Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
85% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly notify the physician and document intake and output for a resident with a foley catheter who had episodes of low urine output.
Complaint Details
The complaint investigation focused on Resident 1, who had a foley catheter and episodes of low urine output that were not properly communicated to the physician. The investigation found the facility failed to document voiding and perform bladder scans, and the physician was not notified as required. The resident's family member reported concerns and requested catheter reinsertion. The physician and Director of Nursing confirmed the importance of notification and documentation.
Findings
The facility failed to notify the physician timely about low urine output episodes and did not properly document the resident's intake and output as required by policy and care plan. This failure had the potential to harm the resident. The facility also lacked clear guidance in its bowel and bladder management policy.
Deficiencies (3)
Failure to notify the physician of low urine output episodes for a resident with a foley catheter.
Failure to develop and implement a complete care plan that meets the resident's needs, including documenting intake and output.
Failure to provide appropriate care to prevent urinary tract infections and monitor bladder function.
Report Facts
Urine output measurements: 60
Urine output measurements: 250
Urine output measurements: 600
Urine output measurements: 200
Urine output measurements: 200
Urine output measurements: 550
Urine output measurements: 350
Urine output measurements: 1150
Urine output measurements: 40
Urine output measurements: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Interviewed regarding Resident 1's catheter care and intake/output documentation |
| FM 1 | Family Member | Reported concerns about Resident 1's catheter removal and pain |
| DON | Director of Nursing | Interviewed about notification policies and care plan implementation |
| CNA 1 | Certified Nursing Assistant | Interviewed about urine output recording and communication with charge nurse |
| Resident 1's physician | Medical Doctor | Interviewed about importance of notification for low urine output |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 68
Deficiencies: 1
Date: Oct 23, 2025
Visit Reason
The visit was conducted in response to a self-reported medication error that occurred on 09/13/2025 involving a resident receiving a discontinued medication.
Complaint Details
The visit was complaint-related due to a self-reported medication error. The complaint was substantiated as a repeat violation with a civil penalty assessed.
Findings
The investigation found that the resident did not experience any injuries or adverse reactions. The medication technician failed to verify the order when administering the medication, resulting in a repeat violation. A civil penalty of $250 was assessed and a Plan of Correction was developed.
Deficiencies (1)
Licensee did not assist 1 of 58 residents with medication according to the physician's order, posing a health risk to persons in care.
Report Facts
Civil Penalty: 250
Residents involved: 1
Census: 58
Total Capacity: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle England | Assisted Living Director | Met during inspection and exit interview. |
| Jessica Mikkola | Wellness Manager | Met during inspection and exit interview. |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 68
Deficiencies: 1
Date: Oct 23, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to a self-reported medication error that occurred on 2025-09-13 involving a resident receiving a discontinued medication.
Complaint Details
The visit was complaint-related due to a self-reported medication error. The complaint was substantiated as a repeat violation with deficiencies cited and a civil penalty assessed.
Findings
The investigation found that the resident did not experience injury or adverse reaction, but the medication technician failed to verify the medication order, constituting a repeat violation. Deficiencies were cited and a civil penalty of $250 was assessed. A plan of correction was developed and an exit interview was conducted.
Deficiencies (1)
Licensee did not assist 1 of 58 residents with medication according to the physician's order, posing a health risk.
Report Facts
Civil Penalty: 250
Residents involved: 1
Census: 58
Total Capacity: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle England | Assisted Living Director | Met during inspection and exit interview. |
| Jessica Mikkola | Wellness Manager | Met during inspection and exit interview. |
| Nacole Patterson | Licensing Program Analyst | Conducted the inspection. |
| Prabhjot Kaur | Administrator/Director | Facility administrator listed in report. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 68
Deficiencies: 1
Date: Aug 15, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to a self-reported medication error that occurred on 2025-07-28.
Complaint Details
The visit was complaint-related due to a self-reported medication error. The facility's internal investigation revealed a communication error between Medication Technicians. The resident did not experience injury. This was the facility's second medication error within 12 months.
Findings
The investigation found that Resident 1 received two doses of a routine medication due to a communication error between two Medication Technicians. No injuries or adverse reactions occurred. Deficiencies were cited, and a repeat civil penalty of $250 was assessed. A Plan of Correction was developed with the licensee.
Deficiencies (1)
Licensee did not assist 1 of 40 residents (R1) with medication according to the physician's order, posing a health risk to persons in care.
