Deficiencies (last 5 years)

Deficiencies (over 5 years) 1.2 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

70% better than California average
California average: 4 deficiencies/year

Deficiencies per year

4 3 2 1 0
2021
2022
2023
2024
2025

Census

Latest occupancy rate 89% occupied

Based on a November 2025 inspection.

Occupancy over time

49 56 63 70 77 Feb 2021 Oct 2021 Oct 2023 Jun 2024 Dec 2024 Nov 2025

Inspection Report

Annual Inspection
Census: 64 Capacity: 72 Deficiencies: 2 Date: Nov 7, 2025

Visit Reason
The inspection was a required 1 year annual inspection conducted to evaluate the facility's compliance with health and safety regulations.

Findings
The facility was generally clean, odor-free, and in good repair with adequate furniture and lighting. However, deficiencies were found related to improper disposal of used syringes and an inadequate staff training plan that did not meet dementia training requirements.

Deficiencies (2)
Two syringe disposal locations without the appropriate container, posing a potential health, safety or personal rights risk to persons in care.
Training plan did not meet Title 22 requirements for 8 hours of dementia training annually, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Capacity: 72 Census: 64 Plan of Correction Due Date: Nov 14, 2025 Plan of Correction Due Date: Nov 21, 2025

Employees mentioned
NameTitleContext
Marina SmetyukhAdministratorMet with Licensing Program Analyst during inspection and involved in facility evaluation
Kevin GouldLicensing Program AnalystConducted the inspection and authored the report
Czarrina A Camilon-LeeLicensing Program ManagerNamed as Licensing Program Manager overseeing the inspection

Inspection Report

Complaint Investigation
Census: 63 Capacity: 72 Deficiencies: 0 Date: Oct 29, 2025

Visit Reason
An unannounced complaint investigation was conducted in response to allegations of questionable death, inadequate nutrition, and lack of adequate care and supervision of a resident.

Complaint Details
The complaint was unsubstantiated based on interviews with nine staff members, review of the resident's death certificate, hospice notes, and staff communications. The department found no evidence to support the allegations of questionable death, neglect, or lack of supervision.
Findings
The investigation found no corroboration of the allegations. Staff interviews, hospice notes, and documentation indicated the resident was declining on hospice care with a decreased appetite. The department determined the allegations were unsubstantiated and no deficiencies were cited.

Report Facts
Staff interviewed: 9 Facility capacity: 72 Census: 63

Employees mentioned
NameTitleContext
Kevin GouldLicensing Program AnalystConducted the complaint investigation and inspection
Marina SmetyukhFacility representative met during the investigation
Czarrina A Camilon-LeeSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 64 Capacity: 72 Deficiencies: 0 Date: Dec 31, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-10-15 regarding staff behavior towards residents.

Complaint Details
The complaint alleged that staff did not ensure residents were spoken to or handled in an appropriate manner. After interviews, observations, and review of documentation, both allegations were found unsubstantiated.
Findings
The investigation found no corroborated evidence that staff spoke to or handled residents inappropriately. Observations and interviews conducted in all four memory care cottages did not reveal any inappropriate staff conduct. Both allegations were unsubstantiated.

Report Facts
Capacity: 72 Census: 64

Employees mentioned
NameTitleContext
Michael BilgerLicensing Program AnalystConducted the complaint investigation and observations
Irene CharnellExecutive DirectorMet with Licensing Program Analyst during the investigation
Liza KingSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 64 Capacity: 72 Deficiencies: 0 Date: Dec 31, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-10-15 regarding staff behavior towards residents.

Complaint Details
The complaint involved allegations that staff did not ensure residents were spoken to or handled in an appropriate manner. After interviews, observations, and review of documentation, these allegations were found to be unsubstantiated.
Findings
The investigation found no corroborated evidence that staff spoke to or handled residents inappropriately. Observations and interviews conducted in all four cottages serving memory care residents did not reveal any inappropriate staff behavior. Both allegations were unsubstantiated.

Report Facts
Capacity: 72 Census: 64

Employees mentioned
NameTitleContext
Michael BilgerLicensing Program AnalystConducted the complaint investigation and observations
Irene CharnellExecutive DirectorMet with Licensing Program Analyst during the investigation
Liza KingLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 67 Capacity: 72 Deficiencies: 0 Date: Dec 4, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-10-15 regarding pest control, staff health, and equipment maintenance at the facility.

