Inspection Reports for Rowntree Gardens
12151 Dale St, Stanton, CA 90680, United States, CA, 90680
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, including allegations of falls, excessive force, and theft. The facility’s most recent report from September 24, 2024, was clean with no deficiencies noted, showing continued compliance and good organization. Earlier reports reflect no serious enforcement actions, fines, or license issues, and the main themes in complaint investigations involved resident falls and care concerns, all resolved without findings of neglect. Financial challenges were discussed in prior years but did not result in regulatory penalties. Overall, the facility’s record shows consistent adherence to regulations with no recent issues.
Deficiencies per Year
4
3
2
1
0
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 182
Capacity: 280
Deficiencies: 0
Sep 24, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well organized, and compliant with all necessary requirements. No deficiencies were cited during the visit. Safety equipment and emergency drills were up to date.
Report Facts
Staff files reviewed: 9
Resident files reviewed: 5
Resident medications reviewed: 5
Resident interviews conducted: 3
Facility capacity: 280
Facility census: 182
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the inspection and authored the report |
| Claudia Lusca-Borcsa | Administrator | Facility administrator present during the inspection and exit interview |
Inspection Report
Complaint Investigation
Census: 176
Capacity: 280
Deficiencies: 0
Aug 28, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident sustained multiple falls while in care.
Findings
The investigation found that although multiple falls occurred, appropriate preventative measures were in place, including a hospital bed, fall pads, and full-time one-on-one supervision. The allegation was determined to be unsubstantiated due to lack of evidence of negligence or failure to provide care.
Complaint Details
The complaint alleged that a resident sustained multiple falls while in care. The investigation included record reviews and interviews, confirming multiple falls but also confirming preventative measures and supervision. The allegation was found unsubstantiated.
Report Facts
Facility capacity: 280
Resident census: 176
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Stephanie Gallegos | Memory Care Director | Met with during the investigation and assisted during the visit |
| Claudia Lusca-Borcsa | Administrator | Facility administrator interviewed during initial complaint investigation |
| Sheila Santos | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 186
Capacity: 280
Deficiencies: 0
Aug 20, 2024
Visit Reason
An unannounced complaint investigation was conducted following an allegation that a facility caregiver used excessive force when restraining a resident, resulting in a hematoma and additional bruising.
Findings
The investigation included interviews, file and hospice record reviews, and found that the resident displayed aggressive behavior and resistance to care. The Department was unable to ascertain if the alleged excessive force occurred as reported, and the allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that a caregiver used excessive force causing injury to a resident. Interviews with staff and review of records showed resident aggression and resistance to care. Hospice notes documented bruising likely caused by the resident's own actions. The allegation was unsubstantiated.
Report Facts
Facility capacity: 280
Resident census: 186
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerri Clark | Director of Operations | Met with during investigation and interview |
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| William Vanegas | Licensing Program Analyst | Assisted in delivering findings for the investigation |
| Armando J Lucero | Licensing Program Manager | Reviewed the report |
Inspection Report
Census: 230
Capacity: 280
Deficiencies: 0
Nov 6, 2023
Visit Reason
This unannounced Case Management – Incident inspection was conducted to follow up on a self-reported incident involving Resident #1 (R1) received on 11/03/2023.
Findings
The inspection found the facility to be clean and organized with no health and safety issues. Medications and sharps were properly stored, and no deficiencies were cited under Title 22 Division 6 of the California Code of Regulations.
Report Facts
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Lusca-Borcsa | Administrator | Met with Licensing Program Analyst during inspection and discussed purpose of inspection |
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and authored the report |
| Armando J Lucero | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Capacity: 280
Deficiencies: 0
Oct 9, 2023
Visit Reason
Office visit to discuss Stipulation and compliance requirements with facility representatives Randy Brown and Allison Nakatomi.
Findings
The Department of Social Services reviewed and approved several compliance-related items including disclosure language, financial plans, escrow agreements, and board member appointments. The facility is required to submit quarterly escrow reports, financial statements, and occupancy reports as part of ongoing compliance.
Report Facts
Capacity: 280
Days to submit Financial Plan: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Brown | Met with during the office visit to discuss stipulation and compliance requirements | |
| Allison Nakatomi | Licensing Program Analyst | Met with during the office visit and signed the report |
| Gary Johnson | Approved to serve on CFH’s Board | |
| Ann Hablitzel | Board Chair | Approved as Board Chair to separate roles from Chief Executive Officer |
| Jeremy Kauffman | Financial Consultant | Approved as financial consultant to improve CFH’s performance |
| Kathryn Hernandez | Licensing Program Manager | Named in the report |
| Pam Kaufmann | Attorney | Working with CDSS on required revisions to disclosure language |
Inspection Report
Complaint Investigation
Census: 237
Capacity: 280
Deficiencies: 0
Oct 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-27 alleging that the facility failed to properly assess a resident.
