Inspection Report Summary
Most inspections at Pepper Tree Assisted Living Facility found no deficiencies, including the most recent annual inspection on December 5, 2024, which noted the facility was generally clean and compliant but cited one deficiency for an expired administrator certification. Earlier reports showed isolated issues such as a missing videoconferencing device dedicated for resident use and a medication labeling concern, both considered minor. A civil penalty was issued in July 2022 for fingerprint clearance violations involving two staff members, but this was resolved during the visit. Several complaint investigations from 2022 and 2023 found no substantiated allegations regarding resident care or pest control. The facility’s record shows improvement and mostly compliance over time, with no fines or severe enforcement actions listed in the available reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
83% occupied
Based on a December 2024 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 1
Dec 5, 2024
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements for the Pepper Tree Assisted Living Facility.
Findings
The facility was found to be generally clean, in good repair, and compliant with most regulations including infection control and safety measures. However, deficiencies were observed and citations were issued, including an expired administrator certification.
Deficiencies (1)
| Description |
|---|
| Administrator Marhlyn Sapugay Certification #6018525740 expiration date of 10/03/2024 was NOT valid at time of inspection. |
Report Facts
Client service records reviewed: 5
Client medication records reviewed: 5
Staff records reviewed: 2
Fire drill date: Oct 1, 2024
Carbon Monoxide detectors: 1
Smoke detectors: 5
Fire extinguishers: 1
First aid kits: 2
PPE supply: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Hilma Matias | Staff | Met with Licensing Program Analyst and assisted during inspection. |
| Marhlyn Sapugay | Administrator | Named in finding regarding expired certification. |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 1
Jan 13, 2024
Visit Reason
An unannounced Required – 1 Year Inspection was conducted to evaluate compliance with licensing regulations at the Pepper Tree Assisted Living Facility.
Findings
The facility was found generally compliant with safety, medication, and hygiene standards; however, a deficiency was cited for not having a videoconferencing device dedicated for resident use, posing a potential personal rights risk.
Deficiencies (1)
| Description |
|---|
| Licensee did not have a videoconferencing device dedicated for resident use, which poses a potential personal rights risk to persons in care. |
Report Facts
Capacity: 6
Census: 5
Plan of Correction Due Date: Jan 30, 2024
Fire Extinguisher Last Service Date: Sep 12, 2023
Hot Water Temperature Range: Measured between 105 and 120 degrees Fahrenheit
Staff Records Reviewed: 5
Resident Records Reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Socorro Leandro | Licensing Program Analyst | Conducted the inspection and cited deficiency |
| Ulysses Coronel | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
| Emma Fernandez | Caregiver/House Manager | Facility staff member met during inspection |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 6
Deficiencies: 0
Dec 22, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not addressing pest infestation at the facility and that uncleared adults were working at the facility.
Findings
The investigation found that the facility had a pest control service agreement and was actively addressing pest infestation with regular treatments. All staff working at the facility had California background clearances. Therefore, both allegations were found to be unsubstantiated and no deficiencies were cited.
Complaint Details
The allegations investigated were: 1) Staff are not addressing pest infestation at the facility, and 2) Uncleared adult(s) are working at the facility. Both allegations were found to be unsubstantiated based on interviews, observations, and records review.
Report Facts
Facility capacity: 6
Census: 3
Pest control service dates: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lourdes Montoya | Licensing Program Analyst | Conducted the complaint investigation visit |
| Marhlyn Sapugay | Administrator | Facility administrator who assisted with the visit and exit interview |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Nov 17, 2022
Visit Reason
An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tool.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with Title 22 regulations. Infection control practices, including screening protocols and PPE supply, were observed and found adequate. No deficiencies were cited during this inspection visit.
Report Facts
Residents present: 6
Facility capacity: 6
PPE supply: 30
Fire extinguishers: 1
Water temperature range: 106.0-110.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Don Senaha | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephanie Klein | Licensee/Administrator | Facility licensee present during the inspection |
| Miguel Can | Caregiver | Met with Licensing Program Analyst during the inspection |
Inspection Report
Census: 5
Capacity: 6
Deficiencies: 1
Jul 15, 2022
Visit Reason
Licensing Program Analyst Don Senaha conducted a Case Management visit to check on the health and safety of the residents living at the facility.
Findings
A deficiency and civil penalty were assessed for fingerprint clearance violations involving two staff members who worked prior to obtaining required California clearances. The citation was cleared during the visit.
Deficiencies (1)
| Description |
|---|
| Failure to obtain California criminal record clearance or exemption for staff prior to working at the facility. |
Report Facts
Civil penalty amount: 100
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Princess Diaz | Caregiver | Named in fingerprint clearance deficiency |
| Miguel Can | Caregiver | Named in fingerprint clearance deficiency |
| Stephanie Klein | Licensee / Administrator | Met with Licensing Program Analyst during visit and exit interview |
| Don Senaha | Licensing Program Analyst | Conducted the Case Management visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 0
May 16, 2022
Visit Reason
Unannounced complaint investigation conducted due to multiple allegations received on 11/15/2021 regarding resident care issues at Pepper Tree Assisted Living Facility.
Findings
The investigation found no substantiated evidence for the allegations including failure to reposition residents, timely diaper changes, bathing, pressure injury care, medication administration, and bedding changes. Hospice nurses provided continuous care for the resident in question, and facility staff assisted as needed.
Complaint Details
The complaint included allegations that staff did not reposition residents, change diapers timely, bathe residents, administer medications, change bedding, and that a resident sustained a pressure injury while in care. All allegations were found unsubstantiated after interviews and record reviews.
Report Facts
Capacity: 6
Census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation |
| Mila Santos | House Manager | Facility representative interviewed during investigation |
| Stephanie Klein | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Plan of Correction
Capacity: 6
Deficiencies: 0
Apr 14, 2022
Visit Reason
An unannounced Plan of Correction (POC) case management visit was conducted to review and clear outstanding corrective actions at the facility.
Findings
The Licensing Program Analyst reviewed all medications for resident R1, including over-the-counter medications, and cleared the outstanding Plan of Correction. An exit interview was conducted with the House Manager.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mila Santos | House Manager | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 0
Mar 11, 2022
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2021-11-15 regarding multiple allegations of inadequate care at Pepper Tree Assisted Living Facility.
Findings
The investigation found no preponderance of evidence to substantiate the allegations, which included failure to reposition residents, timely diaper changes, bathing, medication administration, and bedding changes. Hospice nurses were primarily responsible for care, and staff assisted as needed. All allegations were determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that staff did not reposition residents, change diapers timely, bathe residents, administer medications, or change bedding, and that a resident sustained a pressure injury while in care. The investigation concluded all allegations were unsubstantiated based on interviews and record reviews.
Report Facts
Capacity: 6
Census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation |
| Mila Santos | House Manager | Facility representative interviewed during investigation |
| Stephanie Klein | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 1
Nov 19, 2021
Visit Reason
An unannounced required annual visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tools.
Findings
The facility was found to be clear of Covid-19 infection with adequate infection control practices, PPE supplies, and sanitation. One deficiency was cited related to medication labeling where over-the-counter medication bottles lacked prescription labels.
Deficiencies (1)
| Description |
|---|
| Each medication container shall carry all required information including expiration date and number of refills; observed medication bottles lacked prescription labels. |
Report Facts
Capacity: 6
Census: 5
Plan of Correction Due Date: Dec 3, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted inspection and cited deficiency |
| Janae Hammond | Licensing Program Manager | Supervisor of inspection |
| Mila Santos | House Manager | Facility staff met during inspection and facility representative |
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