Inspection Report Summary
Most inspections found deficiencies related primarily to staffing shortages, delayed medical care, medication management errors, and failure to respond promptly to resident call pendants. Several investigations substantiated neglect contributing to serious outcomes, including a resident choking to death in early 2023, which resulted in civil penalties totaling at least $24,500. Other issues involved inadequate staff training, unsafe storage of cleaning supplies and medications, and isolated food safety concerns. Many complaints about environment and care needs were unsubstantiated, and some improvements were noted, such as no deficiencies cited in the most recent October 27, 2025 follow-up report. While serious enforcement actions occurred earlier, recent visits show some progress though staffing and care response remain key areas of concern.
Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 104
Capacity: 145
Deficiencies: 0
Oct 27, 2025
Visit Reason
The inspection was conducted as a follow-up on a self-reported death incident involving Resident #1, who was found unresponsive in the memory care unit on 2024-11-02.
Findings
The Licensing Program Analyst conducted interviews, file reviews, and document collection related to the incident. Further investigation is required before issuing any findings.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Met with Licensing Program Analyst during the inspection and was involved in interviews related to the incident. |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection visit and interviews. |
| Betsy McCoy | Administrator/Director | Named as facility administrator/director in the report header. |
Inspection Report
Follow-Up
Census: 104
Capacity: 145
Deficiencies: 1
Oct 21, 2025
Visit Reason
The inspection was an unannounced follow-up visit to a substantiated complaint investigation regarding neglect and lack of care that resulted in a resident's death.
Findings
The Department determined that a civil penalty is warranted due to the facility's failure to ensure sufficient competent personnel were present to meet the resident's needs, resulting in the resident choking to death. A civil penalty of $14,500 was issued in addition to a prior $500 penalty.
Complaint Details
The complaint investigation was substantiated, involving neglect and lack of care and supervision where Resident (R1) choked to death without medical intervention while under facility care.
Deficiencies (1)
| Description |
|---|
| Violation of California Code of Regulations (CCR) 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. |
Report Facts
Civil penalty amount: 14500
Immediate civil penalty amount: 500
Facility capacity: 145
Resident census: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Met with Licensing Program Analyst during inspection and named in findings related to failure to ensure sufficient competent personnel |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and signed the report |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 145
Deficiencies: 1
Aug 28, 2025
Visit Reason
An unannounced Case Management - Incident inspection was conducted regarding a self-reported Report of Suspected Elder Abuse (SOC341) involving a resident with an infected wound that was not treated in a timely manner.
Findings
The licensee failed to provide timely medical care to a resident with an infected wound, leaving the resident untreated for over 10 days, which posed an immediate safety and personal rights risk. The resident was eventually hospitalized for cellulitis and wound infection.
Complaint Details
The complaint involved a self-reported suspected elder abuse regarding a resident's infected wound that staff failed to report or advocate for timely medical evaluation. The complaint was substantiated by findings that the resident was left untreated for over 10 days.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Based on self reported SOC341, the licensee did not comply with the section cited above, as resident was left with an infected wound for over 10 days before getting medical care which posed an immediate safety, and personal rights risk to residents in care. | Type A |
Report Facts
Capacity: 145
Days untreated: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Met with Licensing Program Analyst during inspection and involved in discussion of incident |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Annual Inspection
Census: 93
Capacity: 145
Deficiencies: 0
Aug 28, 2025
Visit Reason
The inspection visit was an unannounced Case Management - Annual Continuation visit to continue the inspection that began on 11/18/2024.
Findings
A medication audit was conducted for two residents, revealing that some medications were not properly documented on the centrally stored medications and destruction record (CSMDR), including missing start dates and fill dates. However, all information was available on the facility's online system. No deficiencies were cited at this time.
Report Facts
Residents audited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and medication audit |
| Christian Castillo | Executive Director | Met with Licensing Program Analyst during the inspection |
| Betsy McCoy | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 145
Deficiencies: 1
Aug 13, 2025
Visit Reason
An unannounced Case Management - Incident inspection was conducted regarding a self-reported Unusual Incident/Injury Report (UIR) about missed medications for Resident #1 on 08/05/2025 and 08/06/2025.
Findings
The inspection found that Resident #1 did not receive prescribed Synthroid medication on two separate days due to a staff error in updating medication orders. The resident showed no symptoms or reactions, and staff received medication training. A Type B deficiency was cited for failure to assist residents with self-administered medications as required.
Complaint Details
The visit was complaint-related due to a self-reported Unusual Incident/Injury Report about missed medications for Resident #1. The complaint was substantiated with a cited deficiency.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, evidenced by Resident #1 not receiving ordered medication on two separate days. | Type B |
Report Facts
Census: 102
Total Capacity: 145
Deficiency count: 1
Plan of Correction Due Date: Aug 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Interviewed during inspection regarding medication incident |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kasandra Lopez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 145
Deficiencies: 0
Aug 13, 2025
Visit Reason
An unannounced Case Management - Incident inspection was conducted regarding two self-reported Unusual Incident/Injury Reports involving Resident #1 who sustained falls and injuries on 07/21/2025 and 07/23/2025.
Findings
The inspection found no immediate health and safety concerns during the visit. Resident #1 was reported to have sustained a left rib fracture on the second fall, with safety precautions such as hourly checks and 1:1 supervision in place. The Licensing Program Analyst will return if warranted.
Complaint Details
The visit was triggered by two self-reported Unusual Incident/Injury Reports concerning Resident #1's falls and injuries. The report includes details of the incidents, safety measures implemented, and interviews with facility staff. No substantiation status is explicitly stated.
Report Facts
Capacity: 145
Census: 102
Incident dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Met with Licensing Program Analyst during inspection and involved in interviews |
| Gina Taylor | Director of Nursing | Provided information about Resident #1's injuries and safety measures during phone interview and on-site |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and interviews |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 145
Deficiencies: 0
May 19, 2025
Visit Reason
The inspection was an unannounced Case Management - Incident visit triggered by two self-reported Unusual Incident/Injury Reports involving two residents who sustained injuries requiring hospital evaluation and treatment.
Findings
The Licensing Program Analyst conducted interviews and reviewed pertinent information during the visit. No immediate health and safety concerns were observed, and the Licensing Program Analyst indicated a return visit if warranted.
Complaint Details
The visit was complaint-related due to two incidents: Resident #1 was found sitting on the floor with hip pain and later diagnosed with a fractured pelvis; Resident #2 was found lying on the ground with bleeding around the ear and was admitted for two small subdermal brain bleeds. Both incidents were self-reported by the facility.
Report Facts
Number of residents involved in incidents: 2
Number of staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Met with Licensing Program Analyst during inspection and interviewed regarding incidents |
| Esther Cortez | Licensing Program Analyst | Conducted the unannounced Case Management - Incident inspection |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 145
Deficiencies: 5
Mar 24, 2025
Visit Reason
Unannounced inspection to follow up on a substantiated allegation of a complaint investigation regarding staff failures in reporting changes in resident condition, timely medical attention, medication management, and resident care.
Findings
The facility was cited for multiple violations of California Code of Regulations related to resident observation, reappraisals, basic services, incidental medical care, and food service requirements. A civil penalty of $9,500 was issued for serious bodily injury due to failure to seek guidance for a resident's condition changes resulting in dehydration, acute kidney injury, and hospitalization.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to report condition changes, delayed medical attention, medication mismanagement, unmet resident needs, and multiple falls. A civil penalty was issued for serious bodily injury.
Deficiencies (5)
| Description |
|---|
| Staff did not report a change in condition to resident's authorized representative |
| Staff did not seek medical attention for resident in a timely manner |
| Staff mismanaged resident's medication |
| Staff did not ensure that resident's needs were met |
| Resident fell multiple times while in care |
Report Facts
Civil penalty amount: 9500
Immediate civil penalty amount: 500
Weight loss: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Met during inspection and acknowledged receipt of appeal rights |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection and signed the report |
| Betsy McCoy | Administrator/Director | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 145
Deficiencies: 0
Mar 14, 2025
Visit Reason
The visit was conducted as a case management investigation regarding a self-reported incident on 2025-03-02 involving a resident who took a bottle of pills and required paramedic intervention.
Findings
The Licensing Program Analyst conducted interviews, a file review, and a medication audit related to the incident. No citations were issued during this visit, and further investigation is planned with a return visit scheduled.
Complaint Details
The investigation was triggered by a self-reported incident on 2025-03-02 where Resident 1 took a bottle of pills and was transported to the hospital. The resident had left the community on 2025-02-18 and returned on 2025-02-27 without disclosing a prescription filled outside the facility on 2025-02-19. The complaint remains under further investigation.