Findings
The investigation found that the allegation was unfounded. Interviews and document reviews showed that the resident was properly assessed, with a care plan in place including 1 on 1 care after an attempted elopement, and the facility ultimately determined it could not meet the resident's needs.
Complaint Details
The complaint alleged the facility failed to properly assess a resident. The investigation found the allegation to be unfounded based on interviews with staff and review of assessment and care plans.
Report Facts
Facility capacity: 280
Resident census: 237
Complaint received date: Sep 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Claudia Lusca-Borcsa | Administrator | Facility administrator interviewed during the investigation |
| Luz Adams | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 233
Capacity: 280
Deficiencies: 0
Aug 28, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that jewelry was stolen from a resident.
Findings
The investigation included interviews and document review, revealing that 4 of 6 witnesses could not confirm the allegation. There was no evidence of theft or burglary, and the facility's Theft and Loss Policy was followed. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint allegation was that jewelry was stolen from a resident. The investigation found no clear evidence to prove or refute the allegation, and it was deemed unsubstantiated.
Report Facts
Number of witnesses interviewed: 6
Number of witnesses unable to confirm allegation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Claudia Lusca-Borcsa | Administrator | Facility administrator met during the investigation |
| Luz Adams | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Monitoring
Census: 178
Capacity: 280
Deficiencies: 0
Nov 28, 2022
Visit Reason
The purpose of the meeting was to elaborate on financial plans discussed previously, address financial concerns of Rowntree Gardens, and discuss the viability of their program including issues related to entrance fees, federal grant money, and management company selection.
Findings
The facility is experiencing financial difficulties and has not demonstrated sustainable breakeven operations. The Licensee is working on a financial plan after consultation with experts, with further discussions planned regarding an actuarial study and management company options.
Report Facts
Capacity: 280
Census: 178
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Brown | Chief Executive Officer | Discussed financial plan and facility viability |
| Katie Anderson | Assistant Branch Chief | Spoke about financial situation and viability of the program |
Inspection Report
Monitoring
Census: 178
Capacity: 280
Deficiencies: 0
Nov 14, 2022
Visit Reason
The purpose of this office meeting was to discuss the agreed upon actions noted in the Compliance Plan dated April 25, 2022, including a review of the licensee’s 2nd Quarter Monitoring Report dated November 10, 2022, to determine its accuracy.
Findings
The meeting included discussions about financial documents and the licensee's plans regarding property sales and management company hiring. The licensee indicated no immediate plans to sell properties and intends to rely on a line of credit if a Federal Refund is delayed or not received.
Report Facts
Capacity: 280
Census: 178
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Present at the office meeting and named in the report |
| Luz Adams | Licensing Program Manager | Present at the office meeting and named in the report |
| Marina Stanic | Regional Manager | Present at the office meeting |
| Icela Estrada | Acting Assistant Program Administrator | Present at the office meeting |
| Allison Nakatomi | Staff Services Manager I | Present at the office meeting |
| Katie Anderson | Assistant Branch Chief | Asked about licensee's plan for sale of properties and management company |
| Randy Brown | Chief Executive Officer | Present at the office meeting |
| Michael Beeman | Chief Financial Officer | Present at the office meeting |
| Anna Hablitzel | Board Member | Present at the office meeting |
| Gary Johnson | Board Member | Present at the office meeting |
| Jeff Davis | Board Member | Present at the office meeting |
| Jim Stearman | Attorney | Present at the office meeting |
| Pamela Kaufmann | Attorney | Present at the office meeting |
| Mark Damon | Certified Public Accountant | Present at the office meeting |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 280
Deficiencies: 0
Oct 14, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility failed to address a resident's multiple falls.
Findings
The investigation found that the facility had implemented several procedures to address and prevent resident falls, including a Fall Management policy, the Fallen Stars program, and staff monitoring with alarms and bells. The allegation was deemed unfounded, meaning it was false or without reasonable basis.
Complaint Details
The complaint allegation was that the facility failed to address a resident's multiple falls. The allegation was investigated and deemed unfounded.
