Inspection Reports for
Rowntree Gardens
12151 Dale St, Stanton, CA 90680, United States, CA, 90680
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
220% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
65% occupied
Based on a September 2024 inspection.
Occupancy over time
Inspection Report
Routine
Deficiencies: 16
Date: Dec 11, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, improper medication monitoring and administration, incomplete care plan implementation, inadequate infection control practices, insufficient staff competency verification, and food safety violations. Specific issues included improper storage of oxygen equipment, failure to implement nonpharmacological interventions for psychotropic medication use, inaccurate medical record documentation, and failure to maintain sanitary kitchen conditions.
Deficiencies (16)
Failed to ensure Resident 43's bed controller was within reach, risking unmet needs.
Failed to ensure monitoring for unnecessary psychotropic medications was specific and consistent for Residents 7 and 36.
Failed to implement care plan for safe storage of Resident 2's nasal cannula, risking contamination.
Failed to revise Resident 36's care plan to address specific care needs related to bladder and bowel incontinence.
Failed to administer budesonide medication as ordered for Resident 51 and failed to notify physician of missed dose.
Failed to provide appropriate care to maintain or improve range of motion for Resident 41 by not applying PRAFO boot as ordered.
Failed to ensure adequate supervision and accurate fall risk evaluation for Resident 26 after a fall.
Failed to obtain physician's order for oxygen administration and failed to store nasal cannula in sanitary condition for Residents 2 and 22.
Failed to provide and document nonpharmacological interventions prior to administering pain medication for Residents 5 and 10.
Failed to ensure licensed nurses had competency for PureWick external catheter use.
Failed to implement nonpharmacological interventions for Residents 7, 10, and 36 receiving psychotropic medications.
Failed to obtain levetiracetam oral solution timely and transcribed physician's order inaccurately for Resident 43.
Failed to ensure food safety and sanitation in kitchen including unclean equipment, expired food, improper labeling, and lack of air gap in food prep sink.
Failed to maintain accurate medical records for Residents 10, 29, and 43 including inaccurate documentation of medication administration, crying episodes, and skin assessments.
Failed to implement infection control program including incomplete infection surveillance, lack of Legionella testing protocols, improper PPE use, and failure to offer hand hygiene before meals.
Failed to implement antibiotic stewardship program properly by initiating McGeer's criteria only after antibiotic prescription rather than before.
Report Facts
Residents receiving food prepared in kitchen: 42
Episodes of crying spells: 97
McGeer's Criteria infection surveillance counts: 1
McGeer's Criteria infection surveillance counts: 2
McGeer's Criteria infection surveillance counts: 5
McGeer's Criteria infection surveillance counts: 3
McGeer's Criteria infection surveillance counts: 3
McGeer's Criteria infection surveillance counts: 2
McGeer's Criteria infection surveillance counts: 1
McGeer's Criteria infection surveillance counts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 5 | Licensed Vocational Nurse | Named in findings related to medication administration and refusal for Resident 43 |
| CNA 2 | Certified Nursing Assistant | Named in infection control PPE failure and nonpharmacological intervention implementation for Resident 7 |
| LVN 3 | Licensed Vocational Nurse | Named in transcription error of medication order for Resident 43 |
| LVN 1 | Licensed Vocational Nurse | Named in pain management and nonpharmacological intervention documentation findings |
| LVN 7 | Licensed Vocational Nurse | Named in psychotropic medication monitoring and nonpharmacological intervention findings for Resident 36 |
| IP | Infection Preventionist | Named in infection control surveillance and PPE findings |
| ADON | Assistant Director of Nursing | Named in multiple interviews acknowledging findings |
| DON | Director of Nursing | Named in multiple interviews acknowledging findings |
| Administrator | Facility Administrator | Named in multiple interviews acknowledging findings |
| LVN 6 | Licensed Vocational Nurse | Named in PureWick competency training findings |
| LVN 4 | Licensed Vocational Nurse | Named in psychotropic medication monitoring findings |
| LVN 2 | Licensed Vocational Nurse | Named in medical record documentation error for Resident 10 |
| DSS | Dietary Services Supervisor | Named in kitchen sanitation and food safety findings |
| Maintenance Technician | Maintenance Technician | Named in kitchen air gap and Legionella water management findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 10, 2025
Visit Reason
The inspection was conducted in response to a complaint that Resident 1 did not receive physical therapy (PT) services timely after discharge, specifically that the discharge team delayed sending required home health agency (HHA) referral documents.
