reported respectful treatment, but evidence supported the complaint. Deficiencies were issued related to personal rights violations.
Deficiencies (1)
Facility staff did not treat resident with dignity and respect, violating personal rights under CCR 87468.1(a)(1)(3).
Report Facts
Capacity: 108
Census: 92
Deficiency count: 1
Plan of Correction Due Date: Jun 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susana Fuentes | Administrator | Named in relation to complaint and exit interview |
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw complaint investigation |
| Christina Novoa | Business Office Manager | Received copy of report and appeals rights |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 108
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-04-05 regarding visitation restrictions and unexplained bruises on a resident.
Complaint Details
The complaint involved two allegations: 1) Facility staff not allowing visitation, and 2) Resident having unexplained bruises. Both allegations were investigated through interviews with staff and residents, record reviews, and observations. The findings concluded the allegations were unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff were reported to restrict visitation in certain circumstances but residents and most staff confirmed visitors were allowed. A bruise was observed on a resident's wrist but staff were unaware and the bruise was later healed. Overall, the allegations were unsubstantiated.
Report Facts
Capacity: 108
Census: 92
Number of staff interviewed: 9
Number of residents interviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Susie Fuentes | Director | Facility Director interviewed during the investigation |
| Christina Novoa | Business Office Manager | Received a copy of the complaint investigation report during exit interview |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 108
Deficiencies: 0
Date: May 23, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation of lack of supervision resulting in a physical altercation between residents.
Complaint Details
Allegation: Lack of supervision resulted in physical altercation between residents. Interviews with staff and residents showed differing opinions on supervision. The allegation was determined to be unsubstantiated due to insufficient evidence.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation was unsubstantiated.
Report Facts
Census: 87
Total Capacity: 108
Staff interviewed: 7
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Susana Fuentes | Administrator | Facility Administrator mentioned in report header |
| Christina Novoa | Business Office Manager | Spoke with Licensing Program Analyst upon arrival |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 108
Deficiencies: 1
Date: May 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff refused to provide a resident with medications.
Complaint Details
The complaint investigation was substantiated regarding staff refusal to provide medication to a resident. The allegation that staff did not treat residents with dignity and respect was unsubstantiated.
Findings
The investigation substantiated the allegation that staff refused to provide a resident with blood pressure medication despite it being available and the resident being able to manage their own medication. Deficiencies were cited related to this issue. Another allegation that staff did not treat residents with dignity and respect was unsubstantiated based on interviews and record reviews.
Deficiencies (1)
The facility did not release R1's medication upon request at discharge, posing a potential health risk to the resident. Blood pressure medication was observed in the medication room and is to be taken daily. R1 is able to manage their own medication.
Report Facts
Capacity: 108
Census: 89
Staff interviewed: 6
Residents interviewed: 9
Staff knowledgeable of residents' rights: 5
Staff knowledgeable about elderly abuse: 7
Staff who have not witnessed disrespectful behavior: 9
Residents who indicated staff speak respectfully: 8
Residents who have not witnessed disrespectful behavior: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susana Fuentes | Administrator | Named in relation to findings and exit interview |
| Christina Novoa | Office Manager | Met with Licensing Program Analyst and present during exit interview |
| Regina Cloyd | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 1
Date: Apr 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that facility staff did not allow a resident access to make and receive private phone calls.
Complaint Details
The complaint alleged that facility staff did not allow resident access to make and receive private phone calls. The investigation found that the administrator confiscated the resident's personal cellphone and unplugged the landline phone. The allegation was substantiated based on interviews and record review.
Findings
The investigation substantiated the allegation that the facility administrator confiscated a resident's personal cellphone and unplugged the landline phone in the resident's private room, which posed an immediate health and safety risk. Interviews with staff and residents and record reviews supported these findings.
Deficiencies (1)
Failure to ensure residents have access to telephones to make and receive confidential calls, violating personal rights.
Report Facts
Facility capacity: 108
Deficiency due date: May 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator involved in the findings regarding telephone access |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 108
Deficiencies: 0
Date: Apr 11, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-04-05 regarding staff stealing a resident's ID, failure to ensure residents attend medical appointments, improper medication administration, and restricting resident communication with family members.
Complaint Details
The complaint included four allegations: 1) Facility staff stole ID from resident; 2) Facility is not ensuring resident goes to medical appointments; 3) Facility is not administering medications as ordered by doctor; 4) Facility is not allowing resident to communicate with family members. After investigation, all allegations were determined to be unsubstantiated.
Findings
The investigation included interviews with staff and residents, file reviews, and observation. All allegations were found to be unsubstantiated due to lack of preponderance of evidence supporting the claims.
Report Facts
Capacity: 108
Census: 98
Staff interviewed: 9
Residents interviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Susie Fuentes | Director | Facility representative met during investigation |
Inspection Report
Annual Inspection
Census: 96
Capacity: 108
Deficiencies: 0
Date: Mar 25, 2024
Visit Reason
An unannounced annual required inspection was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the facility.
Findings
The facility was found to be clean, well-maintained, and compliant with regulations. No deficiencies were observed during the visit. Safety equipment and supplies were in good condition, and medications were securely stored.
Report Facts
Resident rooms checked: 5
Residents' P&I money reviewed: 2
Water temperature: 105.6
Facility capacity: 108
Current census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susana Fuentes | Administrator / Director | Met with Licensing Program Analyst during inspection. |
| Felisa Shirley | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Stephanie Cifuentes | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 0
Date: Mar 25, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of illegal eviction received on 2024-01-29.
Complaint Details
Allegation: Illegal Eviction. The complainant alleged the facility illegally evicted resident R-1. The investigation included interviews with staff and residents and review of records. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegation of illegal eviction of resident R-1. The resident was transferred due to a need for a higher level of care following several incidents, including one requiring hospitalization.
Report Facts
Facility capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Susana Fuentes | Administrator | Facility administrator interviewed during the investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 108
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding the allegation that staff did not release resident's personal items upon discharge.
Complaint Details
The complaint alleged that staff did not release resident’s personal items upon discharge. Interviews with staff and residents, and photographic evidence showed the belongings were still in the room and accessible. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff, residents, and the Director, as well as review of resident files and photographs of the resident's room. The allegation was found to be unsubstantiated as the resident's belongings were still in the assigned room and staff confirmed that personal items are released upon discharge.
Report Facts
Capacity: 108
Census: 96
Staff interviewed: 7
Residents interviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation |
| Susie Fuentes | Director | Facility Director interviewed during investigation |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 0
Date: Feb 26, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2023-11-21 regarding staff leaving a resident unattended in a wheelchair and staff not meeting residents' needs.
Complaint Details
The complaint involved two allegations: 1) Staff left a resident unattended in a wheelchair for an extended period, and 2) Staff did not meet residents' needs. Both allegations were found to be unsubstantiated based on interviews with residents and staff and review of records.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Residents and staff interviews indicated that residents are not left unattended in wheelchairs for extended periods and that residents' needs are generally met. The resident involved was found to have violated facility smoking rules and did not pay the required deposit for smoking privileges.