Report Facts
Incident date: Mar 2, 2025
Resident absence dates: Feb 18, 2025
Resident return date: Feb 27, 2025
Prescription fill date: Feb 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Administrator | Met with Licensing Program Analyst during the investigation |
| Esther Cortez | Licensing Program Analyst | Conducted the case management visit and investigation |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 145
Deficiencies: 0
Jan 9, 2025
Visit Reason
The inspection was conducted as a follow-up on a self-reported death report received on 2024-11-05 concerning the death of Resident #1, who was found unresponsive on 2024-11-02 in the memory care unit.
Findings
The Licensing Program Analyst conducted an unannounced case management incident visit, interviewed the Executive Director, toured the facility, and obtained pertinent documents. The incident was referred to the Community Care Licensing Investigations Branch for further review if warranted.
Complaint Details
The visit was complaint-related, following up on a self-reported death incident. The report was referred to the Investigations Branch for further review, with no substantiation status explicitly stated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Met with during the inspection and interviewed regarding the incident. |
| Esther Cortez | Licensing Program Analyst | Conducted the unannounced case management incident visit. |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 145
Deficiencies: 0
Jan 9, 2025
Visit Reason
The inspection was conducted as a follow-up on a self-reported death report received on 2024-12-23, pertaining to the death of Resident #1 who was found unresponsive in bed on 2024-12-20.
Findings
The Licensing Program Analyst conducted an unannounced case management incident visit, including an interview with the Executive Director, a brief tour, and file review. No deficiencies were cited during this visit.
Complaint Details
The visit was triggered by a self-reported death incident involving Resident #1. No deficiencies were cited, and the investigation did not indicate substantiation status.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Met with during the inspection and interviewed regarding the incident. |
| Esther Cortez | Licensing Program Analyst | Conducted the unannounced case management incident visit. |
| Betsy McCoy | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 145
Deficiencies: 2
Dec 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-12 regarding inadequate staffing to assist residents with care needs and failure to assist a resident with restroom needs resulting in multiple UTIs.
Findings
The allegation of inadequate staffing was substantiated based on interviews, file reviews, and resident call pendant data showing long wait times for assistance and staff shortages during 2023. The allegation regarding failure to assist a resident with restroom needs resulting in multiple UTIs was unsubstantiated due to insufficient evidence and lack of medical records confirming the UTIs or their source.
Complaint Details
The complaint investigation was substantiated for inadequate staffing to assist residents, with evidence including resident call pendant wait times averaging 38 minutes, staff interviews confirming understaffing in 2023, and reports of residents waiting up to two hours for assistance. The allegation regarding failure to assist with restroom needs leading to UTIs was unsubstantiated due to lack of medical evidence and unclear causation.
Deficiencies (2)
| Description |
|---|
| Facility does not have adequate staffing to assist resident with care needs. |
| Staff did not assist resident with restroom needs resulting in resident developing multiple UTIs. |
Report Facts
Resident census: 93
Total capacity: 145
Resident pendant call wait time: 38.2
Longest pendant call wait time: 43.57
Number of pendant calls with wait over 15 minutes: 8
Number of caregivers on full staffed morning shift in Assisted Living: 4
Number of MedTechs on full staffed morning shift in Assisted Living: 2
Number of caregivers on full staffed morning shift in Memory Care: 3
Number of MedTechs on full staffed morning shift in Memory Care: 1
Number of staff interviewed on 11/26/2024: 2
Number of residents interviewed on 11/26/2024: 4
Number of staff interviewed on 12/02/2024: 2
Number of residents interviewed on 12/02/2024: 5
Number of staff interviewed on 12/13/2024: 2
Number of staff interviewed on 12/16/2024: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erica Mosley | Licensing Program Analyst | Conducted the unannounced complaint investigation visit and authored the report |
| Christian Castillo | Executive Director | Met with Licensing Program Analyst during the investigation and was involved in the exit interview |
| Janelle Lopez | Administrator | Facility administrator named in the report header |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Elsie Campos | Licensing Program Analyst | Conducted interviews and record reviews during the investigation |
| Esther Cortez | Licensing Program Analyst | Conducted multiple interviews and file reviews during the investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 145
Deficiencies: 1
Nov 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not respond to a resident's call button in a timely manner.
Findings
The investigation substantiated the allegation that staff failed to respond promptly to resident call buttons, with documented delays of up to 35 minutes and 54 seconds to assist a resident. Multiple pendant calls showed wait times exceeding 15 minutes, posing a potential health and safety risk.
Complaint Details
The complaint was substantiated. The allegation was that staff did not respond timely to resident call buttons, specifically citing Resident #1 who waited over 35 minutes for assistance on 09/11/2023. The investigation included file reviews, interviews with staff, residents, and technical support, confirming delays in response times.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff did not respond to resident's call for assistance in a timely manner, violating CCR 87468.2(a)(4) regarding personal rights to care and supervision. | Type B |
Report Facts
Wait time for resident call response: 35.9
Number of pendant calls with wait over 15 minutes: 8
Highest wait time: 43.57
Average reset time: 38.2
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation report |
| Christian Castillo | Executive Director | Facility representative met during the investigation |
| Janelle Lopez | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 145
Deficiencies: 0
Nov 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was overcharging a resident and that the resident was not provided an itemization of charges.
Findings
The investigation included interviews with the Executive Director, staff, and residents, as well as file reviews. It was found that the facility implemented new care cost pricing with options for residents to freeze their rates or receive concessions. Resident #1 was assessed under a new care-level plan and capped at $6000. The allegations were deemed unsubstantiated based on the evidence gathered.
Complaint Details
The complaint involved allegations that the facility was overcharging Resident #1 and not providing an itemization of charges. The complaint was investigated through interviews and file reviews and was found to be unsubstantiated.
Report Facts
Resident census: 93
Total capacity: 145
Resident #1 care cost increase: 6000
Resident #1 previous care cost: 3100
Resident #1 assessment points: 6568.5
Allowance care discount: 1200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Interviewed during the complaint investigation regarding care cost changes |
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 93
Capacity: 145
Deficiencies: 3
Nov 18, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure the facility is free of health and safety hazards.
Findings
The facility was generally found to be in compliance with regulations, with clean and well-maintained common areas and kitchen. However, deficiencies were noted including unsafe storage of cleaning solutions and medications accessible to residents, unsanitary conditions in some resident rooms, and sticky floors in certain restrooms.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Cleaning solutions were stored in two of ten resident restrooms, posing an immediate health and safety risk. | Type A |
| Medications were observed in four resident rooms where residents cannot administer medications, posing an immediate health and safety risk. | Type A |
| Floors in rooms 249, 233, and 238 were not sanitary, posing a potential health and safety risk. | Type B |
Report Facts
Resident rooms observed with deficiencies: 4
Resident rooms observed with unsanitary floors: 3
Resident bedrooms inspected: 10
Resident files reviewed: 5
Hot water temperature range: 105.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Met with Licensing Program Analyst during inspection and involved in removal of medications and cleaning solutions. |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Kasandra Lopez | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 145
Deficiencies: 0
Oct 22, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding the allegation that the facility does not provide a clean and safe environment for residents, specifically concerns about mold causing Resident #1 to cough and wheeze.
Findings
The investigation found no evidence of mold or unsafe conditions in the facility. Observations, interviews with staff and residents, and file reviews indicated the facility was clean and sanitary, and Resident #1's lab results did not show mold exposure. The allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged the facility environment was causing Resident #1 to cough and wheeze due to possible mold in their room. The investigation included observations, interviews, and file reviews. No mold was found, housekeeping was done weekly, and Resident #1's lab tests were negative for mold exposure. The allegation was unsubstantiated.
Report Facts
Capacity: 145
Census: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Christian Castillo | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Betsy McCoy | Administrator | Named as facility administrator |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 145
Deficiencies: 0
Oct 22, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-09-18 regarding the facility allegedly not providing quality meals.
Findings
The investigation found that the allegation of the facility not providing quality meals was unsubstantiated. Observations and interviews with staff and residents confirmed that meals were fresh, varied, and met residents' satisfaction.
Complaint Details
The complaint alleged that the facility was not providing fresh meals, served frozen vegetables, lacked meal variety, and served pork two to three times a week. After observations and interviews, including with ten residents who all stated the food was fresh and varied, the allegation was deemed unsubstantiated.
Report Facts
Capacity: 145
Census: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Christian Castillo | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Kasandra Lopez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 145
Deficiencies: 1
Oct 7, 2024
Visit Reason
The visit was an unannounced Case Management Deficiency inspection conducted in conjunction with an initial 10-day complaint visit to issue citations for deficiencies observed during the complaint investigation that were not related to the complaint allegations.