Report Facts
Civil penalty amount: 250
Residents involved: 1
Total residents present: 40
Total licensed capacity: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mona Kaur | Executive Director | Met during inspection and named in exit interview |
| Michelle England | Assisted Living Director | Met during inspection |
| Nacole Patterson | Licensing Program Analyst | Conducted inspection and signed report |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 68
Deficiencies: 1
Date: Aug 15, 2025
Visit Reason
The visit was conducted in response to a self-reported medication error that occurred on 2025-07-28 involving a resident receiving two doses of a routine medication due to a communication error between medication technicians.
Complaint Details
The visit was complaint-related due to a self-reported medication error on 2025-07-28. The error was substantiated as the facility failed to assist a resident with medication as ordered by the physician. This was the facility's second medication error within a 12-month period.
Findings
The investigation found that the resident did not experience any injuries or adverse reactions from the medication error. Deficiencies were cited related to failure to assist a resident with medication according to physician's orders, posing a health risk. A repeat civil penalty of $250 was assessed, and a plan of correction was developed.
Deficiencies (1)
Licensee did not assist 1 of 40 residents (R1) with medication according to the physician's order, which posed a health risk to persons in care.
Report Facts
Civil penalty amount: 250
Medication errors within 12 months: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mona Kaur | Executive Director | Met during inspection and named in exit interview |
| Michelle England | Assisted Living Director | Met during inspection |
| Nacole Patterson | Licensing Program Analyst | Conducted the inspection |
| Sabel Martinez | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulations, specifically focusing on ensuring the nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Findings
The facility failed to implement adequate interventions to prevent falls for one resident who required total assistance with activities of daily living. This failure resulted in the resident falling off a narrow bed without bedrails, sustaining a fracture to the left leg. Staff did not provide sufficient assistance or appropriate safety measures during care.
Deficiencies (1)
Failure to implement interventions consistent with resident's needs to eliminate or reduce the risk of falling, resulting in a resident falling off the bed and sustaining a fracture.
Report Facts
Fall risk evaluation score: 10
MDS BIMS score: 15
MDS functional ability code: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) 1 | Assigned to Resident 1 and described assistance provided during repositioning | |
| Licensed Nurse (LN) 1 | Provided information about Resident 1's weakness and need for support during repositioning | |
| Certified Nurse Assistant (CNA) 3 | Described the incident when Resident 1 fell off the bed during brief change | |
| Director of Nursing (DON) | Interviewed regarding expectations for staff and awareness of concerns about Resident 1's care |
Inspection Report
Annual Inspection
Census: 60
Capacity: 68
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for the Ridgeview Assisted Living Community facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and documentation were present and in working order.
Report Facts
Hospice waiver beds: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mona Kaur | Administrator | Met with Licensing Program Analyst during inspection and participated in facility tour |
| Michelle England | Assisted Living Director | Participated in facility tour during inspection |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced required annual inspection |
Inspection Report
Census: 60
Capacity: 68
Deficiencies: 1
Date: Jul 8, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted in response to two self-reported incidents: a medication error on 04/30/2025 and an accusation of missing money on 06/17/2025.
Findings
The facility confirmed a medication error where a medication was administered twice and retrained the involved Medication Technician. An internal investigation into missing money was inconclusive with no evidence of staff wrongdoing. A wellness check found no health or safety issues. Deficiencies were cited related to medication administration according to physician's orders.
Deficiencies (1)
Licensee did not assist 1 of 60 residents (R1) with medication according to the physician's order, posing a health risk to persons in care.
Report Facts
Residents present: 60
Total licensed capacity: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mona Kaur | Executive Director | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced Case Management Visit |
| Prabhjot Kaur | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 68
Deficiencies: 1
Date: Jul 8, 2025
Visit Reason
The visit was an unannounced Case Management inspection conducted in response to two self-reported incidents: a medication error on 04/30/2025 and an accusation of missing money on 06/17/2025.
Complaint Details
The visit was complaint-related due to two self-reported incidents: a medication error by Staff 1 where medication was administered twice, and an accusation of missing money for Resident 1. The medication error was substantiated and addressed with retraining. The missing money allegation was inconclusive and not substantiated.