Report Facts
Capacity: 108
Smokers Deposit Fee: 250
Resident interviews: 9
Staff interviews: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 108
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not arrange for medical care as needed and did not dispense medications as prescribed.
Complaint Details
The complaint alleged that facility staff failed to arrange for medical care and did not dispense medications as prescribed. The investigation included interviews with residents and staff, review of medical and medication records, and verification with the prescribing psychiatrist. The allegations were found to be unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Residents and staff interviews, as well as record reviews, indicated that medical care was arranged as needed and medications were dispensed as prescribed. Therefore, the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 108
Census: 87
Resident interviews: 8
Staff interviews: 8
Resident affirmative responses: 5
Staff affirmative responses: 7
Resident affirmative responses on medication: 6
Staff affirmative responses on medication: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Susana Fuentes | Administrator | Facility Administrator met during the investigation and exit interview |
| Pantea Farhadi | Psychiatrist | Prescribed anxiety medications for resident R-1, verified by LPA |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 108
Deficiencies: 1
Date: Jan 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff withheld a resident's personal mobility device.
Complaint Details
The complaint alleged that staff withheld a resident's personal mobility device. The allegation was substantiated based on interviews and record reviews. The preponderance of evidence standard was met.
Findings
The investigation found sufficient evidence to substantiate the allegation that staff withheld a resident's personal mobility device. The facility's Community Rules prohibited motorized scooters and wheelchairs for safety reasons, but these rules were not approved by the licensing division. Interviews with residents and staff confirmed the restriction on use of personal mobility devices.
Deficiencies (1)
Administrator did not allow resident R1 to utilize their mobility device, posing a potential health and safety risk to residents in care.
Report Facts
Capacity: 108
Census: 94
Staff interviewed: 8
Residents interviewed: 8
Staff disallowing mobility device: 5
Residents without wheelchair: 6
Plan of Correction Due Date: Feb 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Susie Fuentes | Director | Facility representative met during the investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 108
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-12-15 regarding resident care and facility conditions at Gardena Retirement Center.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not allowing residents to leave, failure to ensure medical appointments, inadequate meals, room disrepair, and mismanagement of resident funds. Interviews, file reviews, and observations did not corroborate these allegations.
Findings
The investigation found no sufficient evidence to substantiate any of the allegations, including restrictions on residents leaving the facility, failure to ensure medical appointments attendance, inadequate meals, room disrepair, and mismanagement of resident funds.
Report Facts
Capacity: 108
Census: 100
Number of allegations: 5
Resident interviews: 8
Staff interviews: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susie Fuentes | Director | Facility representative met during the investigation and exit interview |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 108
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
The visit was an unannounced case management incident inspection conducted due to incident reports received on 12/05/2023 regarding excessive drinking by residents.
Complaint Details
The visit was triggered by incident reports received on 12/05/2023 regarding excessive drinking by residents. The complaint was substantiated by findings of violations of personal rights.
Findings
The inspection found violations of residents' personal rights, including making a resident sit outside until sober and confining another resident to their room, which posed immediate health and safety risks. Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapters 1 and 6.
Deficiencies (1)
Violation of personal rights by making a resident sit outside until sober and confining a resident to their room, posing immediate health and safety risks.
Report Facts
Capacity: 108
Census: 101
Plan of Correction Due Date: Dec 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the unannounced visit and exit interview |
| Susana Fuentes | Administrator | Facility administrator met with the Licensing Program Analyst during the visit |
| Stephanie Cifuentes | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 108
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that due to lack of supervision, a resident got into a physical altercation with another resident.
Complaint Details
The complaint alleged lack of supervision leading to a physical altercation between residents. Interviews with 10 residents and 9 staff, and review of incident reports and medical records were conducted. Three staff confirmed the incident occurred. One resident was hospitalized. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation included interviews with residents and staff, and review of facility records. It was found that an altercation did occur on 10/4/23, but there was insufficient evidence to substantiate the allegation of lack of supervision. The allegation was determined to be unsubstantiated.
Report Facts
Residents interviewed: 10
Staff interviewed: 9
Facility capacity: 108
Facility census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 108
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not assisting residents at the facility.
Complaint Details
The complaint alleged that staff were not assisting residents. The investigation included interviews with staff, residents, and family, as well as review of relevant documents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Findings
Based on interviews, file review, and observations, there was insufficient evidence to substantiate the allegation that staff were not assisting residents. No deficiencies were cited during the visit.
Report Facts
Capacity: 108
Census: 93
Inspection Report
Complaint Investigation
Census: 93
Capacity: 108
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-09-05 regarding medication errors, denial of private visits, and restriction of personal possessions at the facility.
Complaint Details
The complaint investigation addressed three allegations: 1) Facility staff dispensed medications not prescribed to residents, 2) Facility staff did not allow residents to have private visits with family, and 3) Facility staff did not allow residents to keep their own personal possessions. All allegations were found unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Interviews with residents and staff, as well as records review, did not support claims of medication errors, denial of private visits, or restriction of personal possessions. All allegations were determined to be unsubstantiated.
Report Facts
Number of resident visits by daughters: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
| Christina Novoa | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Capacity: 108
Deficiencies: 0
Date: Sep 8, 2023
Visit Reason
The visit was a Case Management - Other type of unannounced visit to discuss a 30 day Eviction Notice for resident R1 and review related documentation.
Findings
The Licensing Program Analyst met with the Administrator Susana Fuentes to review eviction notices and statements of balances due for resident R1. The resident's belongings were observed still in the room. The Administrator agreed to provide requested email and pay history documentation.
Report Facts
Capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susana Fuentes | Administrator | Met with Licensing Program Analyst regarding eviction notice and documentation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on report |
| Felisa Shirley | Licensing Program Analyst | Conducted the visit and signed the report |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations including staff stealing residents' identification cards, staff interfering with residents' visitation, and staff threatening residents in care.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff stealing residents' identification cards, interfering with residents' visitation, and threatening residents. Interviews and document reviews did not provide sufficient evidence to prove the allegations.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Interviews with staff and residents, as well as document reviews, did not support the claims of stolen IDs, interference with visitation, or threats to residents. No deficiencies were cited during the visit.
Report Facts
Facility capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Susana Fuentes | Administrator | Facility Administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 108
Deficiencies: 0
Date: Jul 26, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-06-02 regarding allegations of staff not responding to residents' calls for assistance, not safeguarding residents' belongings, not allowing personal phone calls, and refusing visitors.
Complaint Details
The complaint involved four allegations: 1) Staff not responding to residents' calls for assistance; 2) Staff did not safeguard residents' belongings; 3) Staff not allowing residents personal phone calls; 4) Staff refusing to allow residents to have visitors. All allegations were investigated through interviews and document review and were found unsubstantiated.
Findings
The investigation included interviews with staff and residents and a tour of the facility. All allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred. No deficiencies were cited during the visit.
Report Facts
Capacity: 108
Census: 79
Number of allegations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susana Fuentes | Administrator | Met with Licensing Program Analyst and interviewed during complaint investigation |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 81
Capacity: 108
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
The visit was a Case Management - Other type of unannounced inspection involving discussion with the Administrator regarding a 30 day Eviction Notice for a resident.