Findings
During the facility tour, cleaning supplies were found left unattended in a hallway accessible to residents, posing an immediate health and safety risk. The Executive Director advised staff to lock away cleaning supplies to prevent resident access.
Complaint Details
The visit was conducted in conjunction with an initial 10-day complaint visit (CC #29-AS-20241003142431). The deficiencies cited were not related to the complaint allegations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients were not stored where inaccessible to clients, as evidenced by cleaning supplies left unattended in a cart accessible to residents. | Type A |
Report Facts
Capacity: 145
Census: 99
Plan of Correction Due Date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Catillo | Executive Director | Met during inspection and advised staff regarding cleaning supplies |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kasandra Lopez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 145
Deficiencies: 0
Sep 23, 2024
Visit Reason
The visit was a case management incident investigation related to a reported allegation of suspected dependent adult/elder abuse involving a possible sexual assault of a resident at the facility.
Findings
The investigation included interviews with residents and staff, review of facility records, and coordination with law enforcement. Conflicting statements were found regarding the alleged sexual assault, and the Department determined there was insufficient evidence to substantiate the allegation. The allegation was deemed unsubstantiated.
Complaint Details
The complaint involved an alleged sexual assault of Resident #1 by Staff #1 on 07/06/2023. Resident #1 reported being kissed on the mouth by Staff #1 during assistance with moving in bed. Staff #1 and Resident #2 denied the allegation. The facility suspended Staff #1 pending investigation. The Department found the allegation unsubstantiated due to conflicting statements and lack of evidence.
Report Facts
Facility capacity: 145
Resident census: 94
Investigation dates: Jul 6, 2023
Investigation dates: Jul 7, 2023
Investigation dates: Jul 11, 2023
Investigation dates: Jul 12, 2023
Investigation dates: Jul 21, 2023
Investigation dates: Jul 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | Executive Director | Met with Licensing Program Analyst during inspection |
| Julius Osorio | Interim Administrator | Met with Licensing Program Analyst during initial visit and provided report |
| Juan Lozano | Investigator | Assigned to investigation by Community Care Licensing Division Investigations Branch |
| Kasandra Lopez | Licensing Program Analyst | Conducted initial unannounced case management incident visit |
| Esther Cortez | Licensing Program Analyst | Conducted subsequent case management visit to deliver findings |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 145
Deficiencies: 2
Jun 25, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not ensure a resident's toileting needs were met and that the resident was billed for services not received.
Findings
The investigation substantiated that staff failed to respond timely to resident calls for toileting assistance, resulting in the resident being wet for extended periods, and that the facility billed the resident for personal care services during a period when the resident was absent from the community, without issuing the appropriate credit or refund.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to meet resident toileting needs timely and billing for services not received. Investigations included interviews, record reviews, and observations confirming these issues.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff did not respond timely and ensure incontinent resident was kept clean and dry, posing an immediate health and safety risk. | Type A |
| Licensee did not comply with admission agreement terms by not ensuring resident received credit/refund for days absent from the community. | Type B |
Report Facts
Capacity: 145
Census: 97
Pendand calls over 30 minutes: 28
Longest pendant call response time: 102
Plan of Correction Due Date: Jun 26, 2024
Plan of Correction Due Date: Jul 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Kasandra Lopez | Licensing Program Manager | Oversaw complaint investigation |
| Betsy Mccoy | Executive Director | Met with Licensing Program Analyst during inspection |
| Jennifer Miller | Business Office Manager | Interviewed regarding billing and credit/refund issues; no longer employed at facility |
| Julius Osorio | Interim Administrator | Interviewed regarding follow-up on resident credit/refund |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 145
Deficiencies: 0
Jun 25, 2024
Visit Reason
The inspection was conducted as a Case Management - Incident visit following the facility's submission of an Unusual Incident/Injury Report regarding theft of credit cards reported by two residents.
Findings
The facility has a theft and loss program in place and is conducting an investigation to assist the residents. Police reports were made by the residents or their family members. The Executive Director reported that one resident's credit card information was stolen outside the facility.
Complaint Details
The visit was triggered by a complaint related to theft of credit cards involving Resident #1 and Resident #2. The complaint is under investigation with police reports filed; no substantiation status is provided.
Report Facts
Capacity: 145
Census: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betsy Mccoy | Executive Director | Met with Licensing Program Analyst during inspection and provided information about the incident and investigation |
| Esther Cortez | Licensing Program Analyst | Conducted the Case Management - Incident visit |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 145
Deficiencies: 2
Jun 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/19/2023 regarding staff not responding timely to a resident's call for assistance and not seeking medical assistance for the resident.
Findings
The investigation substantiated that staff failed to respond timely to Resident #1's call for assistance and did not seek medical assistance after a fall and subsequent emergency. Other allegations regarding pressure injuries due to neglect and facility odor were unsubstantiated. A $250 civil penalty was assessed due to repeat violations.
Complaint Details
The complaint alleged that staff did not respond timely to Resident #1’s call for assistance and did not seek medical assistance for the resident. The investigation found these allegations substantiated based on witness statements and medical records. Other allegations about pressure injuries and facility odor were unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Based on interviews and records review, the licensee did not comply with CCR 87468.2(a)(4) when staff did not respond to R1’s call for assistance and did not seek timely medical treatment for R1 on two occasions, posing an immediate health and safety risk. | Type A |
| Based on interviews and records review, the licensee did not comply with CCR 87465(j). Facility staff did not seek medical assistance for R1 on 12/30/22 and 01/05/23, posing an immediate health and safety risk. | Type A |
Report Facts
Civil penalty amount: 250
Facility capacity: 145
Resident census: 95
Plan of Correction due date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits. |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation and signed reports. |
| Christian Castillo | Executive Director | Met with Licensing Program Analyst during inspection. |
| Betsy Mccoy | Executive Director | Met with Licensing Program Analyst during inspection. |
| Jennifer Miller | Business Office Manager | Interviewed during complaint investigation. |
Inspection Report
Census: 95
Capacity: 145
Deficiencies: 1
Jun 18, 2024
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted unannounced to evaluate the facility's compliance with licensing requirements.
Findings
The report is an amended document with a citation removed following an appeal. No specific deficiencies are detailed in the provided pages, and the deficiency section is intentionally left blank.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| This is an amended report. This page intentionally left blank | Type B |
Report Facts
Capacity: 145
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Castillo | ED | Met with during inspection |
| Kasandra Lopez | Licensing Program Manager / Supervisor | Named in report and supervisor of licensing |
| Esther Cortez | Licensing Program Analyst / Evaluator | Created and signed the report |
| Betsy McCoy | Administrator / Director | Facility administrator/director |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 145
Deficiencies: 2
Jun 17, 2024
Visit Reason
Unannounced complaint investigation visit conducted regarding allegations that staff did not safeguard resident's personal supplies and did not provide resident or authorized person copies of requested records.
Findings
The investigation substantiated that staff took resident's incontinence supplies without safeguarding them and that the facility failed to provide complete requested records to the resident or authorized person, including documentation of a fall. Both allegations were supported by interviews, record reviews, and evidence.
Complaint Details
The complaint was substantiated. Staff admitted to taking resident's incontinence supplies once, and the facility failed to provide complete requested records despite multiple requests and communications. The records were incomplete, notably missing documentation of a fall on 12/30/22.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| 87217(b) Safeguards for Resident Cash, Personal Property, and Valuables - failure to safeguard resident's personal supplies. | Type B |
| 87506(c)(1) Failure to make complete records available to resident or authorized person, including confidential information. | Type B |
Report Facts
Capacity: 145
Census: 95
Plan of Correction Due Date: Jun 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugenia Taylor | Director of Nursing | Met with Licensing Program Analyst during investigation. |
| Janelle Lopez | Administrator | Facility administrator named in report header. |
| Jennifer Miller | Business Office Manager | Interviewed during initial complaint inspection. |
| Julius Osorio | Interim Administrator | Interviewed regarding record requests and management transition. |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation. |
| Esther Cortez | Licensing Program Analyst | Conducted unannounced complaint investigation visit. |
| Sandra Urena | Licensing Program Analyst | Conducted interviews and observations during investigation. |
| Olivia Spindola | CCLD Investigations Branch Investigator | Investigated Personal Rights allegations. |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 145
Deficiencies: 2
May 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to multiple allegations received on 2023-07-21 regarding inadequate food service, unmet resident needs, inadequate transportation services, delayed response to call pendants, and failure to safeguard residents' personal belongings.