Complaint Details
The complaint investigation was unsubstantiated for all allegations: pest presence, staff health, and equipment maintenance. The preponderance of evidence standard was not met for any allegation.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Observations and interviews confirmed the facility is kept free of pests, staff are in good health to perform assigned tasks, and equipment is maintained and in good repair. All allegations were determined to be unsubstantiated.

Report Facts
Capacity: 72 Census: 67

Employees mentioned
NameTitleContext
Irene CharnellExecutive DirectorMet with Licensing Program Analyst during investigation
Michael BilgerLicensing Program AnalystConducted complaint investigation and inspection
Liza KingSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 67 Capacity: 72 Deficiencies: 0 Date: Dec 4, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-10-15 regarding pest presence, staff health, and equipment maintenance at the facility.

Complaint Details
The complaint investigation addressed three allegations: 1) facility not kept free of pests, 2) staff not in good health to perform tasks, and 3) equipment not maintained and in good repair. All allegations were found unsubstantiated based on interviews, observations, and record reviews.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Observations and interviews confirmed the facility is kept free of pests, staff are in good health to perform assigned tasks, and equipment is maintained and in good repair. All allegations were unsubstantiated.

Report Facts
Facility capacity: 72 Census: 67

Employees mentioned
NameTitleContext
Michael BilgerLicensing Program AnalystConducted the complaint investigation and interviews
Irene CharnellExecutive DirectorMet with Licensing Program Analyst during investigation
Liza KingLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Annual Inspection
Census: 67 Capacity: 72 Deficiencies: 0 Date: Oct 10, 2024

Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.

Findings
The facility was found to be clean, odor-free, and in good repair with all required furniture and sufficient lighting. Water temperatures, food supplies, fire safety equipment, carbon monoxide detectors, first aid kits, and medication storage were all compliant. No deficiencies were cited during the inspection.

Employees mentioned
NameTitleContext
Kevin GouldLicensing Program AnalystConducted the inspection and evaluation of the facility.
Irene CharnellAdministratorMet with the Licensing Program Analyst and participated in the facility tour.

Inspection Report

Annual Inspection
Census: 67 Capacity: 72 Deficiencies: 0 Date: Oct 10, 2024

Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.

Findings
The facility was found to be clean, odor-free, and in good repair with all rooms properly furnished and sufficiently lit. Water temperatures, food supplies, fire safety equipment, carbon monoxide detectors, first aid kits, and medication storage were all in compliance. No deficiencies were cited during the inspection.

Employees mentioned
NameTitleContext
Kevin GouldLicensing Program AnalystConducted the inspection and authored the report.
Irene CharnellAdministratorMet with Licensing Program Analyst and participated in the facility tour.

Inspection Report

Census: 71 Capacity: 72 Deficiencies: 0 Date: Jun 20, 2024

Visit Reason
An unannounced case management inspection was conducted to address concerns of recent falls within the last week at the facility.

Findings
The Licensing Program Analyst reviewed recent falls and incident reports, observed residents, and met with one resident regarding a recent fall. No deficiencies were observed during the inspection.

Employees mentioned
NameTitleContext
Kevin GouldLicensing Program AnalystConducted the unannounced case management inspection.
Nicole HemenoverRSC, LVNMet with the Licensing Program Analyst to discuss recent falls.

Inspection Report

Complaint Investigation
Census: 71 Capacity: 72 Deficiencies: 0 Date: Jun 20, 2024

Visit Reason
An unannounced case management inspection was conducted to address concerns of recent falls within the last week at the facility.

Complaint Details
The visit was complaint-related due to concerns about recent falls. No deficiencies were found, and the complaint was effectively investigated.
Findings
The Licensing Program Analyst reviewed recent falls and incident reports, observed residents, and met with one resident regarding a recent fall. All recently reported falls had varying circumstances and occurred at different times and locations. No deficiencies were observed during the inspection.