Findings
The Licensing Program Analyst met with the Administrator to review eviction notices and observed that the resident's belongings were still in the room. Copies of eviction notices and related correspondence were received from the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susana Fuentes | Administrator | Met with Licensing Program Analyst regarding eviction notice and facility matters. |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 108
Deficiencies: 0
Date: Jun 16, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of unlawful eviction of a resident at Gardena Retirement Center.
Complaint Details
The complaint alleged that resident R1 was unlawfully evicted from the facility. Interviews with the resident and facility administrator, along with observations, showed that the resident was currently in a nursing home but continued to pay rent and had not been served eviction notices. The allegation was unsubstantiated.
Findings
The investigation included observations, staff interviews, and document reviews. The allegation of unlawful eviction was found to be unsubstantiated as there was insufficient evidence to prove the eviction occurred; the resident's name was still on the roster and personal belongings remained in the room.
Report Facts
Facility Capacity: 108
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeremiah Randle | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Annual Inspection
Census: 80
Capacity: 108
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
An unannounced annual required inspection was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations for the Gardena Retirement Center.
Findings
The facility was found to be sanitary, appropriately furnished, and in compliance with Title 22 regulations. No deficiencies were observed and no citations were issued during this inspection.
Report Facts
Resident bedrooms inspected: 10
Residents' service files reviewed: 5
Staff personnel files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susana Fuentes | Director | Met with Licensing Program Analyst during inspection and received the Facility Evaluation Report |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eva M Alvarez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 108
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility was not providing a safe environment for residents.
Complaint Details
The complaint alleged that a resident was repeatedly walking back and forth in the driveway while a delivery truck was backing in, posing a risk of harm. Interviews with residents, staff, and the administrator, as well as review of the resident's physician report, supported the allegation. The resident was not able to leave the facility unassisted, confirming the safety risk. The allegation was substantiated.
Findings
The investigation substantiated the allegation that the facility was not providing a safe environment, specifically noting that a resident who was unable to leave the premises unassisted was walking back and forth in the driveway where delivery trucks were backing in, posing a potential safety risk.
Deficiencies (1)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by Resident (R1) being able to walk back and forth in the driveway despite being unable to leave the premises unassisted, creating a potential health and safety risk.
Report Facts
Residents interviewed: 8
Staff interviewed: 4
Deficiency citations: 1
Plan of Correction due date: Oct 14, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martessa Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
| Christina Nova | Office Manager | Facility office manager interviewed and present during investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 108
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
The visit was an unannounced 10-day complaint investigation conducted in response to a complaint received on 03/09/2023 regarding an allegation of illegal eviction at the facility.
Complaint Details
The complaint investigation was substantiated. The allegation was illegal eviction due to failure to timely provide a copy of the eviction notice to the licensing agency as required by Title 22 regulations.
Findings
The investigation substantiated the allegation of illegal eviction due to the administrator's failure to serve the eviction notice to the licensing agency within the required 5-day timeframe as mandated by Title 22 regulations, despite the eviction notice containing all required components.
Deficiencies (1)
A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by the licensee's failure to provide a copy of the eviction notice to Community Care Licensing within 5 days.
Report Facts
Capacity: 108
Census: 77
Plan of Correction Due Date: Mar 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susana Fuentes | Administrator | Facility administrator interviewed regarding the eviction allegation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 108
Deficiencies: 0
Date: Feb 24, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation regarding an allegation of unlawful eviction at Gardena Retirement Center.
Complaint Details
The complaint alleged that the Administrator refused to accept a resident back into the facility. The investigation included interviews, a facility tour, and review of medical and admission documents. The allegation was found unsubstantiated based on evidence that the resident's care needs exceeded the facility's capabilities.
Findings
The investigation found that the allegation of unlawful eviction was unsubstantiated. The facility was unable to provide proper care for the resident due to medical needs requiring a higher level of care. No deficiencies were observed or cited.
Report Facts
Capacity: 108
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit and report |
| Susana Fuentes | Administrator | Facility administrator involved in the investigation and interview |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 108
Deficiencies: 2
Date: Dec 19, 2022
Visit Reason
An unannounced complaint investigation was conducted due to allegations that a resident sustained an unexplained injury while in care and that staff did not seek medical care for the resident in a timely manner.
Complaint Details
The complaint investigation was substantiated. The resident sustained an unexplained injury while in care, and staff did not seek medical care in a timely manner. Evidence included interviews, record reviews, and hospital records confirming the injury and delayed response.
Findings
The investigation substantiated that the resident sustained a deep and gaping wound due to neglect and lack of care and supervision. Staff failed to properly assess and timely report the injury, delaying medical care. The facility was cited for violations related to observation of residents and personnel training.
Deficiencies (2)
Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
Personnel Requirements-General(d)(5) All personnel shall be given on the job training or have related experience assigned to them. This training and/or related experience includes knowledge necessary in order to recognize early signs of illness and the need for professional help.
Report Facts
Facility Capacity: 108
Census: 71
Wound Size: 6
Wound Size: 3
Estimated Days of Completion: 15
Deficiency Count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mario Leon | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Don Senaha | Licensing Program Analyst | Conducted interviews during the investigation |
| Susana Fuentes | Administrator | Facility administrator involved in the investigation and notified staff to call 911 |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 108
Deficiencies: 0
Date: Dec 13, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of unlawful eviction at Gardena Retirement Center.
Complaint Details
The complaint alleged that the facility unlawfully evicted a resident (R1). The allegation was unsubstantiated after investigation, including interviews with the administrator and observation of the resident in their room.
Findings
The investigation included observations, staff interviews, and review of facility records. The allegation of unlawful eviction was found to be unsubstantiated as the resident was present in their room and no eviction notices were found.
Report Facts
Facility Capacity: 108
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeremiah Randle | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susana Fuentes | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 108
Deficiencies: 0
Date: Nov 9, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff were retaining a resident who requires a higher level of care.
Complaint Details
The complaint alleged that staff were retaining a resident requiring a higher level of care. The allegation was investigated through interviews with staff and residents, review of records, and observation. The allegation was found to be unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found no sufficient evidence to support the allegation. Interviews with staff and residents indicated that the resident in question was placed by her doctor, is on hospice care with regular nurse and doctor visits, and the facility staff provide necessary care and supervision. The allegation was deemed unsubstantiated and no deficiencies were cited.
Report Facts
Complaint Control Number: 11-AS-20221020162056
Capacity: 108
Census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Susana Fuentes | Administrator | Facility administrator met during investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 108
Deficiencies: 1
Date: Oct 6, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint alleging the facility was not providing a safe environment for residents, specifically concerning residents walking in the driveway where a truck was backing up.
Complaint Details
The complaint alleged a resident was walking with a walker repeatedly in the driveway where a truck was backing up, creating a safety hazard. The allegation was substantiated based on interviews with residents, staff, and the administrator, as well as record reviews indicating residents with confusion and disorientation walking unsupervised.
Findings
The investigation substantiated the allegation that residents who were not able to leave on their own were walking back and forth in the driveway, posing a potential health and safety risk. Staff and resident interviews, along with record reviews, supported this finding.