Findings
The allegations of inadequate food service, unmet resident needs, and inadequate transportation services were deemed unsubstantiated based on interviews and observations. However, the allegations that staff do not respond to call pendants in a timely manner and do not safeguard residents' personal belongings were substantiated, resulting in citations issued for deficiencies related to theft and loss, and insufficient care response.
Complaint Details
The complaint investigation was triggered by allegations received on 2023-07-21. The investigation found the allegations regarding food service, resident needs, and transportation unsubstantiated. The allegations that staff do not respond timely to call pendants and do not safeguard residents' belongings were substantiated. Citations were issued accordingly.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to document lost property valued at twenty-five dollars or more within 72 hours and maintain a written inventory of items brought into or removed from the facility. | Type B |
| Failure to provide care, supervision, and services that meet individual resident needs, including timely response to call pendants. | Type B |
Report Facts
Capacity: 145
Census: 99
Deficiency count: 2
Plan of Correction Due Date: May 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation |
| Betsy McCoy | Executive Director | Facility representative met during inspection |
| Jennifer Miller | Business Office Manager | Interviewed during complaint investigation |
| Ian Gadea | Nursing Director | Interviewed during complaint investigation |
| Janelle Lopez | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 145
Deficiencies: 2
Feb 1, 2024
Visit Reason
The inspection was an unannounced Case Management Deficiencies inspection conducted due to deficiencies observed during the investigation of complaint control #29-AS-20230125125751 related to a choking incident involving Resident #1.
Findings
The investigation found insufficient evidence that staff failed to respond timely to a pendent call, but sufficient evidence that staff did not respond timely to a stat assistance call during a choking incident, with a response time of approximately 7 to 8 minutes. Additionally, staff member S2 did not perform life-saving procedures and had an expired first aid certification at the time of the incident.
Complaint Details
The complaint investigation was related to allegations that staff did not respond timely to a pendent call for assistance during a choking incident involving Resident #1. The investigation found sufficient evidence that staff did not respond timely to a stat assistance call and that staff member S2’s first aid certification was expired.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff failed to respond timely to an emergent situation pertaining to Resident #1 which posed an immediate health and safety concern. | Type A |
| Staff member S2’s first aid certification expired in February 2022 and was not current during the incident on 01/24/2023, posing a health and safety risk. | Type B |
Report Facts
Response time: 7
Response time: 8
Deficiency due date: Feb 2, 2024
Deficiency due date: Feb 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betsy Mccoy | Nursing Director | Met with Licensing Program Analyst during inspection and involved in findings related to the choking incident |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and investigation |
| Kasandra Lopez | Licensing Program Manager | Supervisor overseeing the inspection and cited deficiencies |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 145
Deficiencies: 3
Feb 1, 2024
Visit Reason
The visit was conducted to conclude an investigation initiated by a complaint received on 2023-01-25 alleging neglect and lack of supervision resulting in Resident #1 choking to death without medical intervention while under facility care.
Findings
The investigation substantiated that Resident #1 choked to death due to neglect and lack of timely medical intervention by staff. It was found that staff did not perform life-saving procedures and delayed response to the emergency. Additionally, a citation was issued for staff not responding timely to a pendent call and for a staff member lacking a valid first aid certificate.
Complaint Details
The complaint alleged neglect and lack of supervision resulting in Resident #1 choking to death without medical intervention. The allegation was substantiated based on interviews, record reviews, and supporting documentation including EMS and Medical Examiner reports.
Severity Breakdown
Type A: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide sufficient, competent staff to provide timely first aid assistance to Resident #1, resulting in death by choking and posing immediate health and safety risks to residents. | Type A |
| Staff did not respond timely to a pendent call for assistance during an emergency situation. | — |
| Staff #2 did not have a valid first aid certificate; certificate expired in February 2022. | — |
Report Facts
Capacity: 145
Census: 100
Civil penalty: 500
Response time: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betsy Mccoy | Nursing Director | Met with Licensing Program Analyst during investigation and informed of civil penalties |
| Jill Ford | Administrator | Administrator during investigation, authorized Nursing Director to review and sign reports |
| Philippe Ryan Miles | Investigator | Conducted interviews and reviewed documentation related to the complaint investigation |
| Esther Cortez | Licensing Program Analyst | Conducted complaint visit and investigation |
| Kasandra Lopez | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Annual Inspection
Census: 102
Capacity: 145
Deficiencies: 4
Nov 15, 2023
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure the facility meets health and safety standards.
Findings
The facility was found to have several deficiencies including lack of emergency food and water supply, uncomfortable room temperature in bedroom #319, strong odor and drainage issues in bedroom #241, and maintenance issues such as a non-draining sink. Plans of correction were agreed upon with due dates.
Severity Breakdown
Type A: 1
Type B: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility did not have a supply of emergency food and water posing a potential health and safety risk. | Type A |
| Bedroom #319 did not have a comfortable temperature for the resident; room was too hot. | Type B |
| Bedroom #241 had a strong odor emitting from the bathroom and carpet near the closet. | Type B |
| Sink in bedroom #241 was not draining and retaining water, posing a potential health and safety risk. | Type B |
Report Facts
Plan of Correction Due Date: Nov 24, 2023
Hot water temperature range: 113
Hot water temperature range: 117.5
Number of resident bedrooms inspected: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as supervisor and licensing program manager overseeing the inspection |
| Elsie Campos | Licensing Program Analyst | Conducted the inspection and signed the report |
| Sherry Nazari | Administrator | Facility administrator present during the inspection and informed of the visit reason |
Inspection Report
Census: 104
Capacity: 145
Deficiencies: 0
Sep 25, 2023
Visit Reason
The visit was a Case Management - Incident visit conducted due to a death report submitted by the facility for a resident who passed away on 09/17/2023.
Findings
The Licensing Program Analyst conducted interviews, document reviews, and a tour related to the resident's death. No deficiencies were observed during the visit.
Report Facts
Facility capacity: 145
Resident census: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the Case Management - Incident visit |
| Sherry Nazari | Administrator/Executive Director | Met with Licensing Program Analyst during the visit and provided information about the incident |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 145
Deficiencies: 3
Aug 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations that facility staff initial training is incomplete and annual training is not completed, as well as an allegation of unqualified staff cooking.
Findings
The investigation substantiated that facility staff did not complete required initial and annual training, including medication and first aid training, posing potential risks to residents. However, the allegation of unqualified staff cooking was unsubstantiated as only qualified staff were found to be cooking resident meals.
Complaint Details
The complaint was substantiated regarding incomplete initial and annual training of staff, including medication and first aid training. The allegation of unqualified staff cooking was unsubstantiated.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide required 40 hours of initial training and 20 hours of annual training for direct care staff. | Type B |
| Failure to provide required 8 hours of annual medication-related in-service training for med-tech staff. | Type B |
| Failure to provide proof of current first aid training for staff providing care. | Type B |
Report Facts
Capacity: 145
Census: 109
Deficiencies cited: 3
Training hours required: 40
Training hours required: 20
Training hours required: 8
Plan of Correction Due Date: Aug 22, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Miller | Business Office Manager | Met with during inspection and named in findings |
| Shahrzad Nazari | Administrator | New Administrator met during inspection and named in findings |
| Jill Ford | Administrator | Administrator at time of complaint initiation, interviewed during investigation |
| Nicole Hoznor | Director of Health and Wellness | Interviewed during initial complaint investigation |
| Michael Tabada | Culinary Director | Met during subsequent visit, provided proof of certification |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 145
Deficiencies: 0
Jul 25, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following an allegation that a resident was sexually harassed while in care.
Findings
The investigation included interviews with staff, residents, and a family member of the resident involved. No evidence was found to support the allegation, and the complaint was deemed unsubstantiated.
Complaint Details
The allegation was that an unknown person exposed themselves to Resident #1 while on the patio. Multiple interviews and record reviews were conducted, but no reports or evidence of sexual harassment were found. The allegation was unsubstantiated.
Report Facts
Capacity: 145
Census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
| Ian Gadea | Director of Nursing | Interviewed during the inspection |
| Jennifer Miller | Business Office Manager | Met with during inspection and interviewee |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 145
Deficiencies: 1
Jul 12, 2023
Visit Reason
An unannounced Case Management Deficiencies inspection was conducted due to a complaint investigation regarding the care and supervision of Resident #1 (R1), who sustained an injury during a transfer.
Findings
The investigation revealed that R1, a two-person assist resident, was transferred by only one staff member resulting in a skin tear injury. Interviews confirmed insufficient staff assistance during the transfer, posing a health and safety risk to the resident.