Report Facts
Capacity: 72 Census: 71

Employees mentioned
NameTitleContext
Kevin GouldLicensing Program AnalystConducted the inspection and investigation of recent falls
Nicole HemenoverRSC, LVNMet with the Licensing Program Analyst to discuss recent falls

Inspection Report

Complaint Investigation
Census: 69 Capacity: 72 Deficiencies: 0 Date: May 9, 2024

Visit Reason
An unannounced complaint investigation was conducted to investigate allegations including staff not preventing a resident from pushing another, a resident being locked out of the facility, failure to follow reporting requirements, and an indecent exposure incident.

Complaint Details
The complaint investigation was unsubstantiated based on interviews with five staff members and three residents. No evidence was found to support allegations of neglect, lack of supervision, or failure to report incidents.
Findings
The investigation found no corroborating evidence to support the allegations after interviews with staff and residents. The allegations were determined to be unsubstantiated, and no deficiencies were cited.

Report Facts
Capacity: 72 Census: 69

Employees mentioned
NameTitleContext
Kevin GouldLicensing Program AnalystConducted the complaint investigation and inspection
Irene CharnellAdministratorFacility administrator met with the evaluator during the investigation

Inspection Report

Complaint Investigation
Census: 69 Capacity: 72 Deficiencies: 0 Date: May 9, 2024

Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations including staff not preventing resident altercations, locking a resident out of the facility, failure to follow reporting requirements, and indecent exposure incidents.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff failing to prevent resident pushing, locking a resident out, failure to report incidents, and indecent exposure. Interviews with five staff and three residents did not corroborate these claims. The department found no preponderance of evidence to prove violations occurred.
Findings
Based on interviews with staff and residents, the investigation was unable to corroborate the allegations. No evidence was found to support claims of resident pushing, indecent exposure, or locking residents out. The allegations were determined to be unsubstantiated.

Report Facts
Staff interviewed: 5 Residents interviewed: 3 Capacity: 72 Census: 69

Employees mentioned
NameTitleContext
Kevin GouldLicensing Program AnalystConducted the complaint investigation and inspection
Irene CharnellAdministratorFacility administrator met with during investigation
Czarrina A Camilon-LeeLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 67 Capacity: 72 Deficiencies: 1 Date: Jan 18, 2024

Visit Reason
The visit was an unannounced case management incident investigation triggered by an incident report regarding a resident (R1) who was reported AWOL from the facility day club program on 01/10/2024.

Complaint Details
The visit was complaint-related, investigating an incident where resident R1 was missing from the facility grounds for less than 10 minutes due to an unsecured gate left open by construction staff. The licensee's responsibility for resident safety was not fulfilled.
Findings
The investigation found that the facility gate had been left slightly ajar by construction staff, allowing R1 to leave the facility grounds unsupervised for less than 10 minutes. This was a violation of Title 22 regulations, as the licensee failed to ensure the health and safety of the resident. Deficiencies were cited accordingly.

Deficiencies (1)
Failure to ensure outdoor facility space was completely enclosed with self-closing latches and gates to protect resident safety, as evidenced by the facility gate being left open during construction.
Report Facts
Census: 67 Total Capacity: 72 Plan of Correction Due Date: Jan 18, 2024

Employees mentioned
NameTitleContext
Irene CharnellAdministratorMet during inspection and named in report
Jamie Ivey CanadyLicensing Program AnalystConducted the inspection and authored the report
Czarrina A Camilon-LeeSupervisorSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 67 Capacity: 72 Deficiencies: 1 Date: Jan 18, 2024

Visit Reason
The visit was an unannounced case management incident investigation triggered by an incident report of a resident (R1) who was reported AWOL from the facility day club program on 01/10/2024.

Complaint Details
The visit was complaint-related based on an incident report received on 01/15/2024 regarding resident R1 being AWOL from the facility day club program. The complaint was substantiated by findings of gate left open by construction staff.
Findings
The investigation found that the facility gate was left slightly ajar by construction staff on 01/10/2024, allowing R1 to leave the facility grounds unsupervised for less than 10 minutes. This was a violation of Title 22 regulations regarding the licensee's responsibility for resident health and safety.