Deficiencies (1)
Facility failed to maintain a clean, safe, sanitary environment in good repair, allowing residents unable to leave on their own to walk up and down the driveway, creating a potential health and safety risk.
Report Facts
Capacity: 108
Census: 77
Plan of Correction Due Date: Oct 14, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martessa Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 108
Deficiencies: 0
Date: Aug 8, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-02-23 alleging multiple issues including residents being left in soiled diapers, untimely call bell responses, unmet hygiene needs, residents left in bed, missed meals, rough handling, lack of assistance, and insufficient staffing.
Complaint Details
The complaint investigation was unannounced and addressed nine allegations related to resident care and staffing. After interviews with residents (R1-R7), staff (S1-S7), and facility administrators, and review of records, the department found no evidence to substantiate the allegations. The allegations included staff leaving residents in soiled diapers, not answering call bells timely, not meeting hygiene needs, leaving residents in bed, not providing lunch, rough handling, not assisting residents, and insufficient staffing. The findings concluded all allegations were unsubstantiated.
Findings
The investigation found no sufficient evidence to support any of the allegations. Interviews with residents and staff, as well as facility record reviews, indicated that the facility met care standards and staffing levels. All allegations were determined to be unsubstantiated.
Report Facts
Capacity: 108
Census: 68
Resident interview count: 7
Staff interview count: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susana Fuentes | Administrator | Facility administrator interviewed regarding allegations |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 108
Deficiencies: 0
Date: Jun 27, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations received on 10/11/2021 regarding medication administration, incontinence care, personal care item restrictions, mask provision, universal precautions, and toilet paper use at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not administering medications as prescribed, not assisting with incontinence care, restricting personal care items, inadequate mask provision, failure to follow universal precautions, and limiting toilet paper use. After interviews, document reviews, and observations, no evidence supported these claims.
Findings
The investigation found no sufficient evidence to support any of the allegations. The department concluded that staff administered medications as prescribed, assisted with incontinence care, allowed residents to keep personal care items, provided adequate masks, followed universal precautions, and did not limit residents' use of toilet paper.
Report Facts
Capacity: 108
Census: 67
Staff interviewed: 7
Residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
| Susana Fuentes | Office Manager | Met with Licensing Program Analyst during investigation and participated in exit interview |
| Susan Fuentes | Administrator | Provided information regarding facility operations and allegations |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 108
Deficiencies: 0
Date: Jun 16, 2022
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that the facility was not following COVID-19 protocols.
Complaint Details
The complaint alleged that the facility was not following COVID-19 protocols. The investigation found no sufficient evidence to support this allegation, and it was determined to be unsubstantiated.
Findings
The investigation, including interviews with staff and residents and inspection of the facility and documents, found that the facility follows COVID-19 protocols, including weekly testing and mask encouragement. The allegation was unsubstantiated due to lack of sufficient evidence.
Report Facts
Staff interviewed: 4
Residents interviewed: 6
Capacity: 108
Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Campos | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Susana Fuentes | Administrator | Facility administrator who allowed entry and participated in the investigation |
| Ulysses Coronel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 108
Deficiencies: 0
Date: Jun 7, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility illegally evicted a resident and retaliated against a resident.
Complaint Details
The complaint alleged that the facility illegally evicted a resident and retaliated against the resident. Interviews with the resident, staff, and review of court paperwork showed the eviction was court-ordered due to violations of house rules and unpaid rent. No evidence of retaliation or improper eviction was found. The allegations were unsubstantiated.
Findings
The investigation found the allegations of illegal eviction and retaliation to be unsubstantiated based on interviews, observations, and review of court and facility documentation.
Report Facts
Capacity: 108
Census: 67
Complaint Control Number: 11-AS-20220601141229
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 108
Deficiencies: 0
Date: Jun 7, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility was not providing a comfortable environment for residents in care.
Complaint Details
The complaint alleged the facility was not providing a comfortable environment for residents. The investigation found no substantiation of the allegation; staff and residents denied the claims, and no deficiencies were cited.
Findings
Interviews with staff and residents indicated that the facility is providing a comfortable environment, residents have personal rights including listening to music on their cellphones without disturbing others, and no harassment or loud music issues were found. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 108
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Angela J Kendrick | Licensing Program Manager | Oversaw the complaint investigation |
| Susan Fuentes | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 108
Deficiencies: 0
Date: May 31, 2022
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff did not seek timely medical attention for a resident in care and that staff refused to let a resident back into the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not seeking timely medical attention for a resident and staff refusing to let a resident back in. Interviews with staff and residents, as well as facility observations, did not support these allegations.
Findings
The investigation found no sufficient evidence to support the allegations. Interviews with staff and residents, facility inspection, and record reviews indicated that medical attention was not denied and residents were not refused reentry. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 108
Census: 69
Staff interviewed: 6
Residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 108
Deficiencies: 0
Date: May 31, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that the facility was not preventing the spread of COVID-19 and that residents were confined to their bedrooms.
Complaint Details
The complaint investigation was unannounced and based on allegations received on 02/09/2022. The allegations were unsubstantiated after investigation, with no evidence found to support claims that the facility was not preventing COVID-19 spread or confining residents to their bedrooms.
Findings
The investigation found no sufficient evidence to support the allegations. The facility was following COVID-19 protocols including weekly testing, isolation procedures, and mask usage. Residents were not confined to their bedrooms as some chose to leave their rooms despite staff redirection.
Report Facts
Capacity: 108
Census: 69
Staff interviewed: 6
Residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator who provided information during investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 108
Deficiencies: 0
Date: May 31, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-01-03 regarding staff administering unprescribed medication to a resident and the facility having pests.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff administering unprescribed medication and presence of pests (bed bugs). The department found insufficient evidence to support either allegation after interviews, record reviews, and inspections.
Findings
The investigation found no evidence to support the allegations that staff administered unprescribed medication to residents or that the facility had pests. Interviews with staff and residents, review of medication administration records, and exterminator reports showed no substantiation of the complaints.
Report Facts
Residents interviewed: 6
Staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 108
Deficiencies: 0
Date: May 27, 2022
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that a resident sustained burns while in care.
Complaint Details
The complaint was that a resident sustained burns while in care. The allegation was investigated through interviews with the resident, staff, and review of facility and medical records. The resident took full responsibility for the injury and did not request assistance. The allegation was unsubstantiated.
Findings
The investigation revealed that the resident sustained severe accidental burns from hot water in a bathtub but was independent and did not request staff assistance for bathing. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 108
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Campos | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Susana Fuentes | Administrator | Facility administrator who allowed entry and participated in exit interview |
| Edward Hector | Investigator | Conducted interviews and reviewed records related to the complaint |
| Ulysses Coronel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 108
Deficiencies: 0
Date: May 26, 2022
Visit Reason
The visit was an unannounced complaint investigation initiated due to an allegation that staff were not providing adequate activities to residents.
Complaint Details
The allegation was that staff were not providing adequate activities to residents. The complaint was investigated and found to be unsubstantiated based on interviews, observations, and records review.