Findings
The facility confirmed the medication error and retrained the involved Medication Technician. The investigation into the missing money accusation was inconclusive with no evidence of staff wrongdoing. A wellness check found no health or safety issues. One Type B deficiency was cited related to medication administration not following physician's orders.
Deficiencies (1)
Licensee did not assist 1 of 60 residents (R1) with medication according to the physician's order, posing a health risk.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mona Kaur | Executive Director | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Prabhjot Kaur | Administrator/Director | Provided signed training sheets during facility visit |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Sabel Martinez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Routine
Census: 19
Deficiencies: 7
Date: Jun 12, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident care, medication administration, nursing competencies, nutrition, and food safety at Ridgeview Skilled Nursing Facility.
Findings
The facility was found deficient in multiple areas including failure to promptly notify physicians of significant weight changes in residents, inadequate care and assessment for a resident with congestive heart failure, failure to accurately measure nutritional supplement intake, lack of nurse competency in managing CHF residents, failure to provide prescribed medication for three weeks, improper food sanitation and safety practices in the kitchen, and failure to monitor dry food storage temperatures.
Deficiencies (7)
Failed to notify physician promptly of significant weight changes in two residents.
Failed to provide care and treatment according to standards for a resident with congestive heart failure, including daily weights and assessment for fluid overload.
Failed to ensure nutritional supplement intake was accurately measured for a resident with significant weight loss.
Failed to ensure two licensed nurses were competent to care for a resident with congestive heart failure.
Failed to provide prescribed Vitamin B-12 medication for three weeks to a resident.
Failed to ensure kitchen staff properly tested sanitizer solution and prepared pureed soup to correct texture.
Failed to monitor dry food storage room temperature and improperly stored trash bins next to clean dishware.
Report Facts
Weight loss: 13.7
Weight gain: 9.5
Medication omission duration: 20
Facility census: 19
Sanitizer ppm reading: 300
Dry food storage room temperature: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 12 | Registered Nurse | Reviewed weight summaries and medication administration; involved in findings related to Resident 22 and Resident 31 |
| LN 4 | Licensed Nurse | Interviewed regarding Resident 31's weight and care; lacked knowledge of CHF assessment |
| LN 5 | Licensed Nurse | Interviewed regarding Resident 31's weight gain and care; noted lack of MD notification |
| DON | Director of Nursing | Provided statements on facility policies, nurse competencies, and care expectations |
| CNA 1 | Certified Nursing Assistant | Reported on Resident 20's meal intake and documentation practices |
| RD | Registered Dietitian | Interviewed about nutritional assessments and expectations for supplement intake documentation |
| RN 13 | Registered Nurse | Interviewed about medication administration and family involvement for Resident 20 |
| CK 2 | Cook | Observed testing sanitizer solution incorrectly |
| DFNS | Director of Food and Nutrition Services | Interviewed about kitchen staff training and food safety practices |
| EC | Executive Chef | Interviewed about food safety and sanitation practices in kitchen |
| UW | Utility Worker | Observed improper trash bin storage near clean dishware |
Inspection Report
Census: 54
Capacity: 68
Deficiencies: 0
Date: Jan 17, 2025
Visit Reason
The visit was conducted in response to a request by the Licensee to increase the facility's bedridden capacity.
Findings
The Licensing Program Analyst toured the facility and inspected the rooms pertinent to the request, observing that the rooms matched the approved bedridden clearance granted by the local fire authority. No health or safety issues were observed and no deficiencies were cited during the visit.
Report Facts
Facility capacity: 68
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle England | Assisted Living Director | Met during the inspection and involved in the exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced Case Management Visit |
Inspection Report
Census: 54
Capacity: 68
Deficiencies: 0
Date: Jan 17, 2025
Visit Reason
The visit was conducted in response to a request by the Licensee to increase the facility's bedridden capacity.
Findings
The Licensing Program Analyst toured the facility and inspected the rooms pertinent to the request, observing that the rooms matched the approved bedridden clearance granted by the local fire authority. No health or safety issues were observed and no deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle England | Assisted Living Director | Met with during the visit and involved in the exit interview. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 68
Deficiencies: 1
Date: May 13, 2024
Visit Reason
The visit was an unannounced Case Management visit conducted in response to a self-reported incident involving a medication error affecting one resident.
Complaint Details
The visit was triggered by a complaint related to a medication error involving Resident 1. The incident was self-reported by the facility.