Deficiencies (1)
Failure to ensure the facility gates stayed locked during construction services, posing an immediate health and safety issue to persons in care.
Report Facts
Census: 67 Total Capacity: 72 Deficiencies cited: 1

Employees mentioned
NameTitleContext
Irene CharnellAdministratorMet during inspection and named in report
Jamie Ivey CanadyLicensing Program AnalystConducted the inspection and authored the report
Czarrina A Camilon-LeeLicensing Program ManagerSupervisor named in report

Inspection Report

Annual Inspection
Census: 60 Capacity: 72 Deficiencies: 0 Date: Oct 24, 2023

Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.

Findings
The facility was found to be clean, odor-free, and in good repair with all required furniture and sufficient lighting. Water temperatures, food supplies, fire safety equipment, carbon monoxide detectors, first aid kit, and medication storage were all in compliance. No deficiencies were cited during the inspection.

Report Facts
Water temperature readings: 111 Water temperature readings: 112 Water temperature readings: 106 Water temperature readings: 114 Capacity: 72 Census: 60

Employees mentioned
NameTitleContext
Irene CharnellAdministratorMet with Licensing Program Analyst during inspection and participated in facility tour
Kevin GouldLicensing Program AnalystConducted the inspection

Inspection Report

Annual Inspection
Census: 60 Capacity: 72 Deficiencies: 0 Date: Oct 24, 2023

Visit Reason
The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.

Findings
The facility was found to be clean, odor-free, and in good repair with all required furniture and sufficient lighting. Water temperatures, food supplies, fire safety equipment, carbon monoxide detectors, first aid kit, and medication storage were all in compliance. No deficiencies were cited during the inspection.

Report Facts
Water temperature readings: 111 Water temperature readings: 112 Water temperature readings: 106 Water temperature readings: 114 Census: 60 Capacity: 72

Employees mentioned
NameTitleContext
Irene CharnellAdministratorMet with Licensing Program Analyst during inspection and participated in facility tour
Kevin GouldLicensing Program AnalystConducted the inspection and authored the report
Czarrina A Camilon-LeeLicensing Program ManagerNamed in report header

Inspection Report

Annual Inspection
Census: 68 Capacity: 72 Deficiencies: 0 Date: Oct 17, 2022

Visit Reason
The visit was a Required - 1 Year unannounced inspection conducted to evaluate the facility's compliance with licensing regulations.

Findings
The Licensing Program Analyst toured and inspected the facility, including physical plant and safety features, and found no violations during the visit. Environmental conditions such as temperature and hot water temperature were within required ranges, and safety equipment and medication storage met regulatory standards.

Report Facts
Residents utilizing hospice services: 6

Employees mentioned
NameTitleContext
Casey SimonAdministratorMet with Licensing Program Analyst during the inspection
Victoria BrownLicensing Program AnalystConducted the Required - 1 Year unannounced inspection
Nicole HemenoverResident Service DirectorMet with Licensing Program Analyst during the inspection
Stephen RichardsonSupervisorSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 68 Capacity: 72 Deficiencies: 0 Date: Oct 17, 2022

Visit Reason
The inspection was an unannounced Required - 1 Year visit conducted to evaluate the facility's compliance with regulations.

Findings
The Licensing Program Analyst toured the facility, inspected physical conditions, safety equipment, medication storage, and first aid supplies. No violations were observed during the visit.

Report Facts
Residents utilizing hospice services: 6 Temperature range inside facility: 73 Temperature range inside facility: 77 Hot water temperature range: 106.3 Hot water temperature range: 109.3

Employees mentioned
NameTitleContext
Casey SimonAdministratorMet with Licensing Program Analyst during inspection
Victoria BrownLicensing Program AnalystConducted the Required - 1 Year inspection visit
Nicole HemenoverResident Service DirectorMet with Licensing Program Analyst during inspection
Stephen RichardsonLicensing Program ManagerNamed in report header

Inspection Report

Capacity: 72 Deficiencies: 0 Date: Jun 30, 2022

Visit Reason
An office meeting was conducted to discuss and review procedures to ensure the facility remains in substantial compliance while participating in the Mitigation of Major Hip Injury due to falls in an at-risk older adult population with a wearable smart belt (Tango Belt Study). The facility is requesting a waiver to participate in this study.

Findings
No deficiencies were cited during this visit. The meeting covered study involvement, purpose, participation requirements, staff training, study duration, confidentiality protocols, resident safety, and belt wear time/replacement.