Findings
The investigation included interviews with staff and residents, observation of activities, and review of records. The evidence did not substantiate the allegation, as activities were observed and residents reported encouragement to participate.
Report Facts
Residents interviewed: 9
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Senaha | Licensing Program Analyst | Conducted the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator involved in the investigation |
| Eva M Alvarez | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 108
Deficiencies: 0
Date: May 23, 2022
Visit Reason
The visit was an unannounced complaint investigation to determine if the facility was allowing residents to work at the facility, as alleged in a complaint received on 2022-05-16.
Complaint Details
The complaint alleged that residents were assisting staff with duties without being fingerprint cleared and were working at the facility. The investigation found no sufficient evidence to substantiate the allegation, concluding it was unsubstantiated.
Findings
The investigation found that some residents assist staff with simple tasks as an activity and not as paid employees. Interviews with staff and residents confirmed this practice but no evidence was found that residents were employed or paid. The allegation was determined to be unsubstantiated.
Report Facts
Residents interviewed: 6
Staff interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 108
Deficiencies: 0
Date: May 23, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate the allegation that staff did not prevent a resident from disturbing another resident in care.
Complaint Details
The complaint alleged that facility residents were yelling and playing loud music and that staff did nothing when it was reported. Interviews with residents and staff did not support these claims, leading to an unsubstantiated finding.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff failed to prevent a resident from disturbing another. Interviews with residents and staff indicated that disturbances were not common and were addressed when they occurred. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 108
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
| Eva M Alvarez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 108
Deficiencies: 0
Date: May 19, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not respond to a resident's call button in a timely manner.
Complaint Details
The complaint alleged that staff did not respond to a resident's call button in a timely manner. The investigation included interviews with residents, staff, and the administrator, as well as review of relevant records. The complaint was found to be unsubstantiated.
Findings
The investigation found that the facility uses a call button and alert system for emergencies and non-emergencies, with staff responding promptly and informing residents of wait times. Interviews with residents and staff indicated no widespread concerns about call button response times. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Resident interviews: 6
Average wait time: 5
Average wait time: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gail Johnson | Licensing Program Analyst | Conducted the complaint investigation and interviews. |
| Eva Alvarez | Licensing Program Manager | Conducted the complaint investigation and interviews. |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 108
Deficiencies: 0
Date: May 19, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that a resident was being financially abused while in care.
Complaint Details
The complaint alleged that a resident was being financially abused while in care. The investigation revealed confusion by the resident regarding trust fund account transactions but no evidence of mismanagement. The facility discontinued management of the resident's trust fund and issued reimbursement. Interviews with residents and staff did not reveal concerns. The allegation was unsubstantiated.
Findings
The investigation included interviews with residents, staff, and the administrator, as well as review of financial and medical records. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, with no discrepancies found in the resident's trust fund account and no reports of concerns from other residents or staff.
Report Facts
Residents interviewed: 7
Residents with Trust Fund accounts: 2
Residents without Trust Fund accounts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gail Johnson | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Eva M Alvarez | Licensing Program Manager | Conducted the complaint investigation and interviews |
| Susana Fuentes | Administrator | Facility administrator interviewed regarding the complaint |
| Christina Nova | Office Manager | Interviewed as witness to Trust Fund transactions |
Inspection Report
Annual Inspection
Census: 69
Capacity: 108
Deficiencies: 0
Date: May 19, 2022
Visit Reason
An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the CARE Inspection Tool.
Findings
The facility was found to be in compliance with infection control practices, including screening protocols, PPE supply, and sanitation. No deficiencies were identified during this annual inspection.
Report Facts
Fire extinguishers: 9
Water temperature: 107.8
PPE supply duration: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gail Johnson | Licensing Program Analyst | Conducted the inspection and observed infection control practices |
| Susana Fuentes | Administrator | Facility administrator met during the inspection and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 108
Deficiencies: 0
Date: May 12, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff speak inappropriately to residents.
Complaint Details
Allegation that staff speak inappropriately to residents was investigated and found unsubstantiated due to lack of sufficient evidence.
Findings
The investigation included interviews with the administrator, staff, and residents, as well as review of relevant training and rosters. The Licensing Program Analyst was unable to verify the allegation and found insufficient evidence to support it, resulting in an unsubstantiated finding.
Report Facts
Capacity: 108
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gail Johnson | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 108
Deficiencies: 3
Date: May 4, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 03/17/2022 regarding resident wandering and facility security issues.
Complaint Details
The complaint investigation was substantiated for allegations that a resident wandered from the facility and that the facility was not properly secured. Other allegations about inappropriate staff communication, denial of heat requests, and denial of television installation were unsubstantiated.
Findings
The investigation substantiated that a resident with dementia wandered outside the facility unattended due to an unmanned front desk and a disabled auditory alarm on the backdoor. Other allegations regarding inappropriate staff behavior, denial of heat requests, and denial of television installation were unsubstantiated.
Deficiencies (3)
The licensee shall have an auditory device or other staff alert feature to monitor exits; this requirement was not met as the backdoor auditory device was inoperable.
The pre-admission appraisal was not updated to note significant changes after wandering behavior was observed.
Safety measures to address wandering behavior were not met as a resident exited the facility unassisted and there was no staff monitoring exits.
Report Facts
Capacity: 108
Census: 71
Deficiencies cited: 3
Plan of Correction due dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jey Cardenas | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susana Fuentes | Administrator | Facility administrator interviewed regarding security and resident issues |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2022-04-06 alleging that residents were not afforded comfortable accommodations and that staff did not ensure residents were taking universal precautions.
Complaint Details
The complaint involved two allegations: 1) residents not being afforded comfortable accommodations, and 2) staff not ensuring residents were taking universal precautions. Interviews with residents and staff indicated residents felt comfortable and cared for, and staff described appropriate handling of catheter care and cleaning procedures. The preponderance of evidence standard was not met, resulting in unsubstantiated findings.
Findings
The investigation included interviews with staff and residents, review of records, and a plant inspection. The allegations were found to be unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.
Report Facts
Capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Senaha | Licensing Program Analyst | Conducted the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator present during investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 108
Deficiencies: 1
Date: Apr 12, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff was not adequately supervising residents in care.
Complaint Details
The complaint alleged inadequate supervision of residents, specifically that a staff member's child was allowed to push resident #1 in a wheelchair unsupervised. The allegation was substantiated based on interviews, video surveillance, and record reviews.
Findings
The investigation substantiated the allegation that a staff member's four-year-old child was allowed to roam the facility unsupervised and pushed resident #1 in a wheelchair without staff supervision, posing a potential health and safety risk to residents.
Deficiencies (1)
Failure to provide safe environment as a child was allowed to roam unattended and unsupervised, pushing a resident in a wheelchair and handling medication cart.
Report Facts
Capacity: 108
Census: 71
Plan of Correction Due Date: Apr 26, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 108
Deficiencies: 0
Date: Apr 11, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident was not provided an appointment to see the onsite nurse.
Complaint Details
Allegation: Resident not provided appointment to see onsite nurse. The allegation was investigated through interviews with resident R1, staff S1-S5, residents R2-R8, and nurse W1, as well as review of medical records. The allegation was unsubstantiated.
