Inspection Report Summary
Most inspections found deficiencies related to resident care, documentation, and safety, with several complaint investigations substantiated over the past two years. The most recent report from September 25, 2025, had no deficiencies and found an unfounded complaint about fee increase notice. Earlier substantiated issues included improper care of a resident’s pressure injury, failure to maintain current medical assessments, and noncompliant eviction notices, along with medication management and safety concerns such as unsecured medications and unlocked hazardous areas. The facility also faced a $500 fine in January 2024 for employing a staff member without proper fingerprint clearance. While many complaints were substantiated, several investigations found no violations, and the latest inspection suggests some improvement in compliance.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 57
Capacity: 90
Deficiencies: 0
Sep 25, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not provide a resident with the required notice of fee increase.
Findings
The investigation found that the complaint was unfounded as the rate increase letter sent to the resident met regulatory requirements. Interviews were conducted with staff and attempts were made to contact the resident.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false, could not have happened, or was without a reasonable basis.
Report Facts
Capacity: 90
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenda Bertucci | Executive Director | Met with Licensing Program Analysts during the investigation |
| Gregory Clark | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 90
Deficiencies: 0
Mar 20, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report regarding a missing resident (R1).
Findings
The facility had been attempting to contact the missing resident without success, and the police were involved in the investigation. Staff interviews and file reviews confirmed that the resident was allowed to leave unassisted and family was providing updates on the police investigation. No deficiencies were cited during this visit.
Complaint Details
The visit was triggered by a complaint or incident report about a missing resident. The investigation included review of the resident's file and interviews with staff. The complaint was not substantiated as no deficiencies were found.
Report Facts
Facility capacity: 90
Resident census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenda Bertucci | Executive Director | Met with Licensing Program Analysts during the visit and involved in the incident report discussion |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 90
Deficiencies: 1
Feb 25, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff did not properly care for a resident's pressure injury and related concerns about resident care and cleanliness.
Findings
The allegation that staff did not properly care for the resident's pressure injury was substantiated, citing a violation of California Code of Regulations, Title 22. Other allegations regarding extended wheelchair use, unclean bed, and unclean room were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation involved improper care of a resident's pressure injury. Other allegations about wheelchair use, bed cleanliness, and room sanitation were unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Staff did not properly care for resident's pressure injury, posing a potential health and safety risk. |
Report Facts
Facility capacity: 90
Census: 50
Plan of Correction due date: Mar 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| Glenda Bertucci | Executive Director | Facility representative met during the investigation |
| Gilbert M Castro | Administrator | Facility administrator mentioned in report header |
Inspection Report
Annual Inspection
Census: 50
Capacity: 90
Deficiencies: 0
Jan 7, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and facility operations.
Findings
The facility was found to be generally safe and sanitary with adequate lighting, emergency preparedness, and proper maintenance of safety equipment. Several resident and staff records were reviewed and found complete. Some forms require updating and submission to the licensing division.
Report Facts
Fire clearance capacity: 40
Hot water temperature: 109.8
Staff records reviewed: 5
Resident records reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenda Bertucci | Executive Director | Met with Licensing Program Analyst during inspection |
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 90
Deficiencies: 1
Dec 4, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted by Licensing Program Analysts to assess deficiencies related to the facility's compliance with medical assessment documentation requirements.
Findings
The Licensing Program Analysts observed that the Physician Report for resident R1 had not been updated, constituting a deficiency for failure to maintain current medical assessments, which poses a potential health and safety risk.
Complaint Details
The visit was complaint-related and involved a substantiated deficiency regarding the outdated Physician Report for resident R1.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain and keep on file a current medical assessment signed by a physician for resident R1. | Type B |
Report Facts
Capacity: 90
Census: 47
Deficiencies cited: 1
Plan of Correction Due Date: Jan 6, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Fowler | Licensing Program Analyst | Conducted the complaint investigation and cited the deficiency |
| David Doidge | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Lostica | Business Office Manager | Met with Licensing Program Analysts during the inspection |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 90
Deficiencies: 1
Oct 28, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-08-26 regarding insufficient notice provided to a resident's authorized person about a change in use of the facility.
Findings
The investigation found that the facility provided a 60-day notice letter dated July 17, 2024, to residents and families about relocating 3rd floor residents and de-licensing the 3rd floor. However, the letter did not comply with California Community Care Licensing regulations and lacked many required components for a notice of eviction. The allegation was substantiated.