Employees mentioned
NameTitleContext
Stacy BarlowAssistant Program AdministratorPresent in the meeting discussing the Tango Belt Study
Liza KingActing Regional Manager/Licensing Program ManagerPresent in the meeting discussing the Tango Belt Study
Victoria BrownLicensing Program AnalystPresent in the meeting and Licensing Evaluator
Wamis SinghatatCEORepresentative of Active Protective Technologies Inc. present in the meeting
Rebecca TarbertDirector of Clinical Programs/Physical TherapistRepresentative of Active Protective Technologies Inc. present in the meeting
Brenda ChappellExecutive DirectorRepresentative of Chancellor Health Care of California VIII Inc. present in the meeting
Nicole HemenoverResident Service DirectorRepresentative of Chancellor Health Care of California VIII Inc. present in the meeting
Casey SimonDirector of Community RelationsRepresentative of Chancellor Health Care of California VIII Inc. present in the meeting

Inspection Report

Capacity: 72 Deficiencies: 0 Date: Jun 30, 2022

Visit Reason
The purpose of the office meeting was to discuss and review procedures to ensure the facility remains in substantial compliance while participating in the Mitigation of Major Hip Injury due to falls in an at-risk, Older Adult population with a wearable smart belt (Tango Belt Study).

Findings
No deficiencies were cited during this visit. The facility is requesting a waiver to participate in the Tango Belt Study. The meeting covered study involvement, purpose, participation requirements, staff training, study duration, confidentiality protocols, resident safety, and belt wear time.

Employees mentioned
NameTitleContext
Brenda ChappellExecutive DirectorNamed as facility representative and participant in the meeting regarding the Tango Belt Study.
Nicole HemenoverResident Service DirectorNamed as participant in the meeting regarding the Tango Belt Study.
Casey SimonDirector of Community RelationsNamed as participant in the meeting regarding the Tango Belt Study.
Stacy BarlowAssistant Program AdministratorNamed as participant in the meeting regarding the Tango Belt Study.
Liza KingActing Regional Manager/Licensing Program ManagerNamed as participant in the meeting regarding the Tango Belt Study.
Victoria BrownLicensing Program AnalystNamed as participant in the meeting regarding the Tango Belt Study.
Wamis SinghatatCEORepresentative of Active Protective Technologies Inc., participant in the meeting regarding the Tango Belt Study.
Rebecca TarbertDirector of Clinical Programs/Physical TherapistRepresentative of Active Protective Technologies Inc., participant in the meeting regarding the Tango Belt Study.

Inspection Report

Complaint Investigation
Census: 70 Capacity: 72 Deficiencies: 1 Date: Dec 30, 2021

Visit Reason
The visit was an unannounced case management incident investigation to conclude an investigation that began on 02/26/2021 regarding a medication error where a resident received medication belonging to another resident.

Complaint Details
The visit was triggered by a complaint regarding a medication error where resident R1 received medication belonging to resident R2. The preponderance of evidence standard was met based on interviews and documentation.
Findings
The investigation found that staff administered incorrect medication to a resident, posing a potential health and safety risk. The licensee did not ensure prescribed medications were administered as prescribed. A deficiency was cited and a plan of correction was required.

Deficiencies (1)
Staff administered the incorrect medication to resident R1 that belonged to resident R2, failing to ensure prescribed medications were administered as prescribed.
Report Facts
Capacity: 72 Census: 70 Deficiencies cited: 1

Employees mentioned
NameTitleContext
Victoria BrownLicensing Program AnalystConducted the investigation and authored the report
Brenda ChappellAdministratorFacility administrator met with the Licensing Program Analyst during the visit
Stephen RichardsonSupervisorSupervisor named in relation to the inspection

Inspection Report

Complaint Investigation
Census: 70 Capacity: 72 Deficiencies: 1 Date: Dec 30, 2021

Visit Reason
The visit was an unannounced case management incident investigation to conclude an investigation that began on 02/26/2021 regarding a medication error where a resident received medication belonging to another resident.

Complaint Details
Investigation was initiated due to a complaint about a medication error where resident R1 received medication belonging to resident R2. The preponderance of evidence standard was met confirming the deficiency.
Findings
The investigation found that staff administered incorrect medication to resident R1 that belonged to resident R2, indicating the licensee did not ensure prescribed medications were administered as prescribed, posing a potential health and safety risk.