Complaint Details
Complaint received on 1/30/25 stated Resident 1 did not receive PT services until the PT order was faxed on 1/29/25, indicating a 12-day delay by the discharge team. The complaint was substantiated by interviews and record reviews.
Findings
The facility failed to send the required discharge referral documents to the HHA for Resident 1, resulting in a 12-day delay before PT services were arranged. The SSD acknowledged forgetting to fax the documents until prompted by the resident's family, and the Director of Nursing was informed and acknowledged the findings.
Deficiencies (1)
Failure to send required discharge referral documents to the home health agency for one of three sampled residents, resulting in delayed ongoing care.
Report Facts
Days delay in sending discharge documents: 12
Pages faxed: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SSD | Acknowledged forgetting to fax required documents until family inquiry | |
| DON | Informed of and acknowledged the findings |
Inspection Report
Routine
Deficiencies: 15
Date: Oct 29, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for nursing home care, including resident rights, care planning, infection control, medication management, and safety.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity, inadequate care planning, improper medication administration and storage, failure to conduct entrapment risk assessments for bed rails, lapses in infection control practices, food safety violations, and incomplete antibiotic stewardship documentation.
Deficiencies (15)
Failure to promote dignity and respect for Resident 3 during meal assistance.
Failure to ensure call light was accessible to Resident 545, risking psychosocial well-being and delayed care.
Failure to provide Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to Resident 22.
Failure to develop comprehensive care plans addressing antibiotic use and infection prevention for Residents 35 and 37.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Resident 41, including failure to provide high protein snacks and protective barriers during wound care.
Failure to provide appropriate catheter care for Residents 37 and 41, including improper cleaning of PureWick catheter supplies and improper positioning of urinary catheter drainage bag.
Failure to conduct entrapment risk assessments and document bed dimensions for 13 residents using side rails, risking entrapment and injury.
Failure to ensure Certification of Infection Preventionist Training Course was current and nursing staff competency on PureWick catheter care.
Failure to ensure safe medication administration and documentation for Resident 42's controlled medications.
Medication administration errors by LVN 1 for Residents 11 and 29, including improper eye drop administration and failure to administer medication with food.
Failure to properly store and label medications and supplies, including expired medications, unlabeled ointments, and inaccurate temperature logs.
Failure to follow food safety and sanitation requirements in the kitchen, including improper handwashing, unlabeled and expired food, unclean equipment, and dirty ice machine.
Failure to provide safe food handling instructions to visitors bringing food and failure to maintain clean resident refrigerator.
Failure to ensure infection prevention and control practices including clean linen storage, proper cleaning of equipment, and hand hygiene during medication administration.
Failure to implement antibiotic stewardship program including assessment of McGeer's criteria for residents on antibiotics admitted from acute care hospitals.