Findings
The inspection found that the facility did not assist one resident with medication administration according to the physician's order, posing a health risk. A Plan of Correction was developed including retraining of staff on medication passes and documentation.
Deficiencies (1)
Licensee did not assist 1 of 54 residents with medication according to the physician's order, posing a health risk.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Prabhjot Kaur | Administrator | Met during the visit and involved in exit interview and Plan of Correction |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Jennifer Lott | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 54
Capacity: 68
Deficiencies: 0
Date: May 13, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and records were in order and properly maintained.
Report Facts
Capacity: 68
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Prabhjot Kaur | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Nacole Patterson | Licensing Program Analyst | Conducted the inspection |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager in report |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 68
Deficiencies: 1
Date: May 13, 2024
Visit Reason
The visit was an unannounced Case Management visit in response to a self-reported incident involving a medication error affecting Resident 1.
Complaint Details
Visit was complaint-related due to a self-reported medication error incident involving Resident 1.
Findings
The Licensee did not assist one resident with medication according to the physician's order, posing a health risk. Deficiencies were cited per California Code of Regulations, Title 22, and a Plan of Correction was developed.
Deficiencies (1)
Licensee did not assist 1 of 54 residents (R1) with medication according to the physician's order, posing a health risk.
Report Facts
Deficiencies cited: 1
Census: 54
Total Capacity: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Prabhjot Kaur | Administrator | Met during inspection and involved in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jennifer Lott | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Annual Inspection
Census: 54
Capacity: 68
Deficiencies: 0
Date: May 13, 2024
Visit Reason
Licensing Program Analyst Nacole Patterson conducted an unannounced Required Annual Inspection to review the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and documentation were present and in order.
Report Facts
Capacity: 68
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Prabhjot Kaur | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Nacole Patterson | Licensing Program Analyst | Conducted the inspection |
| Jennifer Lott | Supervisor | Supervisor named in report |
Inspection Report
Routine
Deficiencies: 3
Date: May 8, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety standards, hospice care coordination, and COVID-19 vaccination protocols at Ridgeview Skilled Nursing Facility.
Findings
The facility failed to ensure food items were properly labeled, dated, and free from mold, risking food-borne illness. Hospice care coordination documentation was incomplete, risking disruption in continuity of care. The facility also failed to offer COVID-19 vaccine boosters to several residents, placing them at risk of infection.
Deficiencies (3)
Food items were found unlabeled, undated, expired, and moldy, posing a risk of food-borne illness.
Failed to ensure documented communication for hospice care coordination for one resident, risking disruption of care.
Failed to offer COVID-19 vaccine boosters to four out of five residents reviewed, increasing risk of infection.
Report Facts
Expired food items: 9
Residents reviewed for COVID-19 booster offer: 5
Current census: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding importance of food labeling and hospice documentation. |
| Registered Dietician | Registered Dietician | Interviewed about risks of expired food and food labeling requirements. |
| Hospice licensed nurse 1 | Hospice Licensed Nurse | Interviewed about hospice visit documentation and communication failures. |
| Medical Records Director | Medical Records Director | Interviewed about missing hospice visit documentation. |
| Licensed Nurse 1 | Licensed Nurse | Interviewed about hospice communication log and visit documentation. |
| Infection Control Nurse | Infection Control Nurse | Interviewed about vaccination records and COVID-19 vaccine offering failures. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 68
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
The visit was conducted in response to three self-reported incidents involving residents who suffered falls.
Complaint Details
The visit was complaint-related due to three self-reported incidents of resident falls. No deficiencies or substantiated issues were found.
Findings
The Licensing Program Analysts conducted interviews and wellness checks, identifying no health or safety issues. No deficiencies were cited or observed during this visit.
Report Facts
Number of self-reported incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mona Kaur | Administrator | Met with Licensing Program Analysts during the visit and involved in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced case management visit |
| Ryan Fulton | Licensing Program Analyst | Conducted the unannounced case management visit |
| Jennifer Lott | Licensing Program Manager | Named in report header |
Inspection Report
Census: 54
Capacity: 68
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
The visit was an unannounced Case Management Visit in response to three self-reported incidents involving residents who suffered falls.
Findings
LPAs interviewed staff and residents and conducted a wellness check; no health or safety issues were identified. No deficiencies were cited or observed on this date.