Report Facts
Complaint Control Number: 22-AS-20220914145127
Capacity: 280
Census: 169
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Claudia Lusca-Borcsa | Administrator | Interviewed during the investigation regarding fall management procedures |
Inspection Report
Census: 171
Capacity: 280
Deficiencies: 0
Oct 10, 2022
Visit Reason
The visit was an office type informal conference to discuss the 1st Quarterly Report dated August 23, 2022, improvements made and planned, expected additional funds and timeframe, and backup plans to ensure resources necessary to meet operating costs.
Findings
The report summarizes discussions held during the informal conference involving licensing and facility representatives about financial documentation, improvement plans including a 6-bed hospice facility and outpatient geriatric frailty syndrome rehabilitation program, and scheduling of the next informal conference.
Report Facts
Capacity: 280
Census: 171
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Present at the informal conference and named in the report |
| Alisa Ortiz | Licensing Program Manager | Present at the informal conference and named in the report |
| Marina Stanic | Regional Manager | Present at the informal conference and named in the report |
| Icela Estrada | Acting Assistant Program Administrator | Present at the informal conference and named in the report |
| Allison Nakatomi | Staff Services Manager I | Present at the informal conference and named in the report |
| Katie Anderson | Assistant Branch Chief | Present at the informal conference and named in the report |
| Randy Brown | Chief Executive Officer | Present at the informal conference and named in the report |
| Michael Beeman | Chief Financial Officer | Present at the informal conference and named in the report |
| Anna Hablitzel | Board Member | Present at the informal conference and named in the report |
| Gary Johnson | Board Member | Present at the informal conference and named in the report |
| Jeff Davis | Board Member | Present at the informal conference and named in the report |
| Jim Stearman | Attorney | Present at the informal conference and named in the report |
| Mark Damon | Certified Public Accountant | Present at the informal conference and named in the report |
Inspection Report
Census: 202
Capacity: 280
Deficiencies: 0
Oct 4, 2022
Visit Reason
The visit was an unannounced Case Management visit to discuss an Unusual Incident Report (LIC624) involving Staff 1 (S1) that was sent to the Orange County Adult and Senior Care Program Regional Office on September 28, 2022.
Findings
No deficiencies were cited during the Case Management visit. The Licensing Program Analyst reviewed Staff 1's Medication Training Certificates, Certificate log, and In-Service Training Tracking Log. An exit interview was conducted and a copy of the report was provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed training documentation. |
| Claudia Lusca-Borcsa | Administrator | Met with Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 200
Capacity: 280
Deficiencies: 0
Jul 6, 2022
Visit Reason
Licensing Program Analyst Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit.
Findings
The facility was found to be clean, well organized, and compliant with infection control requirements. No deficiencies were cited during the visit. The facility had proper screening stations, adequate PPE supplies, and maintained proper food storage and temperature logs.
Report Facts
Fire drill date: Jun 5, 2022
Hot water temperature range: 118.7
Hot water temperature range: 120
Perishable food supply duration: 2
Nonperishable food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the inspection and authored the report |
| Claudia Lusca-Borcsa | Administrator | Facility administrator present during the inspection and exit interview |
Inspection Report
Census: 200
Capacity: 280
Deficiencies: 0
Jul 6, 2022
Visit Reason
The visit was conducted as a Case Management visit to discuss an Unusual Incident Report (LIC 624) that was sent to the Orange County Adult and Senior Care Regional Office on July 1, 2022.
Findings
No deficiencies were cited during the Case Management visit. The Licensing Program Analyst reviewed relevant resident documents and conducted an exit interview with the facility administrator.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the unannounced case management visit and discussed the incident report. |
| Claudia Lusca-Borcsa | Administrator | Met with Licensing Program Analyst to discuss the incident report. |
Inspection Report
Census: 201
Capacity: 280
Deficiencies: 0
Mar 10, 2022
Visit Reason
The Licensing Program Analyst conducted an unannounced Case Management visit regarding an Unusual Incident Report received from the facility on 03/09/2022 involving a resident who was found bleeding from the nose.
Findings
The visit included interviews and review of documentation related to the incident. No deficiencies were cited at this time.
Report Facts
Incident date: Mar 3, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the unannounced visit and interviews |
| Claudia Lusca-Borcsa | Administrator | Facility Administrator interviewed during the visit |
Inspection Report
Complaint Investigation
Census: 186
Capacity: 280
Deficiencies: 0
Oct 25, 2021
Visit Reason
This unannounced case management visit was conducted to follow up on five incident reports involving resident falls and injuries reported between 9/17/2021 and 10/20/2021.
Findings
Based on observations during the visit, no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations.