Complaint Details
The complaint alleged that staff did not provide sufficient notice to the resident's authorized person of change in use. The allegation was substantiated based on interviews and record reviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 60-day notice letter given to residents was not in compliance with regulation, posing a potential health, safety, or personal rights risk to persons in care. | Type B |
Report Facts
Capacity: 90
Census: 47
Deficiency due date: Nov 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Clark | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Glinda Bertucci | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 47
Capacity: 90
Deficiencies: 1
Oct 24, 2024
Visit Reason
The visit was a case management inspection conducted in response to a letter received from the facility regarding intent to de-license the third floor and convert those units for independent individuals aged 55 and older, without proper approval from Community Care Licensing.
Findings
The facility was found to have changed its plan of operation without obtaining approval from Community Care Licensing, specifically advertising independent renters aged 55 and older on its website, which poses a potential health, safety, or personal rights risk to assisted living residents.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit significant changes in the plan of operation to the licensing agency for approval, evidenced by changing the plan of operation without CCLD approval. | Type B |
Report Facts
Plan of Correction Due Date: Nov 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenda Bertucci | Executive Director | Met with Licensing Program Analyst during the visit and involved in discussion of findings |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 90
Deficiencies: 0
Sep 18, 2024
Visit Reason
Unannounced complaint investigation conducted due to allegations that staff did not assist a resident in feeding and that a resident developed a pressure injury while in care.
Findings
The investigation found that the resident was able to feed independently despite a physician's report indicating otherwise, and that the resident was repositioned every 1-2 hours with wound care provided by an outside agency. The allegations were determined to be unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint was unsubstantiated based on investigation findings; no preponderance of evidence to prove alleged violations occurred.
Report Facts
Capacity: 90
Census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted the complaint investigation |
| Glenda Bertucci | Executive Director | Met with Licensing Program Analyst during investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 90
Deficiencies: 1
Sep 5, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not ensure that a resident took medication as prescribed.
Findings
The investigation found that medications were discovered under a resident's bed, indicating the resident was likely 'cheek-ing' medications and not taking them as prescribed. The allegation was substantiated based on interviews and observations.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation involved staff not ensuring a resident took medication as prescribed, with medications found hidden under the resident's bed.
Deficiencies (1)
| Description |
|---|
| Failure to assist residents with self-administered medications as needed, resulting in medications found under resident R3's bed posing a potential health, safety, or personal rights risk. |
Report Facts
Capacity: 90
Census: 41
Deficiency Type: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Clark | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation |
| Glinda Bertucci | Executive Director | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 90
Deficiencies: 0
Sep 5, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not keep the resident's room clean or sanitary.
Findings
The investigation found that the apartments toured were clean and odor free, with weekly housekeeping schedules posted. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleging staff did not keep the resident's room clean or sanitary was investigated and found to be unsubstantiated.
Report Facts
Capacity: 90
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Clark | Licensing Program Analyst | Conducted the complaint investigation |
| Glinda Bertucci | Executive Director | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Census: 46
Capacity: 90
Deficiencies: 1
Jul 30, 2024
Visit Reason
The visit was a case management visit related to an incident reported by the facility involving a resident who was found outside the facility after being dropped off by a stranger.
Findings
The resident was not harmed, staff training was conducted, and the resident was reassessed by a doctor. A technical violation advisory was issued during the visit. The facility plans to ensure the resident's safety pending updated medical information.
Deficiencies (1)
| Description |
|---|
| Technical violation advisory issued during the visit |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luisa Fontanilla | Licensing Program Analyst | Conducted the case management visit |
| Gendelle Camarillo | Resident Services Director | Met with Licensing Program Analyst during the visit |
| Glenda Bertucci | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 90
Deficiencies: 1
May 29, 2024
Visit Reason
The visit was an unannounced case management visit conducted as part of a complaint investigation (#15-AS-20240523150242).
Findings
A deficiency was observed where a staff member (S1) was fingerprint cleared but not associated with the facility in the Guardian system. The facility corrected this during the visit by associating S1 to the facility.
Complaint Details
The visit was conducted while investigating complaint #15-AS-20240523150242.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to associate fingerprint cleared staff (S1) to the facility in the Guardian system, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 90
Census: 43
Deficiencies cited: 1
Plan of Correction Due Date: May 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted the inspection and cited the deficiency. |
| Jeralyn May | Interim Executive Director | Met with the Licensing Program Analyst during the visit. |
| Gilbert M Castro | Administrator/Director | Named as facility administrator/director. |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 90
Deficiencies: 1
Mar 20, 2024
Visit Reason
Unannounced visit to investigate a complaint alleging that the licensee is not assuring the provision of laundry services for residents' clothing without additional cost.
