Inspection Reports for
Sage Glendale

525 W Elk Ave, Glendale, CA 91204, United States, CA, 91204

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Deficiencies (last 7 years)

Deficiencies (over 7 years) 1.1 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

73% better than California average
California average: 4 deficiencies/year

Deficiencies per year

4 3 2 1 0
2020
2021
2022
2023
2024
2025
2026

Census

Latest occupancy rate 65% occupied

Based on a January 2026 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy over time

0 30 60 90 120 Dec 2020 Feb 2023 Apr 2024 Feb 2025 Jan 2026

Inspection Report

Complaint Investigation
Census: 74 Capacity: 113 Deficiencies: 2 Date: Jan 30, 2026

Visit Reason
This case management visit was conducted in conjunction with a complaint investigation to address issues unrelated to the complaint, including concerns about insufficient staffing and failure to report incidents.

Complaint Details
The visit was conducted in conjunction with Complaint #31-AS-20250829141015. The complaint investigation revealed issues unrelated to the complaint, including staffing shortages and failure to report incidents. The complaint was substantiated as citations were issued.
Findings
The investigation found that the facility may have insufficient staffing at the assisted living unit, failed to report at least two serious incidents involving a former resident, and did not accommodate some residents for meal service while the elevator was out. Citations were issued accordingly.

Deficiencies (2)
Failure to report 2 serious incidents threatening the welfare, safety, or health of resident #1 as required by reporting regulations.
Failure to provide timely reasonable accommodation to residents during elevator outage, violating personal rights requirements.
Report Facts
Capacity: 113 Census: 74 Deficiencies cited: 2 Plan of Correction Due Date: Feb 13, 2026

Employees mentioned
NameTitleContext
Angela SmithAdministrator/DirectorFacility administrator named in report
Lindsay SchroederExecutive DirectorMet during inspection and involved in discussion of findings
Naira MargaryanLicensing Program ManagerConducted complaint investigation and issued citations
Antonia Alvizar-EttimaLicensing Program AnalystAssisted in complaint investigation and report creation

Inspection Report

Complaint Investigation
Census: 74 Capacity: 113 Deficiencies: 0 Date: Jan 30, 2026

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-07-14 regarding staffing levels and confidentiality of phone calls at the facility.

Complaint Details
The complaint alleged that the facility did not ensure enough staff to meet residents' needs, particularly in the Memory Care unit, and that residents were unable to receive confidential phone calls. The allegations were found unsubstantiated based on interviews, observations, and records.
Findings
The investigation found insufficient evidence to substantiate the allegations of inadequate staffing and failure to ensure residents could receive confidential phone calls. Observations, interviews, and records review indicated adequate staffing and proper phone call handling.

Report Facts
Capacity: 113 Census: 74

Employees mentioned
NameTitleContext
Angela SmithAdministratorInterviewed regarding staffing levels
Antonia Alvizar-EttimaLicensing Program AnalystConducted the complaint investigation
Naira MargaryanLicensing Program ManagerConducted the complaint investigation
Lindsay SchroederExecutive DirectorMet with investigators during the visit

Inspection Report

Complaint Investigation
Census: 78 Capacity: 113 Deficiencies: 1 Date: Jul 18, 2025

Visit Reason
The visit was a complaint investigation related to staff working without criminal background clearance and association to the facility, triggered by complaint #31-AS-20250714121426.

Complaint Details
Complaint investigation was triggered by complaint #31-AS-20250714121426. The complaint involved staff working without criminal background clearance and association to the facility. The complaint was substantiated as deficiencies were found.
Findings
The investigation found that two staff members (S1 and S2) were present without proper criminal background clearance and association to the facility. Staff S1 left the facility and will not return, while staff S2 was cleared during the visit. A citation and civil penalty were issued.

Deficiencies (1)
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working in a licensed facility request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as staff S1 and S2 were not criminal background cleared and associated to the facility.
Report Facts
Census: 78 Total Capacity: 113 Plan of Correction Due Date: Jul 21, 2025

Employees mentioned
NameTitleContext
Michelle L. ConnotEntrim Executive Director of sister communityStaff S1 found working without clearance; left facility and will not return
Dawn Irene MonahanStaff S2 found working without clearance initially but cleared during visit
Syrina CanezMemory Care DirectorFacility representative who received the report and citation
Antonia Alvizar-EttimaLicensing Program AnalystConducted the complaint investigation and authored the report
Naira MargaryanLicensing Program ManagerOversaw the licensing program related to this inspection

Inspection Report

Complaint Investigation
Census: 78 Capacity: 113 Deficiencies: 1 Date: Jul 18, 2025

Visit Reason
The visit was an initial complaint investigation triggered by complaint #31-AS-20250714121426 regarding staff presence without criminal background clearance and association to the facility.