Findings
The investigation included interviews with residents, staff, and review of medical records. It was found that the resident had been seen monthly by the nurse in 2021 and 2022, and no resident was denied access to doctor or nurse services. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 108
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Susan Fuentes | Administrator | Facility administrator interviewed during investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 108
Deficiencies: 1
Date: Mar 25, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 03/15/2022 regarding a mat/rug in disrepair at the facility.
Complaint Details
The complaint was substantiated. The allegation was that a mat/rug was in disrepair with curled up edges posing a tripping hazard. The investigation included interviews with staff and residents, review of records, and a physical plant walkthrough. The mat was removed during the investigation.
Findings
The investigation substantiated the complaint that a rubber floor mat with curled up edges located in front of the glass doors was in disrepair and posed a potential tripping hazard. The mat was removed by maintenance during the investigation. Staff and residents were interviewed with mixed awareness of the issue, and the facility was cited for not keeping areas free of hazards.
Deficiencies (1)
Building and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. LPA observed a mat in disrepair in front of the glass doors that lead out to the garden.
Report Facts
Capacity: 108
Census: 72
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ngozi Nwaokoro | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susana Fuentes | Administrator | Facility administrator involved in the investigation and exit interview |
| Michael Cava | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 108
Deficiencies: 0
Date: Mar 21, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit triggered by allegations received on 12/23/2021 regarding inadequate staffing and lack of activities for residents at the facility.
Complaint Details
The complaint alleged inadequate staffing and lack of activities for residents. The investigation included interviews with staff, residents, and the administrator; review of staffing schedules and activity calendars; and observations of resident activities. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff and residents, observations, and records review indicated that the facility had adequate staffing and provided activities for residents, including in-person activities resumed after COVID restrictions were lifted.
Report Facts
Residents present: 72
Licensed capacity: 108
Staff interviewed: 7
Residents interviewed: 8
Residents in activity room (morning): 16
Residents in activity room (afternoon): 12
Average residents per staff in activity room: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
| Elizabeth Chavez | Med Tech-AM | Staff member interviewed prior to inspection for risk assessment |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 1
Date: Mar 11, 2022
Visit Reason
The visit was a Case Management - Deficiencies inspection initiated to document deficiencies observed during the investigation of a complaint with complaint control number 11-AS-20220228091331.
Complaint Details
The visit was conducted as part of a complaint investigation with complaint control number 11-AS-20220228091331. The complaint involved unsafe hot water temperatures.
Findings
The inspection found that the hot water temperature in resident rooms was excessively high, ranging from 130.2 to 135.9 degrees Fahrenheit, exceeding the regulatory maximum of 120 degrees Fahrenheit, posing an immediate health and safety risk to residents. The facility administrator took immediate action to lower the water heaters and contacted maintenance and a plumber.
Deficiencies (1)
Faucets used by residents for personal care did not maintain hot water temperature between 105 and 120 degrees Fahrenheit, with temperatures measured between 130.2 and 135.9 degrees Fahrenheit, posing an immediate health and safety risk.
Report Facts
Water temperature: 144.5
Water temperature range: 130.2
Water temperature range: 135.9
Facility capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and documented deficiencies |
| Susana Fuentes | Facility Administrator | Facility administrator present during the visit and took immediate corrective action |
| Eva M Alvarez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 0
Date: Mar 10, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility was not following COVID-19 guidelines, a resident was being illegally evicted, and the facility was retaliating against a resident for making complaints.
Complaint Details
The complaint involved three allegations: failure to follow COVID-19 guidelines, illegal eviction of a resident, and retaliation against a resident for complaints. The investigation found no sufficient evidence to substantiate these allegations, and they were deemed unsubstantiated.
Findings
The investigation included interviews with staff and residents, inspection of the facility, and review of records. The allegations were found to be unsubstantiated due to insufficient evidence to prove violations. The facility was following COVID-19 guidelines, eviction was approved due to behavioral issues, and no retaliation was observed.
Report Facts
Capacity: 108
Number of staff interviewed: 9
Number of residents interviewed: 7
Incident reports reviewed: 8
Behavioral contracts reviewed: 2
Eviction notice date: Feb 2, 2022
Summons date: Mar 10, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst / Retired Annuitant | Conducted the complaint investigation visit |
| Susana Fuentes | Administrator | Facility administrator involved in interviews and findings |
| Stephanie Cifuentes | Licensing Program Analyst | Conducted initial 10-Day visit on 12/21/21 |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 0
Date: Mar 10, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation received on 12/17/2021 that smoke alarms were in disrepair at the facility.
Complaint Details
The complaint alleged that two smoke detectors in the hallway had been beeping for two weeks. Interviews with staff and residents, observations, and records review did not support the allegation. The complaint was unsubstantiated.
Findings
The investigation included interviews with staff and residents, inspection of the facility's fire safety systems, and review of maintenance records. No sufficient evidence was found to substantiate the allegation that smoke alarms were in disrepair; the complaint was determined to be unsubstantiated.
Report Facts
Facility capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst | Conducted the complaint investigation visit |
| Susana Fuentes | Administrator | Facility administrator met during the investigation |
| Carlos Aguirre | Maintenance Director | Spoke regarding the facility's fire alarm system |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 108
Deficiencies: 1
Date: Mar 8, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to allegations including resident harassment, facility retaining residents requiring higher level of care, staff restraining residents, lack of activities, unanswered phones, and unresponsiveness to call buttons.
Complaint Details
The complaint investigation was triggered by allegations that a resident was harassing another resident. The investigation found sufficient evidence to substantiate this allegation. Other allegations about facility care levels, staff restraint, activities, phone answering, and call button response were unsubstantiated.
Findings
The investigation substantiated the allegation of resident harassment between residents. Other allegations regarding retaining residents needing higher care, staff restraining residents, lack of activities, unanswered phones, and call button responsiveness were found to be unsubstantiated based on interviews, observations, and records review.
Deficiencies (1)
Personal Rights of Residents All Facilities: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by resident-on-resident harassment.
Report Facts
Census: 72
Total Capacity: 108
Dementia Residents: 10
Residents interviewed: 9
Staff interviewed: 6
Rooms tested for call button response: 8
Deficiency Plan of Correction Due Date: Mar 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Suzanna Fuentes | Administrator | Facility administrator interviewed during investigation |
| Amy Pratt | Administrator | Named as facility administrator in report header |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Stephanie Cifuentes | Licensing Program Analyst | Conducted initial 10-day visit related to complaint |
| Cynthia LN | Office Manager | Allowed entry to Licensing Program Analyst during visit |
| Christina Novoa | Office Manager | Allowed entry to Licensing Program Analyst during visit |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 108
Deficiencies: 0
Date: Mar 8, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted to investigate allegations that the facility had a leaking pipe.
Complaint Details
The complaint alleged that a pipe at the facility was leaking feces. The investigation included a tour, interviews with staff and residents, and review of plumbing repair invoices. The allegation was found unsubstantiated due to lack of evidence.