Complaint Details
The visit was complaint-related under complaint control # 29-AS-20220322104533. The complaint was substantiated based on interviews and record review showing inadequate staff assistance during transfer leading to resident injury.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care, supervision, and services by sufficient staff to meet individual needs, as evidenced by R1 receiving assistance from only one staff member during a two-person assist transfer, resulting in injury. | Type A |
Report Facts
Census: 114
Total Capacity: 145
Deficiencies cited: 1
Plan of Correction Due Date: Jul 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julius Osorio | Interim Administrator | Met with Licensing Program Analyst during inspection and involved in exit interview |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 145
Deficiencies: 0
Jul 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of physical abuse to a resident while in care, reported on 03/22/2022.
Findings
The investigation found insufficient evidence to support the allegation of physical abuse to the resident. The resident had a fall resulting in injury, but interviews and records did not substantiate abuse by staff.
Complaint Details
The complaint alleged physical abuse to a resident who sustained a laceration to the labia after a fall while being assisted in the shower. The resident is wheelchair bound and a two-person assist. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Complaint Control Number: 29-AS-20220322104533
Facility Capacity: 145
Resident Census: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and subsequent inspection |
| Julius Osorio | Interim Administrator | Met with Licensing Program Analyst during inspection |
| Jill Ford | Administrator | Administrator at time of initial complaint inspection |
| Nicolle Hoznor | Director of Health Wellness | Director at time of initial complaint inspection |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 145
Deficiencies: 0
Jul 12, 2023
Visit Reason
The inspection was conducted as an unannounced Case Management Incident visit following a Report of Suspected Dependent Adult/Elder Abuse related to an alleged incident involving a resident and staff member on 07/06/2023.
Findings
The Licensing Program Analyst reviewed facility records and observed law enforcement interviewing the resident. Further investigation is needed and has been assigned to the Community Care Licensing Division's Investigation Branch.
Complaint Details
The complaint involved suspected dependent adult/elder abuse reported by the interim Administrator regarding an incident on 07/06/2023 involving Resident #1 and Staff #1. Staff #1 is currently on leave pending investigation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julius Osorio | Interim Administrator | Met with Licensing Program Analyst and reported the suspected abuse incident. |
| Juan Lozano | Investigator | Assigned to the investigation by the Community Care Licensing Division's Investigation Branch. |
| Kasandra Lopez | Licensing Program Analyst | Conducted the unannounced Case Management Incident visit. |
| Desaree Perera | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 145
Deficiencies: 0
Jul 7, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that residents were not receiving appropriate care and that resident records were not accurate.
Findings
The investigation found insufficient evidence to support the allegations. Resident records were found to be accurate, and residents were receiving appropriate care. Both allegations were deemed unsubstantiated.
Complaint Details
The complaint control number 29-AS-20210826104708 involved allegations that residents were not receiving appropriate care and that resident records were inaccurate. The investigation included interviews and record reviews, concluding the allegations were unsubstantiated.
Report Facts
Mini-mental state examination score: 27
Mini-mental state examination score: 24
Facility capacity: 145
Facility census: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation. |
| Jennifer Miller | Business Office Manager | Met with the Licensing Program Analyst during the investigation. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Leticia Higares | Regional Nurse | Participated in exit interview and report review. |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 145
Deficiencies: 1
Jun 30, 2023
Visit Reason
The inspection was an unannounced Case Management Deficiencies inspection conducted due to a deficiency observed during a complaint investigation.
Findings
During the complaint inspection, it was found that one resident with dementia had a medical assessment on file that was older than one year, which poses a potential health and safety risk to residents in care.
Complaint Details
The visit was triggered by a deficiency observed during a complaint investigation. The deficiency was substantiated as the licensee failed to comply with the requirement for annual medical assessment for a resident with dementia.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident with dementia had a medical assessment older than one year, failing to meet the requirement for annual medical assessment and reassessment of dementia care needs. | Type B |
Report Facts
Capacity: 145
Census: 113
Plan of Correction Due Date: Jul 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Ian Gadea | Director of Health and Wellness | Participated in the exit interview and report review |
| Desaree Perera | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 145
Deficiencies: 0
Jun 30, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff financially abused residents by unauthorized use of credit cards.
Findings
The investigation found insufficient evidence to support the allegation that facility staff financially abused residents. Law enforcement reports and interviews indicated fraudulent charges occurred but no staff involvement was confirmed. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged facility staff financially abused residents by unauthorized use of credit cards belonging to Resident #1 and Resident #2. The investigation included review of law enforcement reports, interviews with residents and staff, and criminal record checks. The allegation was found unsubstantiated due to insufficient evidence.
Report Facts
Facility capacity: 145
Census: 113
Complaint control number: 29-AS-20210721151329
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Leticia Higares | Regional Nurse | Met with the Licensing Program Analyst during the inspection |
| Ian Gadea | Director of Nursing | Participated in the exit interview and report review |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Martha Berard | Administrator | Facility Administrator named in the report |
| Jacob Primeau | Interim Administrator | Met during previous inspection and provided information about the allegations |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 145
Deficiencies: 2
May 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2021-06-10 regarding medication administration, staff management of medications, and response times to pendent calls.
Findings
The investigation substantiated allegations that medications were not given timely, staff mismanaged resident medications, and staff did not respond timely to pendent calls. Two allegations regarding the administrator's presence and staff falsifying records were unsubstantiated. Deficiencies related to medication administration and pendent call response times were cited.
Complaint Details
The complaint investigation was substantiated for allegations that medications were not given timely, staff mismanaged medications, and staff did not respond timely to pendent calls. The allegations that the administrator did not spend sufficient time in the facility and that staff falsified records were unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to assist residents with self-administered medications as needed, resulting in late and missed medications for Resident #1. | Type A |
| Failed to provide care, supervision, and services with sufficient staff to ensure timely pendent call responses, resulting in excessive wait times for residents. | Type A |
Report Facts
Census: 106
Total Capacity: 145
Medication counts: 10
Medication counts: 6
Medication counts: 4
Medication counts: 2
Pendent call wait times: 20
Pendent call wait times: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation. |
| Jennifer Miller | Business Officer Manager | Met with the Licensing Program Analyst during the inspection and was involved in exit interview. |
| Martha Berard | Administrator | Named in allegations regarding insufficient time spent in the facility. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 145
Deficiencies: 0
May 24, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation in response to an allegation of insufficient staffing at the facility.
Findings
The investigation found insufficient evidence to support the allegation of insufficient staffing. The allegation was deemed unsubstantiated at this time.
Complaint Details
The complaint alleged that the complainant did not receive information timely due to staff on duty not having access to the resident roster and staffing shortages related to the facility having an interim Administrator. The allegation was found unsubstantiated.
Report Facts
Capacity: 145
Census: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Desaree Perera | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Jennifer Miller | Business Office Manager | Met with the Licensing Program Analyst during the inspection |
| Martha Berard | Administrator | Facility Administrator mentioned in the report |
| Jacob Primeau | Interim Administrator | Interviewed during the investigation |
| Anabel Amaya | Business Office Manager | Interviewed during a previous investigation referenced in the report |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 145
Deficiencies: 1
May 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/18/2021 regarding excessive wait times for resident assistance and other facility concerns.
Findings
The allegation that residents were made to wait an excessive amount of time for assistance was substantiated based on pendent call records and resident interviews showing multiple response times exceeding 20 minutes. Other allegations regarding facility disrepair, after-hours access, medication delivery delays, and staff assistance after hours were found to be unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding excessive wait times for resident assistance, with pendent call records from 06/14/2021 through 06/21/2021 showing multiple late response times and resident interviews confirming delays. Other complaints about facility disrepair, after-hours access, medication delivery delays, and staff assistance after hours were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care, supervision, and services by staff sufficient in numbers, qualifications, and competency, evidenced by three residents having pendent call wait times in excess of 20 minutes posing an immediate health and safety risk. | Type A |
Report Facts
Pendent call response times: 7
Facility capacity: 145
Resident census: 105
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit. |
| Jennifer Miller | Business Officer Manager | Met with the Licensing Program Analyst during the inspection and participated in exit interview. |
| Martha Berard | Administrator | Facility administrator involved in the investigation and referenced in findings. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Jace Evans | Maintenance Director | Participated in testing doorbells during inspection. |
Inspection Report
Capacity: 145
Deficiencies: 0
Apr 12, 2023
Visit Reason
An unannounced Case-Management Incident inspection was conducted regarding a death report pertaining to Resident #1 (R1). The visit was to review the circumstances surrounding the resident's death and related records.
Findings
No deficiencies were cited at the time of the inspection. The cause of death was unknown, and the licensing analyst will return if further investigation is needed upon receipt of the death certificate.