Complaint Details
Complaint investigation was initiated based on complaint #31-AS-20250714121426. The complaint was substantiated by the finding that staff were present without criminal background clearance and association to the facility.
Findings
The investigation found two staff members (S1 and S2) present without proper criminal background clearance and association to the facility. Staff S1 was not returning to the facility, while S2 was cleared and associated during the visit. A citation and civil penalty were issued.

Deficiencies (1)
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working in a licensed facility request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by staff S1 and S2 not having criminal background clearance and association to this facility.
Report Facts
Census: 78 Total Capacity: 113 Deficiencies cited: 1

Employees mentioned
NameTitleContext
Michelle L. ConnotEntrim Executive Director of sister community in NebraskaStaff S1 found present without criminal background clearance and association
Dawn Irene MonahanStaff S2 found initially without clearance but cleared during visit
Syrina CanezMemory Care DirectorFacility representative who received copy of report
Antonia Alvizar-EttimaLicensing Program AnalystConducted complaint investigation and authored report
Naira MargaryanLicensing Program ManagerNamed in report header and deficiency section

Inspection Report

Annual Inspection
Census: 75 Capacity: 113 Deficiencies: 0 Date: Mar 25, 2025

Visit Reason
The inspection was an unannounced case management annual continuation visit conducted to complete the required 1-year inspection initiated on 2025-02-10.

Findings
The Licensing Program Analyst toured the facility to ensure no health and safety hazards were present. Several active COVID-19 cases were reported. Resident and staff records reviewed were complete and had required clearances and certifications. No deficiencies were explicitly noted in the report.

Report Facts
Residents records reviewed: 7 Staff files reviewed: 5

Employees mentioned
NameTitleContext
Angela SmithAdministrator/DirectorNamed as facility administrator/director
Peter BonillaExecutive DirectorMet with Licensing Program Analyst during inspection
Antonia Alvizar-EttimaLicensing Program AnalystConducted the inspection visit
Naira MargaryanLicensing Program ManagerNamed on report

Inspection Report

Annual Inspection
Census: 75 Capacity: 113 Deficiencies: 0 Date: Mar 25, 2025

Visit Reason
The visit was an unannounced case management Annual Continuation inspection conducted to complete the required 1-year inspection initiated on 2025-02-10.

Findings
The Licensing Program Analyst toured the facility to ensure no health and safety hazards were present, reviewed seven resident records and five staff files, all of which were complete and compliant at the time of the visit. Several active COVID-19 cases were noted in the facility.

Report Facts
Residents' records reviewed: 7 Staff files reviewed: 5

Employees mentioned
NameTitleContext
Peter BonillaExecutive DirectorMet during inspection and discussed visit purpose
Antonia Alvizar-EttimaLicensing Program AnalystConducted the inspection visit

Inspection Report

Census: 81 Capacity: 113 Deficiencies: 0 Date: Feb 10, 2025

Visit Reason
The case management visit was conducted to ensure the safety and welfare of evacuees from the RCFE-Continuing Care Retirement Community Montecedro due to the Eaton Fire.

Findings
No immediate health or safety hazards were observed during the visit. Interviews with four out of five residents from Montecedro indicated they are doing well and their needs are being met by Sage Glendale and Montecedro.

Employees mentioned
NameTitleContext
Peter BonillaExecutive DirectorMet with Licensing Program Analyst during the visit.
Antonia Alvizar-EttimaLicensing Program AnalystConducted the unannounced case management visit.
Naira MargaryanSupervisorSupervisor overseeing the licensing evaluation.

Inspection Report

Annual Inspection
Census: 81 Capacity: 113 Deficiencies: 0 Date: Feb 10, 2025

Visit Reason
An unannounced Required One (1) year inspection visit was conducted to evaluate compliance with Title 22 Regulations and ensure health and safety standards at the facility.

