Inspection Reports for Roses & Ivy Assisted Living Facility for the Elderly
CA, 95926
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on May 13, 2025, which cited only one minor technical violation. Several complaint investigations between late 2024 and early 2025 were unsubstantiated, with no deficiencies noted in those visits. However, an inspection on October 3, 2024, found multiple substantiated deficiencies related to medication management, staffing shortages, and emergency preparedness. Since then, the facility appears to have improved, as later reports show no further issues. No fines, enforcement actions, or severe findings were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 14
Capacity: 15
Deficiencies: 1
May 13, 2025
Visit Reason
The visit was an unannounced required annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be operating within its approved capacity and in safe, clean, and good repair conditions. One technical violation was cited during the visit. The inspection included a walkthrough, record review, and medication audit.
Deficiencies (1)
| Description |
|---|
| One (1) Technical Violation was given during this visit. |
Report Facts
Residents in care: 14
Facility capacity: 15
Water temperature: 114
Facility temperature: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Doug Hicks | Administrator | Met with Licensing Program Analyst during inspection and received report copies |
| Renese Howell-Small | Licensing Program Analyst | Conducted the inspection visit |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 13
Capacity: 15
Deficiencies: 0
Dec 23, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-09-25 regarding violations of residents' personal rights and staff providing care while under the influence of drugs.
Findings
The investigation included interviews with staff and residents, observations of resident interactions and staff performance, and a facility tour. Both allegations were found to be unsubstantiated based on the evidence gathered.
Complaint Details
The complaint involved two allegations: 1) Facility is violating residents' personal rights, and 2) Staff is providing care while under the influence of drugs. Both allegations were investigated and found to be unsubstantiated.
Report Facts
Number of staff interviewed: 5
Number of residents interviewed: 10
Number of staff observed providing care: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joel Zamora | Administrator | Interviewed during investigation |
| Doug Hicks | House Manager | Met with during investigation and exit interview |
| Renese Howell-Small | Licensing Program Analyst | Conducted the complaint investigation visit |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 15
Capacity: 15
Deficiencies: 0
Nov 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff do not ensure residents use stairs safely and that the facility is not secure from wildlife.
Findings
The investigation found the allegations to be unsubstantiated after interviews with residents and staff, with no deficiencies cited during the visit.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. Residents denied safety issues with stairs and wildlife, and staff reported safety measures and secure waste bins.
Report Facts
Capacity: 15
Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beena Singh | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Doug Hicks | Facility Manager | Met with Licensing Program Analyst during investigation |
| Joel Zamora | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 15
Capacity: 15
Deficiencies: 0
Nov 14, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the licensee did not ensure the facility evacuation plan provides safe temporary accommodations for residents.
Findings
The investigation found that during a recent fire evacuation, residents were relocated to a motel with food and accommodations provided, and staff provided day and night supervision. The allegations were found to be unsubstantiated, and no deficiencies were cited.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation did or did not occur.
Report Facts
Capacity: 15
Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beena Singh | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Doug Hicks | Facility Manager | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 15
Deficiencies: 3
Oct 3, 2024
Visit Reason
An unannounced visit was conducted on 10/03/2024 due to complaint #56-AS-20240925153435 to perform a health and safety check at Pacific Pines Assisted Living Facility.
Findings
Multiple deficiencies were identified including failure to provide medications as prescribed to three residents, insufficient staff coverage with only one staff member for fourteen residents, and lack of required emergency supplies. The needs of the residents were not being met during the inspection.
Complaint Details
The visit was triggered by complaint #56-AS-20240925153435. The complaint was substantiated as multiple health and safety deficiencies were observed during the inspection.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide required medication assistance to Resident #1, Resident #2, and Resident #3 as prescribed by their physician. | Type A |
| Insufficient staff coverage with only one staff member working the morning shift for fourteen residents, including residents on hospice and with dementia. | Type A |
| Lack of required emergency supplies and emergency food to be self-reliant for at least 72 hours following an emergency or disaster. | Type B |
Report Facts
Residents present: 14
Total capacity: 15
Staff on duty: 1
Residents on hospice: 3
Residents with dementia: 3
Plan of Correction Due Dates: 10
Plan of Correction Due Dates: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Hicks | House Manager | Met with during inspection and discussed findings |
| Renese Howell-Small | Licensing Program Analyst | Conducted the inspection and authored the report |
| Melody Brown | Licensing Program Analyst | Conducted the inspection |
| Karen Clemons | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Original Licensing
Capacity: 15
Deficiencies: 0
Mar 13, 2024
Visit Reason
The visit was an announced pre-licensing inspection conducted to evaluate the facility's readiness for licensing as a Residential Care Facility for the Elderly.
Findings
The facility was found to have no deficiencies and met all requirements according to Title 22, California Code of Regulations. The facility was inspected for fire safety, buildings and grounds, storage, supplies, food service, laundry, bedrooms, and bathrooms, all of which were satisfactory.
Report Facts
Facility capacity: 15
Current census: 0
Water temperature range: 108
Water temperature range: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joel Zamora | Administrator | Met with Licensing Program Analyst during pre-licensing inspection |
| Lailanie Zamora | Administrator | Met with Licensing Program Analyst during pre-licensing inspection |
| Anna Bueno | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Anna Fannell | Licensing Program Analyst | Named as Licensing Program Analyst on report |
| Nedra Brown | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Original Licensing
Census: 14
Capacity: 15
Deficiencies: 0
Dec 26, 2023
Visit Reason
The visit was conducted as part of a change of ownership application process and involved a COMP II telephone interview to verify the applicant/administrator's understanding of California Code Title 22 Regulations and facility operation requirements.
Findings
The applicant and administrator demonstrated understanding of licensing requirements including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness. Identification was verified and required documentation was obtained.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joel Zamora | Administrator | Applicant/administrator participating in COMP II and confirmed understanding of regulations. |
| Lailanie Zamora | Applicant/administrator participating in COMP II and confirmed understanding of regulations. | |
| Joshua Miller | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
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