Findings
The investigation found no sufficient evidence to support the allegation of a leaking pipe. The plumbing issue was addressed promptly, and interviews with residents and staff did not confirm the complaint. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 108
Census: 72
Date of plumbing repair: Mar 3, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 108
Deficiencies: 0
Date: Mar 8, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-01-31 regarding transportation to medical appointments, resident injury while in care, and adequacy of services provided to residents.
Complaint Details
The complaint included three allegations: 1) Facility does not provide transportation to medical appointments; 2) Resident was injured while in care; 3) Staff did not provide adequate services to resident in care. After investigation including interviews with staff and residents, review of records and incident reports, all allegations were found unsubstantiated.
Findings
The investigation found no sufficient evidence to support any of the allegations. The facility does not provide transportation but assists residents in arranging it; no evidence of resident injury while in care was found; and staff provided adequate assistance with bathing and grooming. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 108
Census: 72
Staff interviewed: 6
Residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Susana Fuentes | Administrator | Facility administrator interviewed regarding allegations and findings |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 108
Deficiencies: 0
Date: Feb 17, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not administer medication to a resident.
Complaint Details
The complaint alleged that staff did not administer evening medication to resident R1. The investigation included interviews with staff and residents, review of medication administration records, and facility inspection. The allegation was found to be unsubstantiated.
Findings
The investigation found no sufficient evidence to support the allegation that staff failed to administer medication to the resident. Interviews, record reviews, and observations indicated that medications were administered as required, and the allegation was unsubstantiated.
Report Facts
Capacity: 108
Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator interviewed during investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 108
Deficiencies: 2
Date: Jan 21, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that the facility was not assisting residents with transportation needs and did not have required postings in public view.
Complaint Details
The complaint investigation was substantiated. The facility was found not to be assisting residents with transportation needs per admission agreement policy and was not maintaining required postings in public view. The investigation included interviews with 6 staff members and 6 residents, document reviews, and observations.
Findings
The investigation substantiated that the facility was not assisting residents with transportation to medical appointments as required by the admission agreement policy, and that required facility license postings were not consistently displayed in public view due to ongoing repairs and past removal incidents.
Deficiencies (2)
Facility failed to provide assistance in meeting necessary medical transportation needs as required by admission agreement policy.
Facility license was not posted in a prominent location accessible to public view.
Report Facts
Residents interviewed: 6
Staff interviewed: 6
Deficiencies cited: 2
Plan of Correction Due Date: Feb 7, 2022
Facility capacity: 108
Facility census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Campos | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Michael Cava | Licensing Program Manager | Oversaw the complaint investigation |
| Susana Fuentes | Administrator | Facility administrator involved in interviews and exit interview |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 108
Deficiencies: 0
Date: Jan 21, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff do not respond to resident's call button in a timely manner.
Complaint Details
The complaint alleged that staff do not respond to resident's call button in a timely manner. After investigation including interviews with 8 staff members and 6 residents, document review, and video observation, the allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews with staff and residents, review of documents, and observation of call button stations and video footage. The Licensing Program Analyst found no sufficient evidence to support the allegation, concluding the complaint was unsubstantiated.
Report Facts
Staff interviewed: 8
Residents interviewed: 6
Call button stations inspected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Campos | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susana Fuentes | Administrator | Facility administrator who provided access and documents during investigation |
| Michael Cava | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 108
Deficiencies: 1
Date: Jan 5, 2022
Visit Reason
An unannounced Case Management - Deficiencies visit was conducted to document deficiencies observed during investigation of a complaint with control number 11-AS-20211228090259.
Complaint Details
The visit was triggered by a complaint investigation with control number 11-AS-20211228090259.
Findings
During the investigation, it was noted that staff members (Staff 1 through Staff 4) did not have current CPR/First Aid training, posing a potential health and safety risk for clients in care.
Deficiencies (1)
Staff providing care did not have current CPR/First Aid training as required by California Code of Regulations, Title 22, Division 6 and Chapter 8.
Report Facts
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the investigation and documented deficiencies. |
| Susana Fuentes | Administrator | Spoke with Licensing Program Analyst during the visit. |
| Eva M Alvarez | Licensing Program Manager | Supervisor named in the report. |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 108
Deficiencies: 0
Date: Dec 21, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 09/09/2021 regarding multiple allegations about the facility's care and environment.
Complaint Details
The complaint included allegations that staff were failing to meet residents' needs, a resident wandered away while in care, staff spoke to residents inappropriately, staff failed to provide adequate food service, the facility failed to provide a safe and comfortable environment, and the facility was in disrepair. The investigation included interviews with staff and residents, review of incident reports and facility documents, and observations. All allegations were found unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found no sufficient evidence to substantiate any of the allegations, including staff failing to meet residents' needs, resident wandering, inappropriate staff communication, inadequate food service, unsafe environment, and facility disrepair. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 108
Census: 66
Number of allegations: 6
Resident interviews: 8
Staff interviews: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Susana Fuentes | Administrator | Facility administrator interviewed during the investigation |
| Amy Pratt | Facility administrator listed in report header | |
| Eva M Alvarez | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 108
Deficiencies: 0
Date: Dec 21, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 10/04/2021 alleging staff handled a resident roughly and that a resident was being harassed by another resident.
Complaint Details
The complaint involved two allegations: 1) staff handled a resident in a rough manner, and 2) a resident was being harassed by another resident. After interviews with residents, staff, and the administrator, and review of records and observations, the allegations were found unsubstantiated due to lack of evidence. The harassment allegation had been previously substantiated in an earlier complaint and was not re-investigated.
Findings
The investigation found no sufficient evidence to support the allegations that staff handled a resident in a rough manner or that a resident was being harassed by another resident. The allegations were determined to be unsubstantiated.
Report Facts
Complaint received date: Oct 4, 2021
Number of residents interviewed: 8
Number of staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Susana Fuentes | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 108
Deficiencies: 0
Date: Dec 3, 2021
Visit Reason
The visit was an unannounced complaint investigation initiated due to an allegation of illegal eviction received on 2021-11-29.
Complaint Details
The complaint alleged illegal eviction. The investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.
Findings
The investigation found insufficient evidence to support the allegation of illegal eviction. The allegation was determined to be unsubstantiated after inspection, interviews, and document review.
Report Facts
Complaint investigation duration (hours): 2.02
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Campos | Licensing Program Analyst | Conducted the complaint investigation and interview |
| Susana Fuentes | Administrator | Facility administrator interviewed and provided documents during investigation |
| Michael Cava | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 108
Deficiencies: 0
Date: Oct 19, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that residents' meals were late and that a resident's bed was in disrepair.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents' meals being late and a resident's bed being in disrepair. The investigation included interviews with staff and residents, inspection of beds, and review of records. No evidence was found to support the allegations.
Findings
The investigation found no sufficient evidence to support the allegations that residents' meals were late or that residents' beds were in disrepair. Interviews with staff and residents, facility inspection, and record reviews did not substantiate the complaints.
Report Facts
Capacity: 108
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Amy Pratt | Administrator | Facility administrator named in the report |
| Susana Fuentes | Administrator | Interviewed during the investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 108
Deficiencies: 1
Date: Oct 19, 2021
Visit Reason
The visit was an unannounced investigation of a complaint alleging that a resident was harassing another resident at the facility.