Findings
The investigation substantiated the allegation that residents were being charged for personal laundry services starting March 2024, which is not in compliance with regulations. Records and interviews confirmed the charges and notification to residents.
Complaint Details
Complaint was substantiated. The allegation that the licensee charged residents for laundry services was confirmed by records and interviews. The licensee failed to comply with the requirement to provide laundry services without additional cost.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee charged residents for personal laundry services, violating Title 22 CCR 87307(a)(30)(F) which requires basic laundry service to be provided without additional cost. | Type B |
Report Facts
Capacity: 90
Census: 42
Plan of Correction Due Date: Apr 3, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeralyn May | Interim Administrator | Discussed deficiency and plan of correction; involved in interviews |
| Lisa Lostica | Senior Business Office Manager | Met with Licensing Program Analyst during investigation |
| Alicia Delmundo | Licensing Program Analyst | Conducted complaint investigation |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 90
Deficiencies: 1
Mar 20, 2024
Visit Reason
The inspection visit was conducted to investigate a complaint (Control # 15-AS-20240311152642) regarding facility compliance.
Findings
The Licensing Program Analyst observed that the laundry room where laundry supplies are kept was unlocked, posing an immediate health and safety risk to persons in care. A deficiency was cited for failure to secure hazardous items as required by Title 22 California Code of Regulations.
Complaint Details
The visit was complaint-related under Control # 15-AS-20240311152642. The deficiency was substantiated as the unlocked laundry room was observed. Failure to submit proof of correction by the plan of correction due date may result in a civil penalty.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Laundry room was unlocked, allowing access to disinfectants, cleaning solutions, poisons, and other hazardous items, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 90
Census: 42
Deficiencies cited: 1
Plan of Correction Due Date: Mar 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Delmundo | Licensing Program Analyst | Observed the unlocked laundry room and conducted the inspection |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing the inspection |
| Jeralyn May | Interim Administrator | Discussed deficiency and plan of correction |
| Lisa Lostica | Senior Business Office Manager | Informed about the unlocked laundry room during inspection |
| Gendelle Nebril Camarillo | Staff member present on the floor when unlocked laundry room was observed |
Inspection Report
Annual Inspection
Census: 44
Capacity: 90
Deficiencies: 1
Jan 31, 2024
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate compliance with licensing requirements at Pacifica Senior Living San Leandro.
Findings
The facility was inspected thoroughly including resident apartments, common areas, and records. One deficiency was found where a staff member was not fingerprint cleared, posing an immediate risk. A civil penalty of $500 was assessed.
Deficiencies (1)
| Description |
|---|
| One staff member was not fingerprint cleared prior to working in the facility. |
Report Facts
Civil penalty amount: 500
Residents records reviewed: 5
Staff records reviewed: 5
Fingerprint cleared staff: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adiam Welday | Executive Director | Met with Licensing Program Analyst during inspection |
| Gilbert M Castro | Administrator | Facility administrator named in report header |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the inspection and authored the report |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Census: 46
Capacity: 90
Deficiencies: 1
Jan 18, 2024
Visit Reason
The visit was an unannounced case management follow-up on a death report received by Community Care Licensing regarding a resident who passed away on 2023-11-02.
Findings
The Administrator failed to submit the required death report within seven days as mandated by California Code of Regulation, Title 22, posing a potential personal rights risk to the resident. Additional documentation related to the resident's death was obtained during the visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a death report within seven days as required by reporting regulations. | Type B |
Report Facts
Deficiency count: 1
Plan of Correction due date: Jan 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert M Castro | Administrator | Named in relation to the deficiency regarding failure to submit death report. |
| Adiam Welday | Executive Director | Met with Licensing Program Analyst during the visit. |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing the licensing program. |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 90
Deficiencies: 0
Oct 20, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility refused to allow a resident to return to the facility after hospitalization and skilled nursing facility stay.
Findings
The investigation found that the facility informed the resident and family that they could not care for the seriousness of the wound and suggested waiting for the wound to heal or obtaining hospice services. There was insufficient evidence to prove the alleged violation, so the complaint was unsubstantiated.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.
Report Facts
Capacity: 90
Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation visit |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| Maria Locstica | Business Office Manager | Met with Licensing Program Analyst during the visit |
| Gilbert M Castro | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 90
Deficiencies: 0
Aug 2, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-12-20 regarding staff not repositioning residents, not assisting with transfers, not checking on residents, and impaired staff putting residents at risk.
Findings
All allegations investigated were found to be unsubstantiated based on interviews, record reviews, and observations conducted during the visit. There was no preponderance of evidence to prove any of the alleged violations occurred.