Deficiencies (1)
Staff administered the incorrect medication to R1 that belonged to R2, failing to ensure prescribed medication(s) were administered as prescribed.
Report Facts
Capacity: 72 Census: 70 Deficiency count: 1

Employees mentioned
NameTitleContext
Victoria BrownLicensing Program AnalystConducted the investigation and authored the report
Brenda ChappellAdministratorFacility administrator met during the investigation
Stephen RichardsonLicensing Program ManagerSupervisor overseeing the licensing evaluation

Inspection Report

Complaint Investigation
Census: 71 Capacity: 72 Deficiencies: 0 Date: Oct 27, 2021

Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a resident sustained a major injury while in care.

Complaint Details
The complaint alleged that a resident sustained a major injury while in care. The investigation included review of medical records, interviews with staff, and facility documentation. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found no negligence on behalf of the staff. The resident fell and sustained injuries requiring hospital visits, but the facility responded timely and appropriately. The allegation was found to be unsubstantiated with no deficiencies cited.

Report Facts
Estimated Days of Completion: 120

Employees mentioned
NameTitleContext
Victoria BrownLicensing Program AnalystConducted the complaint investigation and authored the report
Brenda ChappellAdministratorFacility administrator met with the Licensing Program Analyst during the investigation
Stephen RichardsonSupervisorSupervisor named in the report

Inspection Report

Complaint Investigation
Census: 71 Capacity: 72 Deficiencies: 0 Date: Oct 27, 2021

Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that a resident sustained a major injury while in care.

Complaint Details
The complaint alleged that a resident sustained a major injury while in care. The investigation included review of medical records, interviews with staff, and facility documentation. The resident fell and was sent to the hospital for a cheek laceration and fractures. Staff actions were found appropriate and timely. The allegation was unsubstantiated.
Findings
The investigation found no negligence on behalf of the staff. The facility reported the incident timely and sought immediate medical attention. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited.

Report Facts
Estimated Days of Completion: 120

Employees mentioned
NameTitleContext
Victoria BrownLicensing Program AnalystConducted the complaint investigation and authored the report
Stephen RichardsonLicensing Program ManagerNamed as Licensing Program Manager on the report
Brenda ChappellAdministratorFacility administrator met with Licensing Program Analyst during investigation

Inspection Report

Annual Inspection
Census: 71 Capacity: 72 Deficiencies: 0 Date: Oct 20, 2021

Visit Reason
The inspection was an unannounced Required - 1 Year visit conducted to evaluate the facility's compliance with licensing regulations.

Findings
No violations were observed during the visit. The facility was inspected for safety hazards, temperature compliance, medication storage, and emergency equipment, all of which met regulatory requirements.

Report Facts
Facility capacity: 72 Census: 71 Temperature range: 72 Temperature range: 77 Hot water temperature range: 88 Hot water temperature range: 123 Required temperature range: 68 Required temperature range: 85 Required hot water temperature range: 105 Required hot water temperature range: 120

Employees mentioned
NameTitleContext
Victoria BrownLicensing Program AnalystConducted the inspection and evaluation
Brenda ChappellAdministratorFacility administrator met with the Licensing Program Analyst during the inspection
Stephen RichardsonSupervisorSupervisor overseeing the licensing evaluation

Inspection Report

Complaint Investigation
Census: 71 Capacity: 72 Deficiencies: 0 Date: Oct 20, 2021

Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to an allegation that the facility was not allowing a resident to leave the facility.

Complaint Details
The complaint alleged that the facility was not allowing a resident to leave. The investigation included review of police involvement, medical and legal documents, visitor logs, and interviews. The allegation was found to be unfounded as evidence showed the resident left the facility multiple times with visitors.
Findings
The investigation found that the allegation was unfounded. Documentation and interviews showed that the resident left the facility several times over an eight-month period with visitors, and no violations of Title 22 regulations were cited.