Complaint Details
The complaint alleged that resident R2 was harassing resident R1 by calling several residents names and making derogatory remarks. The allegation was substantiated based on witness statements, video evidence, and interviews with residents and staff.
Findings
The investigation substantiated the allegation of resident harassment based on witness statements, video evidence, and interviews with residents and staff. The facility failed to ensure residents were free from intimidation or abuse, posing a potential health and safety risk.
Deficiencies (1)
Failure to ensure residents were free from punishment, humiliation, intimidation, abuse, or other punitive actions, including resident-on-resident harassment.
Report Facts
Capacity: 108
Census: 71
Plan of Correction Due Date: Nov 2, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Amy Pratt | Administrator | Facility administrator named in the report |
| Susana Fuentes | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 108
Deficiencies: 0
Date: Sep 15, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 08/09/2021 regarding resident malnutrition, sexual abuse, physical abuse, incorrect medication administration, and unmet hygiene needs.
Complaint Details
The complaint investigation was unsubstantiated for all allegations including resident malnutrition, staff sexual abuse, physical abuse, incorrect medication administration, and unmet hygiene needs.
Findings
The investigation found no sufficient evidence to support any of the allegations. Interviews with residents and staff, review of records, and observations indicated that residents received adequate food, were not sexually or physically abused, medications were administered correctly, and hygiene needs were met.
Report Facts
Capacity: 108
Census: 69
Staff interviewed: 5
Residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Susie Fuentes | Administrator | Facility administrator interviewed during the investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 108
Deficiencies: 0
Date: Aug 25, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate the allegation that the facility is in disrepair.
Complaint Details
The complaint alleged that toilets on the first floor had been out of order for three weeks and that the elevator was faulty. The investigation included interviews with residents and staff, inspection of facility grounds, and review of records. The allegation was unsubstantiated.
Findings
The investigation found no sufficient evidence to support the allegation that the facility is in disrepair. Toilets and elevators were found to be in working order based on inspections and interviews with residents and staff. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 108
Census: 64
Residents interviewed: 6
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Susie Fuentes | Administrator | Facility administrator who was interviewed during the investigation |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 0
Date: Aug 25, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2021-06-29 regarding staff interfering with residents' hygiene needs, medication administration, transportation services, accommodations, eviction threats, and care supervision.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff interfering with hygiene needs, not administering medications as needed, not providing transportation, not providing comfortable accommodations, threatening eviction, and improper care and supervision. The Department found no sufficient evidence to support these allegations.
Findings
The investigation found no sufficient evidence to substantiate any of the allegations. Interviews with residents, staff, and the administrator, as well as facility inspections and record reviews, indicated that the facility was providing appropriate care, accommodations, transportation assistance, and medication administration policies were followed. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 108
Residents interviewed: 7
Staff interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Susana Fuentes | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 1
Date: Aug 5, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident sustained multiple falls while in care and that facility staff did not seek medical attention in a timely manner.
Complaint Details
The complaint involved allegations that a resident sustained multiple falls while in care and that facility staff did not seek medical attention in a timely manner. The first allegation was substantiated; the second was unsubstantiated.
Findings
The allegation that the resident sustained multiple falls while in care was substantiated due to lack of a fall prevention plan despite the resident's fall risk. The allegation that staff did not seek medical attention in a timely manner was unsubstantiated as staff called a non-emergency ambulance immediately but experienced delays due to ambulance availability.
Deficiencies (1)
Resident R1, a fall risk, did not have a fall prevention plan which poses a potential health risk to residents in care.
Report Facts
Facility capacity: 108
Plan of Correction due date: Aug 19, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Susie Fuentes | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 0
Date: Aug 5, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility was not adhering to the admissions agreement and that a resident was not being allowed to smoke.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included the facility not adhering to the admissions agreement regarding private room assignment and a resident not being allowed to smoke. Interviews with residents and staff, review of records, and observations found no evidence to support these allegations.
Findings
The investigation found no sufficient evidence to support the allegations. The admissions agreements did not indicate private room status, and residents were allowed to smoke in designated areas. The allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Amy Pratt | Administrator | Facility administrator involved in the investigation |
| Susie Fuentes | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 1
Date: Aug 5, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2021-07-06 regarding missed medical appointments, refusal of transportation for medical appointments, failure to meet residents' hygiene needs, and insufficient staffing.
Complaint Details
The complaint investigation was triggered by allegations that a resident missed medical appointments due to lack of transportation, staff refused to provide transportation, staff failed to meet residents' hygiene needs, and there was insufficient staffing to meet residents' needs. The first three allegations were found unsubstantiated, while the insufficient staffing allegation was substantiated.
Findings
The investigation found insufficient evidence to substantiate allegations related to missed medical appointments, refusal to provide transportation, and failure to meet hygiene needs. However, the allegation of insufficient staffing to meet residents' needs was substantiated, with evidence showing the facility lacked sufficient staff, posing a potential health risk.
Deficiencies (1)
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 as evidenced by insufficient staff posing a potential health risk to residents.
Report Facts
Facility Capacity: 108
Staff Interview Count: 6
Resident Interview Count: 7
Plan of Correction Due Date: Aug 19, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Susie Fuentes | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 108
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 07/16/2021 regarding staff interference with residents' daily living functions and residents not being accorded dignity in their relationships with staff.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff interfering with residents' daily living functions and residents not being accorded dignity. Interviews with 7 residents and 5 staff members indicated no interference or lack of dignity. The evidence did not prove the alleged violations occurred.
Findings
The investigation included interviews with residents and staff, a tour of the facility, and review of records. The preponderance of evidence standard was not met for either allegation, resulting in both allegations being unsubstantiated.
Report Facts
Residents interviewed: 7
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
| Amy Pratt | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 108
Deficiencies: 0
Date: Jun 8, 2021
Visit Reason
The visit was an unannounced case management inspection regarding an incident reported to the Community Care Licensing on 2021-06-04.
Complaint Details
The visit was triggered by an incident complaint reported on 2021-06-04. The investigation was ongoing with no substantiation or deficiencies cited at the time of the report.
Findings
No deficiencies were cited at the time of the visit; however, additional investigation was required including analysis of records obtained and follow-up interviews.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the unannounced case management visit and interviews. |
| Alejandra Guzman | Administrator | Facility administrator met with Licensing Program Analyst during the visit. |
| Eva M Alvarez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 108
Deficiencies: 0
Date: May 25, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted to investigate the allegation that food is not of good quality or quantity at the facility.
Complaint Details
The complaint alleged that food was not of good quality or quantity. The investigation found no preponderance of evidence to prove the allegation, and it was determined to be unsubstantiated.
Findings
The investigation included a tour of the facility, interviews with the administrator, residents, and staff, and review of menus and food supply. The evidence did not substantiate the allegation; residents generally reported receiving enough food and good quality meals, and staff confirmed adequate food provision.
Report Facts
Capacity: 108
Census: 65
Number of residents interviewed: 6
Number of staff interviewed: 5
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alejandra Mendoza | Administrator | Interviewed during investigation and exit interview |
| Stephanie Cifuentes | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
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