Report Facts
Medication error rate: 8
Residents with side rails: 13
Missing temperature log entries: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Observed medication administration errors for Residents 11 and 29 |
| LVN 2 | Licensed Vocational Nurse | Observed medication administration lapses and improper cleaning of equipment |
| LVN 3 | Licensed Vocational Nurse | Acknowledged lack of knowledge and documentation on PureWick catheter care |
| LVN 4 | Licensed Vocational Nurse | Interviewed regarding use of bed rails for multiple residents |
| LVN 5 | Licensed Vocational Nurse | Observed respiratory care lapses for Resident 38 |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding meal assistance and call light accessibility |
| CNA 3 | Certified Nursing Assistant | Observed assisting Resident 3 to eat and interviewed about feeding practices |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding use of bed rails for Residents 15, 30, and 545 |
| CNA 5 | Certified Nursing Assistant | Interviewed regarding food preferences of Resident 25 |
| DON | Director of Nursing | Acknowledged multiple findings including infection control, medication errors, and entrapment assessments |
| RD | Registered Dietitian | Interviewed regarding food preferences and kitchen sanitation |
| DSD/Acting IP | Director of Staff Development / Acting Infection Preventionist | Interviewed regarding infection prevention training and antibiotic stewardship |
| RA | Risk Assessor | Interviewed regarding entrapment risk assessments and bed measurements |
| Food Services Director | Food Services Director | Interviewed regarding kitchen sanitation and food safety practices |
| ADON | Assistant Director of Nursing | Interviewed regarding medication storage and infection control practices |
Inspection Report
Annual Inspection
Census: 182
Capacity: 280
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Date: 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
Date: 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
Date: 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.
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.
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.
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
Date: Aug 28, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that jewelry was stolen from a resident.
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.
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.
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
Routine
Deficiencies: 18
Date: Mar 3, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, dietary services, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during care, improper medication administration and documentation, inadequate infection control practices, failure to properly prepare and serve pureed foods, unsafe bed rail assessments and maintenance, and deficiencies in kitchen sanitation and food safety practices.
Deficiencies (18)
Failure to ensure staff provided care and promoted dignity and respect, including entering resident rooms without knocking and improper feeding assistance.
Failure to determine if a resident was safe to self-administer medications, lacking assessment, physician order, and care plan.
Failure to maintain a copy of a resident's advance directives in the medical record.
Failure to notify the Long-Term Care Ombudsman of a resident's transfer to an acute care hospital.
Failure to provide accurate resident assessments, including errors in Minimum Data Set (MDS) coding.
Failure to provide necessary hospice care and communication with hospice agency, resulting in incomplete documentation and missed visits.
Failure to ensure safe and appropriate respiratory care, including improper labeling, storage, and changing of oxygen and nebulizer equipment.
Failure to provide appropriate pain management, including delay in administering pain medication available in the emergency kit.
Failure to provide safe and appropriate dialysis care, including failure to administer medications and supplements as ordered on dialysis days.
Failure to assess residents for safety risks related to bed rail use, including lack of entrapment risk assessments for residents with side rails.
Failure to provide pharmaceutical services meeting resident needs, including discrepancies between controlled medication count sheets and medication administration records, and failure to administer supplements as ordered.
Failure to follow puree food recipes, resulting in inconsistent puree product with excess liquid and thickener added, and prolonged holding times.
Failure to ensure puree food was prepared to preserve nutritive value, with excess water and thickener added and puree vegetables cooked and held for extended periods.
Failure to ensure entree substitutes provided equal nutritive value, with grilled cheese sandwiches having significantly less protein than the main entrée.
Failure to maintain sanitary conditions in the kitchen, including improper hand hygiene, improper storage of wiping cloths, lack of cooling logs, dirty ice machine, unlabeled food items, improper air drying of equipment, lack of hair restraints, plumbing issues, damaged utensils, dirty food carts, unclean knife rack, and improperly stored cleaning equipment.
Failure to implement and monitor quality assessment and assurance plans, including lack of documentation of staff training and monitoring of corrective actions for medication and food labeling deficiencies.
Failure to implement infection prevention and control program, including failure to perform hand hygiene during meal assistance and wound care, use of porous and damaged side rail pads, and poor infection control in laundry area.
Failure to regularly inspect all bed frames, mattresses, and bed rails for safety and entrapment risks, including lack of inspections after changes in bed or mattress and incomplete entrapment assessments.