Report Facts
Facility capacity: 145
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Miller | Business Manager | Met with the Licensing Program Analyst during the inspection |
| Ian Gadea | Director of Health and Wellness | Met with the Licensing Program Analyst and contacted the mortuary during the inspection |
Inspection Report
Complaint Investigation
Capacity: 145
Deficiencies: 1
Apr 12, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that facility staff did not respond to resident's requests for assistance in a timely manner and other related complaints.
Findings
The allegation that staff did not respond timely to resident requests was substantiated with evidence of multiple pendent call response times exceeding 20 minutes. Other allegations regarding carpet stains, wheelchair maneuvering, food adequacy, and apartment cleaning were found unsubstantiated based on interviews and record reviews.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff did not respond to resident's requests for assistance in a timely manner. Other allegations were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care, supervision, and services that meet residents' needs delivered by staff sufficient in numbers, qualifications, and competency, evidenced by approximately 46 pendent response times in excess of 20 minutes during a one month period. | Type A |
Report Facts
Pendent response times over 20 minutes: 46
Facility capacity: 145
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and inspection. |
| Jill Ford | Administrator | Facility administrator present during inspection and exit interview. |
| Jennifer Miller | Business Office Manager | Met with Licensing Program Analyst during inspection. |
| Jace Evans | Maintenance Director | Interviewed regarding facility maintenance and carpet issues. |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 145
Deficiencies: 0
Feb 16, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility does not provide a comfortable environment for residents.
Findings
The investigation found that residents interviewed had no fear of speaking with the long term care ombudsman or fear of retaliation. There was insufficient evidence to support the allegation, and it was deemed unsubstantiated.
Complaint Details
The complaint alleged that the facility does not provide a comfortable environment for residents and that residents were fearful to speak with the long term care ombudsman. The allegation was found unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the unannounced complaint inspection and investigation. |
| Jill Ford | Facility Administrator met with the Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 145
Deficiencies: 0
Feb 16, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the licensee was allowing a resident's personal rights to be violated by restricting the Certified Ombudsman from attending Resident Council meetings.
Findings
The investigation found insufficient evidence to support the allegation that the licensee was violating the resident's personal rights. Interviews with residents revealed no issues with the ombudsman's attendance at council meetings. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that Resident #1 was blocking and/or restricting the Certified Ombudsman from attending Resident Council meetings and that the facility was allowing this. After interviews with seven residents, including Resident #1, no evidence was found to support the allegation. The complaint was unsubstantiated.
Report Facts
Complaint Control Number: 29
Complaint Control Number Suffix: 20210824100751
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and met with facility representative Jill Ford. |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 145
Deficiencies: 1
Feb 10, 2023
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff drank alcohol while on duty at Sage Mountain Senior Living Facility.
Findings
The investigation substantiated the allegation that staff drank alcohol while on duty, supported by social media photos and observations of an alcoholic beverage on facility grounds. Another allegation that staff left residents unattended during the potluck was unsubstantiated.
Complaint Details
The complaint alleged staff drank alcohol while on duty. The allegation was substantiated based on social media evidence and staff interviews. A second complaint alleging staff left residents unattended was unsubstantiated due to insufficient evidence.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87468.1 Personal Rights of Residents in All Facilities (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by a photo of an alcoholic beverage taken in the memory care and staff posted on social media they were drinking while at work which poses an immediate health and safety risk to residents in care. | Type A |
Report Facts
Capacity: 145
Census: 108
Deficiency count: 1
Plan of Correction Due Date: Feb 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jennifer Miller | Business Office Manager | Interviewed during the investigation and participated in exit interview |
| Ian Gadea | Director of Health and Wellness | Interviewed during the investigation |
| Jill Ford | Administrator | Facility administrator unavailable during inspection but confirmed photo authenticity |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 145
Deficiencies: 1
Jan 18, 2023
Visit Reason
The inspection was an unannounced Case Management - Deficiencies visit conducted due to a deficiency observed during a prior complaint investigation.
Findings
The facility failed to transfer and associate Staff #1's criminal record clearance to the facility despite the staff working there since August 2022. This deficiency poses an immediate health and safety risk and is a repeat violation from a prior citation within the last 12 months.
Complaint Details
The visit was triggered by a deficiency observed during a complaint investigation. The deficiency was substantiated as Staff #1's criminal record clearance was not transferred to the facility, posing an immediate health and safety risk. Civil penalties of $100 per day for up to 30 days were assessed due to this repeat violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to transfer and associate Staff #1's criminal record clearance to the facility as required by California Code of Regulations, Title 22 and California Health and Safety Code. | Type A |
Report Facts
Civil penalty amount per day: 100
Maximum days for civil penalty: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Miller | Business Office Manager | Interviewed regarding Staff #1's criminal record clearance and associated to the facility during inspection |
| Kasandra Lopez | Licensing Program Analyst | Conducted the unannounced Case Management - Deficiencies inspection |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager and Supervisor |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 145
Deficiencies: 0
Dec 13, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that services were not being provided in a timely manner and that residents were being left soiled for extended periods of time.
Findings
After interviews with staff and residents, review of medication administration, and examination of facility policies during a significant COVID-19 outbreak, the allegations were found to be unsubstantiated due to insufficient evidence. Residents reported satisfaction with care timelines and incontinence needs being met despite staffing challenges.
Complaint Details
The complaint investigation was triggered by allegations of untimely service provision and residents being left soiled. The investigation included interviews with residents, staff, and administrators, as well as document reviews. Both allegations were deemed unsubstantiated based on the evidence gathered.
Report Facts
Capacity: 145
Census: 113
Complaint control number: 29-AS-20210112140705
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Jill Ford | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jennifer Miller | Business Office Manager | Assisted with facility tour and resident/staff interviews during prior complaint inspection |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 145
Deficiencies: 0
Dec 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to multiple allegations received on 01/28/2021 regarding inadequate staffing, safeguarding of residents' belongings, notification of changes in residents' conditions, lack of activities, insufficient food variety, and failure to ensure residents received meals during a COVID-19 outbreak.
Findings
The investigation found that although the allegations may have some validity, there was insufficient evidence to substantiate any violations. Staffing shortages were due to a significant COVID outbreak, but residents' needs were met. Residents' belongings were safeguarded during cohort relocations. Communication with families improved after initial transition issues. Activities were limited due to public health restrictions. Food variety was adequate, and meals were delivered despite delays. No citations were issued.
Complaint Details
The complaint investigation was unsubstantiated for all allegations including inadequate staffing, failure to safeguard residents' belongings, failure to notify authorized representatives of changes, lack of activities, inappropriate food variety, and failure to ensure residents received meals. The investigation included interviews with staff, residents, family members, and review of documents during a COVID-19 outbreak.
Report Facts
Agency care staff hours: 788.25
Capacity: 145
Census: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Jill Ford | Executive Director | Met with Licensing Program Analyst during inspection |
| Jade Alma-Harris | Administrator | Facility Administrator during complaint period |
| Kristin Heffernan | Licensing Program Manager | Oversaw complaint investigation |
| Jennifer Miller | Business Office Manager | Assisted during facility tour and interviews |
| Martha Berard | Administrator | Administrator during initial virtual complaint inspection |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 145
Deficiencies: 5
Oct 26, 2022
Visit Reason
Unannounced complaint investigation conducted due to allegations including failure to report change in resident's condition, failure to seek timely medical attention, medication mismanagement, unmet resident needs, and multiple falls.
Findings
The investigation substantiated all allegations, finding failures in reporting changes in condition, timely medical attention, medication administration, meeting resident dietary needs, and fall monitoring. The facility did not notify the resident's physician or family appropriately, failed to follow medication orders, and did not provide adequate vegan dietary options, resulting in significant weight loss and multiple falls for Resident #1.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to report changes in condition to authorized representatives, failure to seek timely medical attention, medication mismanagement, failure to meet resident needs, and multiple falls. Resident #1 experienced significant weight loss, multiple falls, and medication errors. The facility failed to notify the physician and family timely and did not provide appropriate dietary accommodations.
Severity Breakdown
Type A: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to regularly observe residents for changes and provide appropriate assistance. | Type A |
| Failure to immediately notify resident's physician and family of changes. | Type A |
| Failure to provide basic care and supervision, including fall risk monitoring. | Type A |
| Failure to assist residents with self-administered medications as ordered. | Type A |
| Failure to provide meals consistent with resident's dietary needs and preferences. | Type A |
Report Facts
Resident weight loss: 36
Resident falls: 4
Civil penalty: 500
Menu entrée counts: 35
Menu entrée counts: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Ford | Executive Director | Met during investigation and named in findings related to failure to report and manage resident care. |
| Jade Alma-Harris | Administrator | Facility designee interviewed during initial complaint inspections. |
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 145
Deficiencies: 0
Oct 26, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that a resident passed away due to lack of care and supervision.