Report Facts
Self-reported incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mona Kaur | Administrator | Met with LPAs during the visit and participated in the exit interview |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 19, 2024
Visit Reason
The inspection was conducted to identify deficiencies related to the facility's failure to provide ordered nutritional supplemental feeding and apply a CPAP machine as prescribed by the physician for a sampled resident.
Findings
The facility failed to provide enteral feeding and apply CPAP as ordered for Resident 1, with multiple instances of unsigned medication and treatment administration records indicating tasks were not completed. The facility also lacked a policy requiring staff to follow physician's orders.
Deficiencies (1)
Failure to provide nutritional supplemental feeding and apply CPAP machine as ordered by the physician for one resident.
Report Facts
Unsigned enteral feeding doses: 7
Unsigned CPAP applications: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding unsigned medication and treatment administration records and facility policies. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 19, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to complete a post-fall assessment and proper documentation for Resident 5 following a fall incident on 11/22/23.
Complaint Details
The complaint investigation found that Resident 5 had a fall on 11/22/23 with no post-fall assessment completed and no documentation of the fall incident in progress notes. Resident 5 later developed pain and was diagnosed with a right hip fracture. The facility's policy requires post-fall assessments and documentation, which were not followed.
Findings
The facility failed to complete a post-fall assessment and accurate documentation after Resident 5's fall on 11/22/23, despite the resident being identified as high fall risk. This failure had the potential to increase the risk of repeat falls and delayed identification of injuries, as Resident 5 was later found to have a right hip fracture.
Deficiencies (2)
Failure to complete a post-fall assessment for Resident 5 after a fall incident on 11/22/23.
Failure to complete accurate documentation related to Resident 5's fall incident and post-fall assessment.
Report Facts
Fall risk score: 10
Fall risk score: 16
Fall risk score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 1 | Certified Nurse Assistant | Interviewed regarding Resident 5's unsafe behavior and fall incidents |
| Clinical Support Nurse | Clinical Support Nurse | Interviewed and reviewed Resident 5's fall assessments and documentation |
| Licensed Nurse 1 | Licensed Nurse | Interviewed regarding post-fall assessments and Resident 5's condition |
| Director of Nurses | Director of Nursing | Interviewed regarding facility policy and review of Resident 5's fall assessments and documentation |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 68
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following an allegation received on 2023-03-13 that facility staff did not administer medications as prescribed.
Complaint Details
The complaint alleged that staff did not administer medications as prescribed to resident R1. The investigation included interviews, record reviews, and observations. It was found that R1 had multiple medication administration changes and that 8 out of 10 medications were ordered for unsupervised self-administration. No medication errors by staff were found. The allegation was unsubstantiated.
Findings
The investigation found insufficient evidence to support the allegation. Interviews, record reviews, and observations indicated that medications were administered according to physician prescriptions, and the allegation was unsubstantiated.
Report Facts
Capacity: 68
Census: 62
Medications prescribed to R1: 10
Medications ordered for unsupervised self-administration: 8
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Meegan Kline | Executive Director | Facility representative met during the investigation and exit interview |
| Robert Daynes | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 21, 2023
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident dignity, care planning, medication use, and overall facility practices.
Findings
The facility was found deficient in promoting resident dignity during feeding assistance, assessing and addressing unintended weight loss in a resident, and ensuring proper assessment and non-pharmacological interventions for psychotropic medication use. Deficiencies were noted in care planning, monitoring, and evaluation of medication effects, with minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failure to ensure staff promoted dignity and respect by maintaining eye-to-eye level during meal assistance for Resident 1.
Failure to assess and collaborate on unintended weight loss and decline in oral food intake for Resident 2, with no documented interdisciplinary team meeting or updated care plan.
Failure to ensure assessments, non-pharmacological interventions, and evaluation of medications use for Resident 5's psychotropic medication, including lack of evaluation for continued use of Ambien and combined effects with Elavil.
