Most inspections found no deficiencies, including the most recent visit on May 14, 2025, which was clean and addressed a prior concern about fire extinguisher accessibility. Earlier reports did cite a few isolated issues, such as staff working while COVID-positive in August 2024 and a medtech lacking a First Aid/CPR card in March 2025. A complaint investigation in May 2025 substantiated that staff caused bruising to a resident during an elopement incident, resulting in a citation for violating personal rights. Several complaint investigations were substantiated, but none led to fines or license actions, which are not listed in the available reports. The facility appears to have improved compliance over time, with recent inspections showing fewer deficiencies and no enforcement actions.
The inspection was an unannounced complaint investigation conducted due to an allegation that facility staff caused bruising to a resident in care during an elopement incident.
Findings
The investigation substantiated the allegation that staff caused bruising to a resident while redirecting them back to their room during an elopement. Surveillance and hospital medical records confirmed bruising on the resident's upper extremities, and interviews supported the findings. The facility was cited for violating personal rights regulations.
Complaint Details
The complaint was substantiated. The allegation was that facility staff caused bruising to a resident during an elopement incident. Evidence included surveillance footage, hospital medical records, and interviews. The preponderance of evidence standard was met.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to ensure staff followed residents' personal rights, resulting in bruising of a resident in care.
Type A
Report Facts
Estimated Days of Completion: 90
Employees Mentioned
Name
Title
Context
Mario Leon
Licensing Program Analyst
Conducted the complaint investigation and signed the report
Ulysses Coronel
Licensing Program Manager
Oversaw the complaint investigation and signed the report
Desiree Kitagawa
Administrator
Interviewed during the investigation
Julius Osorio
Executive Director
Met with Licensing Program Analyst during the visit
The visit was a Case Management visit conducted by Licensing Program Analyst Alfonso Iniguez to review the facility's compliance and address previous concerns.
Findings
No deficiencies were observed during this visit. The previous concern about locked fire extinguishers was reviewed, and it was noted that one out of eight fire extinguishers had a sticker indicating emergency use and was accessible. No citations were issued.
Report Facts
Fire extinguishers inspected: 8
Employees Mentioned
Name
Title
Context
Julius Osorio
Executive Director
Met with Licensing Program Analyst during the Case Management visit and involved in facility tour
Alfonso Iniguez
Licensing Program Analyst
Conducted the Case Management visit and facility inspection
The inspection was an unannounced annual required visit conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, sanitary, and appropriately furnished with no discrepancies in medication administration records. One deficiency was cited regarding a medtech lacking a First Aid/CPR card on file, which poses a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
MedTech with no First Aid/CPR card on file
Type B
Report Facts
Residents' service files reviewed: 5Staff personnel files reviewed: 5Medication Administration Records reviewed: 5Fire/Disaster Drills last conducted: Jan 25, 2025Plan of Correction Due Date: Apr 7, 2025Facility Annual Fees Due Date: Apr 12, 2025
Employees Mentioned
Name
Title
Context
Julius Osorio
Executive Director
Met with Licensing Program Analyst during inspection and received report
An unannounced complaint investigation was conducted due to an allegation that staff were exposing residents to a contagious illness.
Findings
The investigation substantiated the allegation that two staff members who tested positive for COVID-19 continued to work within five days of testing positive, contrary to Los Angeles County Department of Public Health guidelines. Deficiencies were issued and plans of correction were developed.
Complaint Details
The complaint alleged that staff were exposing residents to a contagious illness. The allegation was substantiated based on record review and interviews, including with the Executive Director. Two staff members worked within five days after testing positive for COVID-19, violating public health guidance.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
The licensee did not comply with the requirement to exclude staff who tested positive for COVID-19 from the workplace for five days, posing an immediate health risk to residents.
Type A
Report Facts
Capacity: 121Census: 20Staff interviews: 8Resident interviews: 3Deficiency due date: 1
Employees Mentioned
Name
Title
Context
Desiree Kitagawa
Executive Director
Interviewed during the investigation and named in findings
Regina Cloyd
Licensing Program Analyst
Conducted the complaint investigation
Ulysses Coronel
Licensing Program Manager
Oversaw the complaint investigation
Inspection Report Original LicensingCensus: 8Capacity: 121Deficiencies: 0May 8, 2024
Visit Reason
An unannounced post-licensing visit was conducted to review personnel policies, abuse reporting procedures, in-service training, and medication procedures as part of the initial licensing process.
Findings
No deficiencies were observed during the visit, and no citations were issued. The Licensing Program Analyst and Executive Director reviewed policies and conducted a joint tour of the facility.
Met with Licensing Program Analyst during post-licensing visit
Alfonso Iniguez
Licensing Program Analyst
Conducted the unannounced post-licensing visit
Inspection Report Original LicensingCapacity: 121Deficiencies: 0Apr 3, 2024
Visit Reason
A pre-licensing evaluation was conducted for an RCFE facility type to assess the facility prior to licensing and to evaluate compliance with regulations for serving elderly residents.
Findings
The facility was found to be clean, sanitary, and in good repair with all required protective devices in place. No corrections were needed during this pre-licensing inspection. The facility has appropriate medication storage, adequate bedrooms and bathrooms, sufficient supplies, proper food service, confidential record storage, and emergency and safety measures in place.
Facility Administrator present during pre-licensing evaluation and exit interview
Alfonso Iniguez
Licensing Program Analyst
Conducted pre-licensing evaluation and Component III Orientation
Wendy Gibbs
Licensing Program Analyst
Conducted pre-licensing evaluation and observed delay egress functioning
Eva M Alvarez
Licensing Program Manager
Named as Licensing Program Manager on report
Inspection Report Original LicensingCapacity: 121Deficiencies: 0Jan 29, 2024
Visit Reason
The visit was conducted as an initial facility evaluation for licensing of a Residential Care Facility for Elderly (RCFE).
Findings
The Component II completion was successful, confirming the applicant and administrator's understanding of licensing laws and facility operation requirements. No deficiencies or issues were noted in the report.
Report Facts
Capacity: 121Census: 0
Employees Mentioned
Name
Title
Context
Desiree Kitagawa
Administrator
Met during inspection and participant in Component II
Benoit Levesque
Applicant
Met during inspection and participant in Component II
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