Findings
The investigation found that the facility failed to notify or seek guidance from a qualified health professional regarding the resident's unplanned weight loss, decreased oral consumption, and hypoglycemia, which contributed to the resident's hospitalization. However, there was insufficient evidence to substantiate that these failures caused or contributed to the resident's death, and the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that a resident passed away due to lack of care and supervision. The investigation included interviews with family members and staff, medical record reviews, and found the allegation unsubstantiated due to insufficient evidence linking the facility's actions to the resident's death.
Report Facts
Falls: 4
Weight loss (pounds): 24
Blood glucose hypoglycemia episodes: 8
Blood glucose levels: 23
Blood glucose levels: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and interviews. |
| Jill Ford | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 145
Deficiencies: 1
Oct 14, 2022
Visit Reason
The visit was a Case Management - Incident inspection to conclude an investigation initiated on 06/10/2022 regarding multiple falls and a death of Resident #1 (R1) at the facility.
Findings
The investigation found no deficiencies related to R1's death, which was due to End Stage Ischemic Cerebrovascular Disease. However, a deficiency was cited for the facility's failure to report multiple falls of R1 to the Community Care Licensing Division (CCLD).
Complaint Details
Investigation was initiated due to a death report and history of falls for Resident #1. Interviews and record reviews revealed no neglect or suspicious circumstances related to the death. The deficiency cited was for failure to report falls.
Deficiencies (1)
| Description |
|---|
| Facility failed to submit written incident reports to CCLD pertaining to Resident #1's multiple falls, posing a potential personal rights risk to residents in care. |
Report Facts
Census: 97
Total Capacity: 145
Plan of Correction Due Date: Oct 21, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Initiated and conducted the Case Management - Incident visit and investigation |
| Desaree Perera | Licensing Program Manager | Supervisor and assigned Investigator for further investigation |
| Peter Zertuche | Investigator | Assigned to complete the investigation, reviewed records and conducted interviews |
| Nicolle Hozner | Director of Health and Wellness | Met with during inspection and interview |
| Jill Ford | Administrator | Discussed Resident #1's history during investigation |
Inspection Report
Annual Inspection
Census: 97
Capacity: 145
Deficiencies: 1
Oct 14, 2022
Visit Reason
An unannounced Required 1 Year annual inspection was conducted to evaluate compliance with Title 22 Regulations and the Health and Safety Code, with an emphasis on infection control practices and procedures.
Findings
The facility was generally found to be in compliance with health and safety regulations, including operational smoke and carbon monoxide detectors, appropriate hot water temperatures, and sufficient infection control measures. However, a deficiency was noted where the delayed egress auditory alarm in the memory care front desk/medication room was not operational, posing a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Delayed egress auditory alarm located in the memory care front desk/medication room was not operational, posing a potential health and safety risk to residents. | Type B |
Report Facts
Census: 97
Total Capacity: 145
Assisted Living Residents: 64
Memory Care Residents: 23
Hot Water Temperature Range: 111.2-116.6
Deficiency Count: 1
Plan of Correction Due Date: Oct 18, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Miller | Business Office Manager | Met with Licensing Program Analyst during inspection and participated in infection control discussion |
| Jace Evans | Maintenance Director | Participated in physical plant tour and tested delayed egress alarm |
| Anthony Aquino | Director of Culinary Services | Accompanied Licensing Program Analyst during kitchen and kitchen storage tour |
| Jill Ford | Administrator | Named as facility administrator but was not available during inspection |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 145
Deficiencies: 0
Sep 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was physically abused while in care.
Findings
The investigation found insufficient evidence to substantiate the allegation of physical abuse. Records showed discoloration on the resident but no evidence of injury was found during medical evaluation, and the resident denied pain or discomfort. No deficiencies were cited.
Complaint Details
The complaint alleged that Resident #1 was physically abused while in care. The investigation included interviews, record reviews, and facility tours. The allegation was deemed unsubstantiated due to lack of evidence.
Report Facts
Capacity: 145
Census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Jill Ford | Executive Director | Interviewed during the investigation |
| Jennifer Miller | Business Office Manager | Participated in exit interview |
| Jade Alma-Harris | Associate Executive Director | Interviewed during initial complaint inspection |
| Melissa Saldibar | Sales and Marketing Director | Conducted facility tour with Licensing Program Analyst |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 145
Deficiencies: 0
Sep 15, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff were not assisting a resident with hygiene needs.
Findings
The investigation found insufficient evidence to substantiate the allegation that facility staff were not assisting the resident with hygiene needs. The resident was receiving hospice care and had a private caregiver, and care notes did not indicate any refusal of showers. No deficiencies were cited.
Complaint Details
The complaint alleged that facility staff were not assisting Resident #1 with showering. The allegation was deemed unsubstantiated after review of care plans, interviews, and records.
Report Facts
Facility capacity: 145
Resident census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Jill Ford | Executive Director | Interviewed during the investigation |
| Jennifer Miller | Business Office Manager | Participated in exit interview |
| Kristin Heffernan | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 145
Deficiencies: 0
Sep 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee failed to meet a resident's hygiene needs.
Findings
The investigation found insufficient evidence to substantiate the allegation that a resident developed a severe infection while in care. Resident records and interviews indicated the resident was independent with hygiene and received prescribed antibiotics for a tooth abscess unrelated to facility care. No deficiencies were cited.
Complaint Details
The complaint alleged that Resident #1 developed a severe infection due to unmet hygiene needs. The allegation was deemed unsubstantiated after review of care plans, records, interviews, and observations.
Report Facts
Capacity: 145
Census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Jill Ford | Executive Director | Interviewed during the investigation |
| Jennifer Miller | Business Office Manager | Participated in exit interview |
| Melissa Saldibar | Sales and Marketing Director | Participated in facility tour during prior complaint inspection |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 145
Deficiencies: 1
Jul 26, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 07/18/2022 regarding food quality and dishwasher operation at Sage Mountain Senior Living Facility.
Findings
The allegation that food served was not of good quality was substantiated based on observation of expired and spoiled food items posing health risks. The allegation that the facility did not have an operating dishwasher and was unable to sanitize dishes was found unsubstantiated as the dishwasher was operational and maintained.
Complaint Details
The complaint was substantiated regarding food quality issues with spoiled and expired food items served to residents. The dishwasher-related allegations were unsubstantiated after inspection and interviews.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with General Food Service Requirements; food items with expired use by and best by dates were observed, posing immediate health and personal rights risks to residents. | Type A |
Report Facts
Facility Capacity: 145
Census: 96
Deficiency Type: 1
Plan of Correction Due Date: Aug 5, 2022
Dishwasher Repair Dates: Jul 8, 2022
Dishwasher Repair Dates: Apr 26, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jill Ford | Administrator | Facility administrator named in the report |
| Nicolle Hozner | Director of Health and Wellness | Met with Licensing Program Analyst during inspection and interviewee |
| Michael Tabada | Culinary Director | Interviewed regarding food service and kitchen operations |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 145
Deficiencies: 2
Jun 10, 2022
Visit Reason
The inspection was an unannounced Case Management - Incident visit to follow up on self-reported reports, including a resident death and a memory care resident elopement.
Findings
The investigation found that a new agency caregiver allowed a resident to leave a secured memory care unit unassisted, resulting in the resident eloping from the facility, posing an immediate health and safety risk. Additionally, the facility failed to post a phone number on the locked entry door for after-hours guests, creating a potential safety risk.
Complaint Details
The visit was complaint-related following reports of a resident death and a memory care resident elopement. The elopement was substantiated as staff allowed the resident to leave the secured unit unassisted.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| S1 allowed Resident #2 to leave the secured memory care unit unassisted, resulting in elopement and an immediate health and safety risk. | Type A |
| A phone number was not posted on the locked entry door for after hour guests, emergencies, deliveries, etc., posing a potential health, safety, and personal rights risk. | Type B |
Report Facts
Census: 93
Total Capacity: 145
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Ford | Administrator | Met with Licensing Program Analyst during inspection and involved in discussion of findings |
| Nicole Hozner | Director of Health and Wellness | Met with Licensing Program Analyst and involved in discussion of resident incidents and findings |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor of the Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 145
Deficiencies: 1
Mar 30, 2022
Visit Reason
The visit was conducted to investigate complaints received on 10/26/2020 alleging lack of care and supervision resulting in a resident developing a pressure injury, inadequate care leading to a resident's death, retention of a resident with active tuberculosis, and a scabies outbreak at the facility.