Report Facts
Estimated Days of Completion: 120

Employees mentioned
NameTitleContext
Victoria BrownLicensing Program AnalystConducted the complaint investigation
Brenda ChappellAdministratorFacility administrator met during investigation
Stephen RichardsonSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 71 Capacity: 72 Deficiencies: 0 Date: Oct 20, 2021

Visit Reason
The visit was an unannounced complaint investigation regarding the allegation that the facility was not allowing a resident to leave the facility.

Complaint Details
The complaint alleged that the facility was not allowing a resident to leave. The allegation was investigated and found to be unfounded based on documentation, interviews, and observation. No violations were cited.
Findings
The investigation found that the resident left the facility several times over an eight-month period with visitors and appointments, and there was no court order restricting the resident's movement. The allegation was found to be unfounded with no violations cited.

Report Facts
Estimated Days of Completion: 120

Employees mentioned
NameTitleContext
Victoria BrownLicensing Program AnalystConducted the complaint investigation and authored the report
Brenda ChappellAdministratorFacility administrator met during the investigation
Stephen RichardsonLicensing Program ManagerNamed in the report as Licensing Program Manager

Inspection Report

Annual Inspection
Census: 71 Capacity: 72 Deficiencies: 0 Date: Oct 20, 2021

Visit Reason
The inspection was a Required - 1 Year unannounced visit to evaluate the facility's compliance with regulations and ensure safety and proper operation.

Findings
No violations were observed during the visit. The facility was found to be in compliance with safety standards, medication storage, and first aid requirements. The administrator will research hot water heater temperatures to ensure compliance.

Report Facts
Facility capacity: 72 Census: 71 Inspection duration: 2 Hot water temperature range: 88 Hot water temperature range: 123 Indoor temperature range: 72 Indoor temperature range: 77

Employees mentioned
NameTitleContext
Brenda ChappellAdministratorMet with Licensing Program Analyst during inspection
Victoria BrownLicensing Program AnalystConducted the inspection visit
Stephen RichardsonLicensing Program ManagerNamed in report header

Inspection Report

Complaint Investigation
Census: 71 Capacity: 72 Deficiencies: 0 Date: Oct 15, 2021

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that a resident was not allowed to have visitors and was not allowed to have contact with people via phone.

Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis. No violations were cited.
Findings
The investigation found that visitation protocols were properly provided and followed, with residents receiving visitors and using the facility phone as needed. The allegations were determined to be unfounded with no violations cited during the visit.

Report Facts
Capacity: 72 Census: 71 Estimated Days of Completion: 120

Employees mentioned
NameTitleContext
Victoria BrownLicensing Program AnalystConducted the complaint investigation
Brenda ChappellAdministratorFacility administrator met during the investigation
Stephen RichardsonSupervisorSupervisor named in the report

Inspection Report

Complaint Investigation
Census: 71 Capacity: 72 Deficiencies: 0 Date: Oct 15, 2021

Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that a resident was not allowed to have visitors and was not allowed to have contact with people via phone.

Complaint Details
The complaint alleged that a resident was not allowed to have visitors and was not allowed to have contact with people via phone. The investigation concluded the allegations were unfounded based on interviews and documentation.
Findings
The investigation found that visitation protocols were in place and followed, with residents receiving visitors and using the facility phone as needed. The allegations were found to be unfounded with no violations cited during the visit.

Report Facts
Estimated Days of Completion: 120

Employees mentioned
NameTitleContext
Victoria BrownLicensing Program AnalystConducted the complaint investigation and authored the report
Brenda ChappellAdministratorFacility administrator met with the Licensing Program Analyst during the investigation
Stephen RichardsonLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 56 Capacity: 72 Deficiencies: 0 Date: Feb 26, 2021

Visit Reason
The visit was conducted as a case management incident investigation due to a reported medication error where one resident received medication belonging to another resident.

Complaint Details
The visit was triggered by a complaint regarding a medication error involving residents R1 and R2. The complaint remains under further investigation with no substantiation or violations cited at this time.
Findings
No violations were cited during this unannounced tele-visit as further investigation is needed. Interviews were conducted and documentation was requested related to the medication error incident.

Report Facts
Capacity: 72 Census: 56

Employees mentioned
NameTitleContext
Brenda ChappellExecutive DirectorInterviewed during the visit and participated in exit interview
Victoria BrownLicensing Program AnalystConducted the tele-visit and interviews

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