Report Facts
Medication administration discrepancies: 6
Puree thickener scoops: 14
Resident count: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA 1 | Observed assisting two residents with meals simultaneously without performing hand hygiene | |
| CNA 1 | Observed entering resident rooms without knocking during dining observation | |
| LVN 1 | Verified findings related to respiratory equipment labeling and storage | |
| LVN 2 | Interviewed regarding pain medication administration delay | |
| LVN 3 | Interviewed regarding medication administration on dialysis days | |
| LVN 4 | Interviewed regarding hospice documentation and side rail assessments | |
| LVN 5 | Verified discrepancies in controlled medication count sheets and MARs | |
| Treatment Nurse | Observed failing to perform hand hygiene during wound care | |
| MT | Maintenance Technician | Interviewed regarding bed inspections and kitchen maintenance issues |
| DON | Director of Nursing | Interviewed regarding multiple findings including medication administration, infection control, and quality assurance |
| NSD | Nutrition Services Director | Interviewed regarding kitchen sanitation and food preparation practices |
| RDN | Registered Dietitian Nutritionist | Interviewed regarding puree food preparation and menu nutritional adequacy |
Inspection Report
Routine
Census: 46
Capacity: 49
Deficiencies: 14
Date: Mar 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfer notifications, bed-hold policies, and sanitary conditions in the kitchen.
Findings
The facility failed to notify the Long-Term Care Ombudsman of a resident's transfer to an acute care hospital and failed to inform the resident or representative about the bed-hold policy. Additionally, multiple sanitary deficiencies were found in the kitchen, including improper handwashing, inadequate sanitizing of wiping cloths, lack of cooling logs, unclean ice machine, unlabeled food items, improper air drying of equipment, lack of hair restraints, absence of backflow prevention, and poor maintenance of food service utensils and equipment.
Deficiencies (14)
Failed to notify the Long-Term Care Ombudsman of Resident 50's transfer to acute care hospital.
Failed to inform Resident 50 or representative of the facility's bed-hold policy upon transfer to acute care hospital.
Failed to ensure proper hand washing when preparing food.
Wiping cloths used to sanitize kitchen surfaces were not properly stored in sanitizing solution.
Failed to use a cool down procedure for Time/Temperature Control for Safety Foods.
Ice machine was not clean.
Food items in the freezer were not properly labeled.
Food preparation equipment was not air dried properly.
Dietary staff did not consistently use hair restraints.
Backflow prevention of two food preparation sinks was not properly maintained.
Food service utensils were not in good repair (e.g., chipped spatulas).
One food cart was unclean with crusty residue and rust.
Knife rack magnetic strip was rusty and needed replacement.
Cleaning equipment (broom) was improperly stored on the floor.
Report Facts
Residents receiving food prepared in kitchen: 46
Total residents in facility: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 4 | Interviewed regarding notification to Ombudsman and bed-hold policy; unable to provide fax confirmation or documentation | |
| MRD | Verified lack of fax confirmation for Ombudsman notification in Resident 50's medical record | |
| SSD | Verified absence of Bed Hold Informed Consent documentation for Resident 50 | |
| NSD | Verified multiple kitchen sanitation deficiencies including handwashing, wiping cloth storage, cooling logs, ice machine cleanliness, food labeling, air drying, hair restraints, backflow prevention, utensil repair, food cart cleanliness, knife rack condition, and cleaning equipment storage | |
| MT | Verified ice machine cleanliness issue | |
| RDN | Verified food cart cleanliness issues | |
| FSC | Verified lack of air gap in food preparation sinks |
Inspection Report
Monitoring
Census: 178
Capacity: 280
Deficiencies: 0
Date: 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
Date: 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
Date: 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.
Complaint Details
The complaint allegation was that the facility failed to address a resident's multiple falls. The allegation was investigated and deemed unfounded.
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.
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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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.
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.
Findings
Based on observations during the visit, no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations.
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
Date: 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.
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.
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.
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
Date: 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
Date: 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
Date: 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. |
Report
November 18, 2025
Viewing
Loading inspection reports...
