Inspection Report Summary
Most inspections of Roseberry Care Facility found no deficiencies, with the most recent report on August 13, 2025, showing no issues and residents expressing satisfaction with care. However, a substantiated complaint investigation from December 31, 2020, revealed a serious failure to seek timely medical attention for a resident who suffered a secondary hip fracture, resulting in significant fines totaling $10,000. Since that event, annual inspections consistently showed compliance with no further deficiencies, particularly in infection control, safety, and resident care. Several complaint investigations were unsubstantiated, and no enforcement actions have been noted after 2020. This suggests the facility has maintained good standards and improved following the serious incident.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
0.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
93% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 14
Capacity: 15
Deficiencies: 0
Date: Aug 13, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the health, safety, and compliance of the Roseberry Care Facility using the CARE inspection tool.
Findings
No immediate health, safety, or personal rights violations were observed during the inspection. Resident and staff files were complete and well organized, and residents expressed satisfaction with care and staff interactions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Quistguard | Administrator | Met with Licensing Program Analyst during the inspection and discussed several issues. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the annual inspection using the CARE inspection tool. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 13
Capacity: 15
Deficiencies: 0
Date: Aug 22, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted to ensure compliance with health and safety regulations using the CARE inspection tool.
Findings
No immediate health, safety, or personal rights violations were observed. Resident and staff files were complete and well organized, and residents expressed satisfaction with care and staff interactions. No deficiencies were cited as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Quistgard | Administrator | Met with Licensing Program Analyst during inspection and discussed several issues. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the annual inspection using the CARE inspection tool. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 13
Capacity: 15
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
Licensing Program Analysts conducted an unannounced collateral visit to the facility to evaluate compliance.
Findings
No deficiencies were observed during the visit. The analysts spoke with the Administrator and a resident about an unrelated issue.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Quistgard | Administrator | Met with Licensing Program Analysts during the visit. |
Inspection Report
Annual Inspection
Census: 12
Capacity: 15
Deficiencies: 0
Date: Aug 9, 2023
Visit Reason
The visit was an unannounced 1-year annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. Infection control practices, physical plant safety, food service, and resident accommodations were all observed to meet required standards.
Report Facts
Residents' files reviewed: 5
Staff files reviewed: 5
Bedrooms: 9
Bathrooms: 7
Food supply - perishables: 2
Food supply - non-perishables: 7
Hot water temperature range: 105
Hot water temperature range: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Quistgard | Administrator | Met with Licensing Program Analysts during inspection |
| Ivan Avila | Licensing Program Analyst | Conducted the inspection |
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection |
| Lauren Crocker | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 11
Capacity: 15
Deficiencies: 0
Date: Aug 2, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure compliance with health and safety standards.
Findings
The facility was found to be in substantial compliance with infection control requirements. No immediate health, safety, or personal rights violations were observed, and no deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Quistguard | Administrator | Met with Licensing Program Analyst during the inspection and is the Infection Control Leader. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the Required-1 Year Inspection. |
| Maribeth Senty | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 7
Capacity: 15
Deficiencies: 0
Date: Aug 5, 2021
Visit Reason
The inspection was a Required-1 Year unannounced visit to conduct an annual inspection utilizing the infection control domain, including COVID-19 protocols and a facility risk assessment.
Findings
The facility was found to be in substantial compliance with infection control requirements, with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Report Facts
Resident bedrooms toured: 9
Bathrooms toured: 7
Inspection start time: 930
Inspection end time: 1055
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Quistgard | Administrator and Infection Control Leader | Met with Licensing Program Analyst and participated in infection control domain review |
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and infection control review |
Inspection Report
Complaint Investigation
Census: 12
Capacity: 15
Deficiencies: 1
Date: Dec 31, 2020
Visit Reason
The visit was conducted to follow up on a substantiated allegation that the facility staff failed to seek medical attention in a timely manner for a resident, resulting in serious injury.
Complaint Details
The complaint investigation was substantiated. The facility staff failed to seek medical attention in a timely manner for a resident who fell on June 18, 2019, and medical care was delayed over eighteen hours. An immediate civil penalty of $500 was issued on October 8, 2019, and a further civil penalty of $9,500 was issued on December 30, 2020 for serious bodily injury.
Findings
The investigation confirmed that staff failed to seek timely medical care for a resident who sustained a secondary hip fracture after a fall. The facility delayed calling 9-1-1 for over eighteen hours despite knowledge of the resident's recent hip surgery, resulting in a substantiated violation and civil penalties.
Deficiencies (1)
Facility staff failed to seek timely medical care for a resident after a fall, resulting in a secondary hip fracture and extreme pain.
Report Facts
Civil penalty amount: 9500
Immediate civil penalty amount: 500
Time delay in seeking medical care (hours): 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Quistgard | Administrator | Named in relation to failure to seek timely medical care for resident. |
| Jimelia Sterling | Administrator | Named in relation to failure to seek timely medical care for resident. |
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