Report Facts
Weight loss: 22
Weight loss: 5.2
Meal intake record: 88
Meals refused: 6
Meals uneaten: 38
Meals 25% consumed: 30
Meals 50% consumed: 6
Meals 100% consumed: 2
Sedation hours: 3
Sedation hours: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Named in dignity deficiency for feeding Resident 1. | |
| CNA 1 | Named in dignity deficiency for feeding Resident 3 and promoting eye-to-eye level feeding. | |
| DON | Director of Nursing | Interviewed regarding dignity, weight loss monitoring, and psychotropic medication deficiencies. |
| CNA 2 | Interviewed regarding Resident 2's food intake and Resident 5's care needs. | |
| RD 1 | Registered Dietitian | Documented weight loss and nutritional assessments for Resident 2. |
| RD 2 | Registered Dietitian | Reviewed Resident 2's chart and weights, interviewed about care planning. |
| DOR | Director of Rehabilitation | Interviewed about Resident 5's therapy responses and sedation. |
| PT | Physical Therapist | Interviewed about Resident 5's confusion and unstable gait during therapy. |
| PC | Pharmacist Consultant | Interviewed about psychotropic medication risks and non-pharmacological interventions for Resident 5. |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 68
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident was not treated with dignity.
Complaint Details
The complaint alleged that a resident was not treated with dignity. The investigation found no substantiation of the allegation based on interviews and records review.
Findings
The investigation included interviews with staff, residents, and review of records. It was found that the resident had mild cognitive impairment and confusion, and while the resident reported discomfort around a male staff member, there was no evidence of mistreatment. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 68
Census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Administrator | Met with during the investigation and involved in interviews |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lilian Escobar | Assisted Living Director | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 68
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident was not treated with dignity.
Complaint Details
The complaint alleged that a resident was not treated with dignity. The investigation found no substantiation of the allegation based on interviews and records review.
Findings
The investigation included interviews with staff, residents, and review of records. The allegation was found to be unsubstantiated as the resident could not recall any mistreatment and no evidence of abuse was found. The facility took precautionary measures by removing male staff from the resident's care.
Report Facts
Capacity: 68
Census: 63
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Robert Daynes | Administrator | Facility administrator interviewed during the investigation |
| Lilian Escobar | Assisted Living Director | Participated in the exit interview |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 61
Capacity: 68
Deficiencies: 0
Date: Mar 13, 2023
Visit Reason
An unannounced Case Management Visit was conducted to observe the physical plant and review the facility's application to increase licensed capacity from 64 to 68 non-ambulatory residents.
Findings
The Licensing Program Analysts conducted a tour of the facility and observed no immediate health or safety issues. No deficiencies were cited, and the facility's floor plan was consistent with the current layout.
Report Facts
Licensed capacity: 68
Current census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Administrator | Met with Licensing Program Analysts during the visit |
| Kathy Demos | Community Liaison | Met with Licensing Program Analysts during the visit |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management Visit |
| Alyssa Ramirez | Licensing Program Analyst | Conducted the unannounced Case Management Visit |
Inspection Report
Census: 61
Capacity: 68
Deficiencies: 0
Date: Mar 13, 2023
Visit Reason
An unannounced Case Management Visit was conducted to observe the physical plant and review the facility's application to increase its licensed capacity from 64 to 68 non-ambulatory residents.
Findings
The Licensing Program Analysts conducted a tour of the facility and observed no immediate health or safety issues. No deficiencies were cited, and the facility's floor plan was consistent with the current layout.
Report Facts
Licensed capacity change: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Administrator | Met during the visit and participated in the exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management Visit |
| Alyssa Ramirez | Licensing Program Analyst | Conducted the unannounced Case Management Visit |
| Kathy Demos | Community Liaison | Met and discussed the purpose of the visit |
Inspection Report
Census: 40
Capacity: 64
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
The visit was an unannounced Case Management Visit conducted in response to a self-reported incident occurring around 11/14/2022 involving a staff member and a resident.
Findings
The Licensing Program Analyst conducted interviews and a wellness check, observed residents, and reviewed records. The facility's internal investigation was inconclusive but resulted in the staff member no longer working with the resident. No deficiencies were cited or observed during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lillian Escobar | Resident Services Director | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Kayla Hilario | Licensing Program Analyst | Conducted the unannounced Case Management Visit. |
| John Rante | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 40
Capacity: 64
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
The visit was an unannounced Case Management Visit in response to a self-reported incident occurring around 11/14/2022 involving a staff member and a resident.