Findings
The facility was found to be in compliance with health and safety regulations with no hazards or deficiencies noted during the physical plant inspection. All areas including kitchen, dining, laundry, medication storage, bedrooms, bathrooms, common areas, and surrounding grounds were observed to be clean, functional, and secure. No health and safety issues were identified at the time of the visit.

Report Facts
Fire extinguisher last inspection date: Apr 25, 2024 Fire drill last conducted: Jan 8, 2025 Residents interviewed: 8 Hot water temperature range (°F): 106.3-119.3 Perishable food supply duration (days): 2 Non-perishable food supply duration (days): 7

Employees mentioned
NameTitleContext
Antonia Alvizar-EttimaLicensing Program AnalystConducted the unannounced Required One (1) year inspection visit.
Peter BonillaExecutive DirectorMet with Licensing Program Analyst during the inspection and received the report.

Inspection Report

Census: 81 Capacity: 113 Deficiencies: 0 Date: Feb 10, 2025

Visit Reason
The case management visit was conducted to ensure the safety and welfare of evacuees from the RCFE-Continuing Care Retirement Community Montecedro due to the Eaton Fire.

Findings
No immediate health or safety hazards were observed during the visit. Interviews with four out of five evacuee residents indicated they are doing well and that Sage Glendale is meeting their needs while Montecedro is providing the service.

Employees mentioned
NameTitleContext
Peter BonillaExecutive DirectorMet with Licensing Program Analyst during the visit.
Antonia Alvizar-EttimaLicensing Program AnalystConducted the unannounced case management visit.
Naira MargaryanLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Annual Inspection
Census: 81 Capacity: 113 Deficiencies: 0 Date: Feb 10, 2025

Visit Reason
An unannounced required one-year inspection visit was conducted to evaluate compliance with Title 22 regulations and ensure health and safety standards at the facility.

Findings
The facility was found to be in good repair with no health and safety hazards noted. Physical plant areas, kitchen, dining, medication storage, resident bedrooms, bathrooms, common areas, and surrounding grounds were all observed to be clean, functional, and compliant. Fire safety equipment was current and functional. The inspection was not fully completed due to time constraints and will be continued later.

Report Facts
Fire extinguisher last inspection date: Apr 25, 2024 Fire drill last conducted: Jan 8, 2025 Residents interviewed: 8 Hot water temperature range (Fahrenheit): 106.3-119.3 Perishable food supply duration (days): 2 Non-perishable food supply duration (days): 7

Employees mentioned
NameTitleContext
Antonia Alvizar-EttimaLicensing Program AnalystConducted the inspection and met with Executive Director
Peter BonillaExecutive DirectorMet with Licensing Program Analyst during inspection
Naira MargaryanLicensing Program ManagerNamed in report header and signature section

Inspection Report

Complaint Investigation
Census: 113 Capacity: 113 Deficiencies: 2 Date: Oct 16, 2024

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that facility staff were mismanaging a resident's medication and not cleaning the resident's room.

Complaint Details
The complaint investigation was substantiated. Allegations included mismanagement of Resident #1's medication and failure to clean the resident's room. Both allegations were verified based on record reviews, staff interviews, and physical plant tour.
Findings
The investigation substantiated both allegations: the facility failed to assist Resident #1 with self-administered medications as prescribed, and the resident's room was not cleaned for an extended period due to staff miscommunication. No other health and safety hazards were noted during the visit.

Deficiencies (2)
The licensee did not assist Resident #1 with self-administered medications as prescribed, posing a potential health and safety and personal right risk.
The facility was not clean, safe, sanitary, and in good repair as Resident #1's room was not cleaned for an extended time.
Report Facts
Capacity: 113 Census: 113 Plan of Correction Due Date: Oct 18, 2024

Employees mentioned
NameTitleContext
Abeye DugumaLicensing Program AnalystConducted the complaint investigation and authored the report
Angela SmithAdministratorFacility administrator named in the report and responsible for plan of correction
Becky LangdonMet with Licensing Program Analyst during the investigation

Inspection Report

Annual Inspection
Census: 69 Capacity: 113 Deficiencies: 0 Date: Jul 3, 2024

Visit Reason
Licensing Program Analyst Rosaura Valenzuela conducted an unannounced 1 year required inspection visit to evaluate compliance with licensing regulations.

Findings
The facility was found to be operating within capacity limits with no health and safety issues noted. Fire and carbon monoxide detectors were operational, medication storage was secure, and the environment was free of hazards and obstructions.