Findings
The investigation substantiated the allegation that due to lack of care and supervision, Resident #1 developed a Stage IV pressure injury. The allegation that inadequate care resulted in Resident #2's death was unsubstantiated. The allegations that the facility was retaining a resident with active tuberculosis and had a scabies outbreak were also unsubstantiated based on medical record reviews and public health input. A $500 immediate civil penalty was assessed for the substantiated deficiency.
Complaint Details
The complaint investigation was substantiated for the allegation that lack of care and supervision caused a resident to develop a pressure injury. The allegations regarding inadequate care causing a resident's death, retention of a resident with active tuberculosis, and a scabies outbreak were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not provide adequate care and supervision to Resident #1 which attributed to sustaining pressure injuries not reported and not cared for, posing an immediate health and safety risk. | Type A |
Report Facts
Civil penalty amount: 500
Capacity: 145
Census: 102
Plan of Correction Due Date: Plan of Correction due on or before 04/06/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit and signed the report |
| Jill Ford | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jade Alma-Harris | Administrator | Facility administrator involved in the investigation and communication |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 145
Deficiencies: 1
Mar 22, 2022
Visit Reason
The inspection was an unannounced Case Management - Incident inspection conducted during the investigation of complaint control #29-AS-20220322104533.
Findings
Two staff members (S1 and S2) were found not to be associated with the facility, constituting a violation of criminal record clearance requirements. Civil penalties were assessed for this repeat violation.
Complaint Details
The visit was complaint-related under complaint control #29-AS-20220322104533. The deficiency was substantiated as a repeat violation from a previous citation issued on 11/22/2021.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with criminal record clearance requirements as two staff (S1 & S2) were not associated with the facility, posing an immediate health and safety concern. | Type A |
Report Facts
Civil penalty amount: 100
Civil penalty amount: 100
Number of days penalty assessed for Staff #1: 30
Number of days penalty assessed for Staff #2: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Ford | Administrator | Met with Licensing Program Analyst during inspection and reviewed amended report. |
| Jennifer Miller | Business Office Manager | Participated in exit interview and report review. |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Desaree Perera | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 145
Deficiencies: 1
Mar 2, 2022
Visit Reason
The inspection was conducted as an unannounced Case Management - Incident visit following a written report of an incident involving a resident and staff, as well as a follow-up on a self-reported incident where three memory care residents eloped through a delayed egress patio.
Findings
The inspection found that the delayed egress alarm system in the memory care unit was not loud enough to be heard audibly in all areas, and staff were not carrying iPods that would alert them to the alarm, posing an immediate safety risk to residents. A deficiency was cited related to this issue.
Complaint Details
The visit was triggered by a written report of an incident on 02/12/2022 involving Resident #1 and Staff #1. Further investigation was needed and planned. Additionally, a follow-up was conducted on a self-reported incident on 01/29/2022 where three memory care residents eloped through a delayed egress patio without injury.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Delayed egress system alarm is not loud enough for staff to hear audibly inside all areas of the memory care unit and staff were observed not using iPods which would alert them of the egress system, posing an immediate safety risk to residents. | Type A |
Report Facts
Deficiency Plan of Correction Due Date: Mar 11, 2022
Census: 98
Total Capacity: 145
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Ford | Administrator | Met with Licensing Program Analyst and interviewed during inspection. |
| Nicolle Hoznor | Director of Health and Wellness | Interviewed during inspection. |
| Vivian Reyes | LVN | Interviewed during inspection and participated in memory care unit tour. |
| Jennifer Miller | Business Office Manager | Interviewed during inspection. |
| Jace Evans | Maintenance Director | Tested delayed egress door alarm and provided information about alarm system during memory care unit tour. |
Inspection Report
Annual Inspection
Census: 90
Capacity: 145
Deficiencies: 3
Nov 22, 2021
Visit Reason
An unannounced Required 1-Year annual inspection was conducted with an emphasis on infection control practices and procedures to ensure compliance with Title 22 Regulations and the Health and Safety Code.
Findings
The facility was generally compliant with health and safety regulations, including infection control, fire safety, and physical plant conditions. However, deficiencies were cited related to criminal record clearance for one staff member, unsecured cleaning supplies in the laundry room, and lack of emergency water supply for residents.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| One staff member's criminal record clearance was not transferred to the facility, posing an immediate health, safety, or personal rights risk. | Type A |
| Laundry room with bleach and other cleaning supplies was unlocked, posing an immediate health, safety, or personal rights risk to persons in care. | Type A |
| Facility had no bottled water or any other emergency water supply, posing a potential health, safety, or personal rights risk to persons in care. | Type B |
Report Facts
Deficiencies cited: 3
Capacity: 145
Census: 90
Plan of Correction Due Date: Nov 22, 2021
Plan of Correction Due Date: Dec 3, 2021
Plan of Correction Due Date: Nov 26, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Ford | Administrator | Named as facility administrator; not available during inspection |
| Hannah Robertson | Business Office Manager | Met with Licensing Program Analyst during inspection and discussed infection control |
| Jace Evans | Maintenance Director | Participated in physical plant tour during inspection |
| Christian Torres | Director of Culinary Services | Toured kitchen and discussed food storage and emergency water supply |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 145
Deficiencies: 0
Sep 9, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 04/13/2021 alleging that facility staff were not allowing the LTCO to have confidential meetings with residents.
Findings
The investigation found that LTCO representatives were allowed to move freely within the facility and visit residents as they chose. One LTCO representative remained inside a resident room for the entire visit by choice and did not meet privately with any residents. Based on the information gathered, the complaint allegation was deemed unsubstantiated.
Complaint Details
The complaint allegation was that facility staff were not allowing the LTCO to have confidential meetings with residents. The allegation was found to be unsubstantiated based on interviews and record reviews.
Report Facts
Complaint Control Number: 29-AS-20210413145029
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and interviews. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Martha Berard | Administrator | Facility Administrator interviewed during investigation. |
| Jill Ford | Facility Administrator met with during the visit. | |
| Tammy Doss | Regional Director of Operations | Met with Licensing Program Analyst during the visit. |
| Melissa Saldibar | Sales and Marketing Director | Conducted facility tour with Licensing Program Analyst. |
| Annabelle Amaya | Facility staff who conducted facility tour with LPAs. |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 145
Deficiencies: 0
Jul 22, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility trash was not emptied on a regular basis.
Findings
The investigation found no issues or concerns regarding trash removal; the allegation was deemed unsubstantiated based on interviews with residents and staff and observations during the physical plant tour.
Complaint Details
The complaint alleged that facility trash was not emptied regularly. After interviews with six residents and one staff member, and a physical plant tour, the allegation was found unsubstantiated.
Report Facts
Capacity: 145
Census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Jacob Primeau | Interim Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 145
Deficiencies: 1
Jun 21, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 05/24/2021 regarding unclean resident rooms and disrepair in the facility.
Findings
The investigation substantiated that Resident 1's room was not cleaned, with multiple stains from dog excrement on the carpet, and that the room was in disrepair, including an indentation in the kitchen wall and a missing toilet paper holder bracket. The facility corrected the deficiencies during the visit by replacing the carpet and repairing the wall and toilet paper holder.
Complaint Details
The complaint investigation was substantiated based on evidence that Resident 1's room was not cleaned and was in disrepair. The allegations included unclean resident rooms and room disrepair, both of which were confirmed during the investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to keep Resident 1's bedroom clean, safe, and sanitary, posing a potential safety risk to residents. | Type B |
Report Facts
Capacity: 145
Census: 68
Resident bedrooms observed clean: 7
Deficiency Type: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation and cited deficiencies |
| Martha Berard | Administrator | Facility administrator met with LPAs during the investigation and acknowledged the findings |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 145
Deficiencies: 1
May 27, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 05/24/2021 regarding a malodorous room in the facility.
Findings
The investigation substantiated the allegation that Resident 1's bedroom was malodorous due to a strong odor of pet urine. The facility failed to maintain the room in a clean, safe, and sanitary condition, posing a potential safety risk to residents.
Complaint Details
The complaint was substantiated based on observations and evidence gathered during the investigation. The allegation of a malodorous room was confirmed.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87303(a) Maintenance and operation: The facility shall be clean, safe, sanitary and in good repair at all times. The facility failed to keep Resident 1's bedroom clean, safe and sanitary. | Type B |
Report Facts
Deficiency Plan of Correction Due Date: Jun 11, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation and cited deficiencies. |
| Martha Berard | Executive Director | Facility administrator who agreed to the plan of correction. |
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