Findings
The Licensing Program Analyst conducted interviews and a wellness check, found residents appropriate for the facility, and noted the facility's own inconclusive investigation. No deficiencies were cited or observed during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Hilario | Licensing Program Analyst | Conducted the unannounced Case Management Visit and investigation. |
| Lilllian Escobar | Resident Services Director | Met with the Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Annual Inspection
Census: 36
Capacity: 64
Deficiencies: 0
Date: Aug 12, 2022
Visit Reason
An unannounced annual required licensing inspection was conducted to verify compliance with statutes, regulations, and other requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation measures, and no deficiencies were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Javier | Director of Nursing | Met during inspection and involved in review of COVID-19 mitigation plan. |
| Denise L. Johnson | Director of Staff Development/Infection Preventionist | Met during inspection and involved in review of COVID-19 mitigation plan. |
| Robert Daynes | Executive Director | Granted entry for inspection and participated in exit interview. |
Inspection Report
Annual Inspection
Census: 36
Capacity: 64
Deficiencies: 0
Date: Aug 12, 2022
Visit Reason
An unannounced annual required licensing inspection was conducted to verify compliance with statutes, regulations, and other requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation strategies, and no deficiencies were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Javier | Director of Nursing | Participated in review of COVID-19 mitigation plan and infection control practices. |
| Denise L. Johnson | Director of Staff Development/Infection Preventionist | Participated in review of COVID-19 mitigation plan and infection control practices. |
| Robert Daynes | Executive Director | Granted entry to Licensing Program Analyst and participated in exit interview. |
Inspection Report
Census: 39
Capacity: 64
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
An unannounced case management visit was conducted following a self-reported incident involving a resident who was sent to the hospital after an unwitnessed fall.
Findings
No immediate health and safety concerns were noted during the facility tour and health and safety check, and no deficiencies were cited at this time.
Report Facts
Capacity: 64
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lillian Escobar | Assisted Living Director | Met with during the inspection and involved in the exit interview |
| Robert Baynes | Administrator | Met with during the inspection and involved in the exit interview |
| Liliana Silveira | Licensing Program Analyst | Conducted the unannounced case management visit |
| Denise Powell | Licensing Program Manager | Named in the report header |
Inspection Report
Census: 39
Capacity: 64
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
An unannounced case management visit was conducted following a self-reported incident involving a resident who was sent to the hospital due to an unwitnessed fall.
Findings
No immediate health and safety concerns were noted during the visit, and no deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liliana Silveira | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Robert Baynes | Administrator | Facility administrator present during the visit. |
| Lillian Escobar | Assisted Living Director | Facility director present during the visit. |
Inspection Report
Census: 20
Capacity: 64
Deficiencies: 0
Date: Feb 4, 2022
Visit Reason
Licensing Program Analyst Natasha Persaud conducted an unannounced visit to check on the health and welfare of residents in care.
Findings
During the visit, a brief tour, health and safety check, staff interviews, and resident record reviews were conducted. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marjorie Pacquing | Licensed Vocational Nurse | Met with during the visit and participated in exit interview. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced visit. |
| John Rante | Supervisor | Named as supervisor in the report. |
Inspection Report
Census: 20
Capacity: 64
Deficiencies: 0
Date: Feb 4, 2022
Visit Reason
An unannounced visit was conducted to check on the health and welfare of residents in care, including a health and safety check, staff interviews, and review of resident records.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst toured the facility, interviewed staff, and reviewed records without identifying any issues.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marjorie Pacquing | Licensed Vocational Nurse | Met with during the visit and participated in the exit interview. |
Inspection Report
Original Licensing
Census: 11
Capacity: 64
Deficiencies: 0
Date: Nov 30, 2021
Visit Reason
Licensing Program Analyst Natasha Persaud conducted an unannounced post-licensing inspection to verify compliance with statutes, regulations, and other requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation strategies, with no deficiencies observed during the visit.
Report Facts
Capacity: 64
Census: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Administrator | Met with Licensing Program Analyst during inspection |
| Liliian Escobar | Assisted Living Director | Met with Licensing Program Analyst during inspection |
| Natasha Persaud | Licensing Program Analyst | Conducted the post-licensing inspection |
Inspection Report
Original Licensing
Census: 11
Capacity: 64
Deficiencies: 0
Date: Nov 30, 2021
Visit Reason
The visit was an unannounced post-licensing inspection to verify compliance with statutes, regulations, and other requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation strategies, with no deficiencies observed during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Administrator | Met with Licensing Program Analyst during inspection |
| Liliian Escobar | Assisted Living Director | Met with Licensing Program Analyst during inspection |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection |
| John Rante | Licensing Program Manager | Named in report header |
Inspection Report
Census: 11
Capacity: 64
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's disinfection, screening protocols, and use of personal protective equipment during the COVID-19 pandemic.