Report Facts
First aid kits: 8 Fire extinguisher service date: 2024 Facility capacity: 113 Facility census: 69

Employees mentioned
NameTitleContext
Angela SmithAdministratorMet with Licensing Program Analyst during inspection
Rosaura ValenzuelaLicensing Program AnalystConducted the inspection visit
Naira MargaryanSupervisorSupervisor named in the report

Inspection Report

Annual Inspection
Census: 69 Capacity: 113 Deficiencies: 0 Date: Jul 3, 2024

Visit Reason
An unannounced 1 year required inspection visit was conducted to evaluate compliance with licensing regulations for the Sage Glendale Senior Living Facility.

Findings
The facility was found to be operating within capacity limits with no health and safety issues noted. Fire safety equipment was operational and up to date, resident rooms were properly furnished, and medication storage was secure. Passageways were free of obstructions and environmental conditions met regulatory standards.

Report Facts
Capacity: 113 Census: 69 First aid kits: 8 Fire extinguisher service date: 2024

Employees mentioned
NameTitleContext
Angela SmithAdministratorMet with Licensing Program Analyst during inspection
Rosaura ValenzuelaLicensing Program AnalystConducted the inspection visit
Naira MargaryanLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 60 Capacity: 113 Deficiencies: 0 Date: Apr 26, 2024

Visit Reason
An unannounced complaint investigation was conducted to investigate an allegation that the facility took payment but did not admit a resident to the facility.

Complaint Details
The complaint alleged that the facility took payment but did not admit the resident. The allegation was found unsubstantiated based on the investigation and record review.
Findings
The investigation revealed that the resident's family member decided not to move the resident to the facility despite paying over $9,000. The allegation was deemed unsubstantiated as the facility was about to refund the money but the payment check had bounced.

Report Facts
Payment amount: 9250 Capacity: 113 Census: 60

Employees mentioned
NameTitleContext
Jose Gary TanLicensing Program AnalystConducted the complaint investigation
Angela Monette-SmithExecutive DirectorMet with Licensing Program Analyst during investigation
Troy AgardSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 60 Capacity: 113 Deficiencies: 0 Date: Apr 26, 2024

Visit Reason
An unannounced complaint investigation was conducted to investigate an allegation that the facility took payment but did not admit a resident.

Complaint Details
The complaint alleged that the facility took payment but did not admit the resident. The allegation was found unsubstantiated after investigation.
Findings
The investigation found that the resident's family member paid over $9,000 for admission but decided not to move the resident to the facility. The allegation was deemed unsubstantiated as the facility was about to refund the payment, but the refund was not issued due to a bounced check.

Report Facts
Payment amount: 9250 Capacity: 113 Census: 60

Employees mentioned
NameTitleContext
Jose Gary TanLicensing Program AnalystConducted the complaint investigation
Angela Monette-SmithExecutive DirectorMet with Licensing Program Analyst during investigation
Troy AgardLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Follow-Up
Census: 63 Capacity: 113 Deficiencies: 0 Date: Apr 8, 2024

Visit Reason
An unannounced Case Management Incident visit was conducted to follow up on an incident report submitted on 04/04/2024 regarding Resident #1 who had an alleged medication overdose.

Findings
The investigation revealed that Resident #1 was still hospitalized and awaiting discharge. Records showed the resident is depressed and approved to self-administer medication. Hospital blood work was unremarkable and it was determined the resident did not ingest the reported medication. No health and safety issues were noted.

Employees mentioned
NameTitleContext
Mary Lou DominguezLVNMet with Licensing Program Analyst during the visit and provided information about Resident #1.
Rosaura ValenzuelaLicensing Program AnalystConducted the unannounced Case Management Incident visit.

Inspection Report

Follow-Up
Census: 63 Capacity: 113 Deficiencies: 0 Date: Apr 8, 2024

Visit Reason
An unannounced Case Management Incident visit was conducted to follow-up on an incident report submitted regarding Resident #1 who allegedly overdosed on prescribed medication.

Complaint Details
The visit was triggered by a complaint incident report submitted on 04/04/2024 regarding an alleged medication overdose by Resident #1. The report was unsubstantiated as the resident did not ingest the medication.
Findings
The investigation revealed that Resident #1 is still hospitalized and awaiting discharge orders. Records showed the resident is depressed and approved to self-administer medication. Hospital blood work was unremarkable and it appears the resident did not ingest the reported medication. No health and safety issues were noted.