Complaint Details
The visit addressed five incident reports involving residents who sustained injuries from falls, including hematoma, skin tears, head lacerations, and a hip fracture. Emergency personnel were contacted in each case, and some residents were transferred to hospitals or remain in skilled nursing care.
Report Facts
Incident reports: 5
Facility capacity: 280
Census: 186
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the case management visit |
| Claudia Lusca-Borcsa | Administrator / Executive Director | Spoke with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 182
Capacity: 280
Deficiencies: 0
Oct 8, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that a resident sustained a fall while in care.
Findings
The investigation found that Resident 1 fell on September 30, 2021, sustaining a hematoma to the head and was sent to the hospital the same day. The complaint was determined to be unfounded as there was no neglect by the facility and the fall was possibly due to a stroke and hypertension.
Complaint Details
The complaint alleged that a resident sustained a fall while in care. The investigation concluded the complaint was unfounded, meaning the allegation was false or without reasonable basis.
Report Facts
Facility capacity: 280
Census: 182
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation |
| Claudia Lusca-Borcsa | Executive Director | Interviewed during the investigation |
| Celeste Gonzalez | Administrative Assistant | Met with investigators and received report copy |
| Sheila Santos | Licensing Program Manager | Named in report |
Inspection Report
Census: 177
Capacity: 280
Deficiencies: 0
Aug 23, 2021
Visit Reason
The visit was an office informal conference to discuss financial and operational issues including clarifying line items in calculating the monthly burn rate and addressing outstanding issues from a previous meeting.
Findings
The report summarizes agreements on financial reporting methodologies, including what revenues and expenses can be included or deducted in calculating the monthly burn rate. It also outlines deadlines for the Licensee to provide additional financial information, projections, and responses related to grants, entrance fees, COVID-19 expenses, and corrective action plan milestones.
Report Facts
Capacity: 280
Census: 177
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Brown | Executive Director | Present at the informal conference |
| Michael Beeman | Chief Financial Officer | Present at the informal conference |
| Pam Kaufmann | Attorney | Present at the informal conference |
| Mark Damon | Certified Public Accountant | Present at the informal conference and explained his advisory role |
| Jim Stearman | Attorney | Present at the informal conference |
| Stan Leach | Licensee Board Member | Present at the informal conference |
| Bill Hendrickson | CDSS Financial Consultant | Present at the informal conference |
| William Young | Financial Analyst | Present at the informal conference |
| Paramjit Judge | Financial Analyst | Present at the informal conference |
| Marina Stanic | Licensing Program Analyst | Present at the informal conference and Licensing Program Analyst |
| Allison Nakatomi | Manager | Present at the informal conference |
| Katie Anderson | Assistant Branch Chief | Present at the informal conference |
| Robert Gomez | Licensing Program Manager | Named as Licensing Program Manager |
Inspection Report
Census: 175
Capacity: 280
Deficiencies: 0
Aug 11, 2021
Visit Reason
The visit was an office type informal conference to discuss the facility's unsound financial condition, board accountability, and short-term plans to ensure financial obligations are met, including compliance plan monitoring and restrictions on offering certain contracts.
Findings
The report details discussions with the Licensee regarding financial instability, plans for bridge funding, sale of properties to raise funds, and the establishment of financial goals and compliance plans. Agreements were made on monitoring duration, contract restrictions, and potential updates to the Corrective Action Plan.
Report Facts
Expected gross proceeds from property sales: 1600000
Capacity: 280
Census: 175
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Brown | Executive Director | Present at informal conference |
| Michael Beeman | Chief Financial Officer | Present at informal conference |
| Pam Kaufmann | Attorney | Present at informal conference |
| Mark Damon | Certified Public Accountant | Present at informal conference |
| Jim Stearman | Attorney | Present at informal conference |
| Don Allen | Licensee Board Member | Present at informal conference |
| Ann Hablitzel | Licensee Board Member | Present at informal conference |
| Jeff Davis | Licensee Board Member | Present at informal conference |
| Stan Leach | Licensee Board Member | Present at informal conference |
Inspection Report
Census: 175
Capacity: 280
Deficiencies: 0
Jul 20, 2021
Visit Reason
An unannounced case management-incident visit was conducted at the Continuing Care Retirement Community to assess compliance and mitigation plan adherence.
Findings
Facility staff were observed to follow the mitigation plan and had sufficient PPE supplies. No deficiencies were observed during this review as per Title 22 of the California Code of Regulations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerri Clark | Director of Operations | Met with during the visit and provided a tour of the facility. |
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