Findings
No deficiencies were issued during the visit. The Executive Director was interviewed and a walk-through of the facility was conducted, followed by a debriefing.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Executive Director | Interviewed and met during the visit |
| Natasha Persaud | Licensing Program Analyst | Conducted the on-site visit |
| Sandra Brackman | County of San Diego Nurse Contractor | Conducted the on-site visit |
| Robert Montillano | County of San Diego Nurse Contractor | Conducted the on-site visit |
Inspection Report
Census: 11
Capacity: 64
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's disinfection, screening protocols, and use of personal protective equipment during the COVID-19 pandemic.
Findings
No deficiencies were issued during the visit. The Executive Director was interviewed and a walk-through of the facility was conducted, followed by a debriefing.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Executive Director | Interviewed and met during the visit |
| Natasha Persaud | Licensing Program Analyst | Conducted the on-site visit |
| Sandra Brackman | County of San Diego Nurse Contractor | Conducted the on-site visit |
| Robert Montillano | County of San Diego Nurse Contractor | Conducted the on-site visit |
Inspection Report
Original Licensing
Capacity: 64
Deficiencies: 0
Date: Aug 3, 2021
Visit Reason
A prelicensing inspection was conducted as part of the initial application to operate a Residential Care Facility for the Elderly.
Findings
The facility was found to be in compliance with CCR, Title 22 and the Health and Safety Code with no deficiencies noted. The inspection included a tour of the facility, review of safety measures, and verification of operational requirements.
Report Facts
Capacity: 64
Census: 0
Fire inspection date: Jun 28, 2021
Hot water temperature: 108
Hospice waiver capacity: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Administrator | Met during inspection and involved in facility operations |
| Meegan Kline | Executive Director | Met during inspection |
| Lillian Escobar | Assisted Living Director | Met during inspection |
| Natasha Persaud | Licensing Program Analyst | Conducted the prelicensing inspection |
Inspection Report
Original Licensing
Capacity: 64
Deficiencies: 0
Date: Aug 3, 2021
Visit Reason
The inspection was a prelicensing visit conducted as part of the initial application process to operate a Residential Care Facility for the Elderly.
Findings
The facility was found to be in compliance with CCR, Title 22 and the Health and Safety Code, with no deficiencies noted. The facility met all physical plant, safety, and operational requirements during the prelicensing inspection.
Report Facts
Licensed capacity: 64
Hospice waiver capacity: 6
Census: 0
Hot water temperature: 108
Administrator Certification Expiration: Aug 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Administrator | Met with Licensing Program Analyst during prelicensing inspection. |
| Meegan Kline | Executive Director | Met with Licensing Program Analyst during prelicensing inspection. |
| Lillian Escobar | Assisted Living Director | Met with Licensing Program Analyst during prelicensing inspection. |
| Natasha Persaud | Licensing Program Analyst | Conducted the prelicensing inspection. |
| John Rante | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Original Licensing
Capacity: 64
Deficiencies: 0
Date: Jul 23, 2021
Visit Reason
The visit was an initial licensing evaluation for the facility Crestview HC LLC to assess compliance with regulatory requirements and confirm understanding of Title 22 regulations.
Findings
The applicant/administrator participated in a telephone call with the analyst to verify identity and confirm understanding of facility operation, staff qualifications, program policies, and application document requirements. Component II of the licensing process was successfully completed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Administrator | Applicant/administrator participating in licensing evaluation and identity verification |
| Nicole Rouse | Licensing Evaluator | Conducted licensing evaluation and signed report |
| Julia Kim | Supervisor | Supervisor overseeing licensing evaluation |
Inspection Report
Original Licensing
Capacity: 64
Deficiencies: 0
Date: Jul 23, 2021
Visit Reason
Initial licensing evaluation of Crestview HC LLC facility to assess compliance with regulatory requirements and verify applicant/administrator understanding of Title 22 and related policies.
Findings
The applicant/administrator successfully completed Component II of the licensing process via telephone, demonstrating understanding of facility operation, staff qualifications, program policies, and application requirements. The report confirms completion of pre-licensing inspection and other compliance verifications.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Daynes | Administrator | Applicant/administrator who participated in licensing evaluation and confirmed understanding of Title 22. |
| Julia Kim | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Nicole Rouse | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
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