Report Facts
Facility capacity: 113 Census: 63

Employees mentioned
NameTitleContext
Mary Lou DominguezLVNMet with Licensing Program Analyst during inspection and provided information about Resident #1
Rosaura ValenzuelaLicensing Program AnalystConducted the unannounced Case Management Incident visit
Naira MargaryanLicensing Program ManagerNamed in the exit interview section of the report

Inspection Report

Complaint Investigation
Census: 55 Capacity: 113 Deficiencies: 0 Date: Feb 22, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that staff did not prevent a resident from being sexually abused while in care.

Complaint Details
The allegation was that a resident was touched inappropriately by a male staff member. Interviews with 7 of 60 staff, 5 of 55 residents, and 2 witnesses were conducted. None of the staff or residents interviewed confirmed the allegation. One witness stated the event happened based on what was told by the resident but was unaware of the alleged perpetrator. The resident denied any abuse. The allegation was determined to be unsubstantiated.
Findings
The investigation included interviews with staff, residents, and witnesses, as well as a review of records and the physical plant. No preponderance of evidence was found to substantiate the allegation, and the facility was observed to be in good repair with no reports or observations confirming the alleged sexual abuse.

Report Facts
Staff interviewed: 7 Residents interviewed: 5 Facility capacity: 113 Facility census: 55

Employees mentioned
NameTitleContext
Troy AgardLicensing Program AnalystConducted the complaint investigation
Angela SmithMet with Licensing Program Analyst during investigation
Angela J KendrickSupervisorSupervisor overseeing the investigation
Martha BerardAdministratorFacility administrator

Inspection Report

Complaint Investigation
Census: 55 Capacity: 113 Deficiencies: 0 Date: Feb 22, 2023

Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-01-17 alleging that staff did not prevent a resident from being sexually abused while in care.

Complaint Details
The complaint alleged that a resident was touched inappropriately by a male staff member. Interviews with staff, residents, and witnesses did not confirm the allegation. The resident involved denied any abuse. The allegation was unsubstantiated due to lack of sufficient evidence.
Findings
The investigation included interviews with staff, residents, and witnesses, as well as a review of records and observations. No preponderance of evidence was found to substantiate the allegation of sexual abuse, and the allegation was determined to be unsubstantiated.

Report Facts
Staff interviewed: 7 Staff unavailable for interview: 2 Witnesses interviewed: 2 Residents interviewed: 5 Residents unavailable for interview: 1

Employees mentioned
NameTitleContext
Troy AgardLicensing Program AnalystConducted the complaint investigation and authored the report.
Angela SmithMet with the Licensing Program Analyst during the investigation.
Angela J KendrickLicensing Program ManagerNamed as Licensing Program Manager on the report.

Inspection Report

Complaint Investigation
Census: 53 Capacity: 113 Deficiencies: 0 Date: Feb 13, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-05-26 concerning resident care and facility conditions at Sage Glendale Senior Living.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included non-working emergency buttons, unwitnessed falls, residents left unattended, insufficient food, non-working motion detectors, inadequate staffing, and staff neglect. All were denied by staff and not corroborated by residents or records.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations, including issues with emergency buttons, unwitnessed falls, unattended residents, insufficient food, non-functioning motion detectors, inadequate staffing, and staff neglect. All allegations were determined to be unsubstantiated based on staff and resident interviews, observations, and record reviews.

Report Facts
Capacity: 113 Census: 53 Staff interviewed: 6 Residents interviewed: 5 Memory care unit residents: 17 Caregiving staff in memory care unit: 4 Med tech staff in memory care unit: 1

Employees mentioned
NameTitleContext
Jose VillalobosLicensing Program AnalystConducted the complaint investigation visit
Angela Monette-SmithAdministratorMet with Licensing Program Analyst during investigation
Fernando FierrosSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 53 Capacity: 113 Deficiencies: 0 Date: Feb 13, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 2022-05-26 regarding resident care issues including emergency buttons not working, unwitnessed falls, residents left unattended, insufficient food, non-functioning motion detectors, staffing shortages, and staff neglect.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included emergency buttons not working, unwitnessed falls, residents left unattended, insufficient food, motion detectors not working, inadequate staffing, and staff neglect. Interviews with 6 staff and 5 residents, observations, and record reviews did not corroborate the allegations. No incident reports or evidence supported the claims.
Findings
The investigation included interviews with staff and residents, observations, and record reviews. All allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove the alleged violations did or did not occur.

Report Facts
Staff interviewed: 6 Residents interviewed: 5 Memory care unit residents: 17 Caregiving staff: 3 Med tech staff: 1 Caregiving staff observed: 4 Med tech staff observed: 1

Employees mentioned
NameTitleContext
Jose VillalobosLicensing Program AnalystConducted the complaint investigation visit
Fernando FierrosLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation
Angela Monette-SmithAdministratorMet with Licensing Program Analyst during the investigation

Inspection Report

Annual Inspection
Census: 35 Capacity: 113 Deficiencies: 1 Date: Mar 15, 2022

Visit Reason
Licensing Program Analyst Alberto Lopez conducted an unannounced Required 1-year visit focusing on COVID-19 Infection Control Practices.

Findings
The facility was inspected for infection control and safety practices, with observations including posted COVID-19 signs, visitor screening, water temperature issues, availability of PPE, and food supply. Deficiencies were noted related to water temperature regulation in resident faucets.

Deficiencies (1)
Water temperature in the 1st floor restroom sinks measured 74 degrees F, which is below the required minimum of 105 degrees F, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Water temperature: 74 Deficiencies cited: 1 POC Due Date: Mar 25, 2022

Employees mentioned
NameTitleContext
Alberto LopezLicensing Program AnalystConducted the inspection and authored the report
Elizabeth WhittingtonAdministratorFacility administrator met during inspection and exit interview
Christine YeeSupervisorSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 35 Capacity: 113 Deficiencies: 1 Date: Mar 15, 2022

Visit Reason
The inspection was an unannounced required 1-year visit focusing on COVID-19 Infection Control Practices at Sage Glendale Senior Living Facility.

Findings
The inspection found that COVID-19 signage and infection control measures were generally in place, but water temperature in the first floor restrooms was below the required range, posing an immediate health and safety risk. Deficiencies were cited related to water temperature regulation.

Deficiencies (1)
Water temperature in the 1st floor restroom sinks measured 74 degrees F, which is below the required minimum of 105 degrees F, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Deficiency due date: Mar 25, 2022 Census: 35 Total Capacity: 113

Employees mentioned
NameTitleContext
Elizabeth WhittingtonAdministratorAdministrator present during inspection and exit interview
Alberto LopezLicensing Program AnalystConducted the inspection
Christine YeeLicensing Program ManagerSupervisor overseeing the inspection

Inspection Report

Original Licensing
Capacity: 113 Deficiencies: 0 Date: Mar 4, 2021

Visit Reason
The inspection was conducted as a pre-licensing visit for initial licensing of a Residential Care Facility for the Elderly.

Findings
The facility was found to be clean, sanitary, and in good repair with no observed items of noncompliance with applicable laws and regulations. Safety features such as fire extinguishers, smoke detectors, and carbon monoxide detectors were operational, and emergency plans and supplies were in place.

Report Facts
Capacity: 113 Census: 0 Hospice waiver: 2 Non-ambulatory residents: 113 Bedridden residents: 9

Employees mentioned
NameTitleContext
Elizabeth WhittingtonExecutive DirectorMet with during inspection
Kruz LongLicensing Program AnalystConducted the pre-licensing inspection
Fernando FierrosLicensing Program ManagerNamed in report header

Inspection Report

Original Licensing
Capacity: 113 Deficiencies: 0 Date: Dec 14, 2020

Visit Reason
Initial licensing evaluation visit for a Residential Care Facility for the Elderly with delayed egress application type.

Findings
The applicant and administrator participated in a comprehensive licensing interview (COMP II) confirming understanding of Title 22 regulations, facility operation, staff qualifications, program policies, and application document requirements. The evaluation was successfully completed with no deficiencies noted.

Employees mentioned
NameTitleContext
Martha BerardAdministratorApplicant and administrator who participated in the licensing evaluation and COMP II call.
Jude De La ConcepcionLicensing Program ManagerNamed as Licensing Program Manager overseeing the evaluation.
Bethany HunterLicensing Program AnalystConducted the COMP II call and signed the evaluation report.

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