Complaint Details
The complaint included allegations that staff were not repositioning residents as needed, not assisting residents with transfers, not checking on residents, and that impaired staff put residents at risk. All allegations were investigated and found unsubstantiated.
Report Facts
Capacity: 90
Census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert Castro | Administrator | Met with during inspection and mentioned in findings |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 90
Deficiencies: 1
May 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-02-21 regarding medication security and administration at Pacifica Senior Living San Leandro.
Findings
The allegation that staff did not secure residents' medications was substantiated due to unsecured medication delivery posing immediate health and safety risks. Allegations that staff did not administer medications as prescribed, did not properly document medications, and were not properly trained were found to be unsubstantiated based on record reviews and staff interviews.
Complaint Details
The complaint was substantiated regarding medication security. The allegation that staff did not secure resident's medications was substantiated. Other allegations related to medication administration, documentation, and staff training were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to secure medication when being delivered to resident’s apartment, posing immediate health and safety risk. | Type A |
Report Facts
Capacity: 90
Census: 54
Deficiencies cited: 1
Plan of Correction Due Date: May 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert Castro | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Carol Fowler | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 57
Capacity: 90
Deficiencies: 0
Feb 15, 2023
Visit Reason
The visit was an unannounced case management visit to deliver an amended report regarding a prior allegation that the facility was in disrepair.
Findings
No deficiencies were cited during the visit. The amended report was delivered to the administrator and an exit interview was conducted.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert Castro | Administrator | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Capacity: 90
Deficiencies: 1
Jan 26, 2023
Visit Reason
The visit was an unannounced case management inspection to investigate allegations of the facility being in disrepair, specifically water damage in a resident's apartment.
Findings
The Licensing Program Analyst observed water damage in the walls and ceiling of one resident's apartment, confirmed by resident interviews, and found the allegations substantiated. The facility did not comply with maintenance and operation requirements, posing a potential safety risk.
Complaint Details
The complaint was substantiated based on observations and interviews. The allegation was that the facility was in disrepair due to water damage in a resident's apartment.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Water damage in the walls and ceiling of Apartment 12, posing potential safety risk to persons in care. | Type B |
Report Facts
Capacity: 90
Deficiency count: 1
Plan of Correction Due Date: Feb 23, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Clark | Licensing Program Analyst | Conducted the investigation and cited deficiencies |
| Gilbert Castro | Administrator | Facility administrator met during the investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 57
Capacity: 90
Deficiencies: 0
Jan 25, 2023
Visit Reason
The visit was an unannounced annual Infection Control Inspection conducted to assess the facility's infection control practices and compliance.
Findings
The inspection found the facility to be compliant with infection control standards, including adequate food supply, posted visitor policies, proper screening procedures, sufficient PPE supplies, and functional safety equipment. No deficiencies were cited during the visit.
Report Facts
Capacity: 90
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert Castro | Administrator | Met with Licensing Program Analyst during inspection |
| Paris Watson | Licensing Program Analyst | Conducted the annual Infection Control Inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 90
Deficiencies: 2
Jan 17, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2023-01-10 alleging that the facility was in disrepair.
Findings
The investigation found water damage to the ceiling and walls in one resident's apartment due to leaking during a storm, substantiating the complaint. Additional findings included frozen condensers on the roof causing heating issues, which were addressed by maintenance and contractors. Facility temperatures were comfortable during the visit.
Complaint Details
The complaint was substantiated based on observations and interviews. The allegation was that the facility was in disrepair, specifically water damage and heating issues.
Deficiencies (2)
| Description |
|---|
| Water damage to ceiling and walls in a resident's apartment due to leaking during a storm |
| Frozen condensers on the roof causing heating issues |
Report Facts
Facility capacity: 90
Census: 59
Temperature readings: 73
Temperature readings: 72
Temperature readings: 72
Temperature readings: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert Castro | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Gregory Clark | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 90
Deficiencies: 0
Jun 2, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not providing a comfortable temperature for residents.
Findings
The investigation found that the facility has centralized air conditioning only in common areas and hallways, with heaters but no air conditioning units in residents' rooms. Most residents did not report temperature issues, and temperature measurements were within acceptable ranges. The allegation was unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint was unsubstantiated based on interviews with staff and residents, temperature measurements, and lack of evidence supporting the allegation.
Report Facts
Temperature measurement: 72.9
Temperature measurement: 81.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Delmundo | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Lostica | Senior Business Office Manager | Met with Licensing Program Analyst during investigation |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
| Gilbert M Castro | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 90
Deficiencies: 2
May 4, 2022
Visit Reason
The inspection was conducted as an investigation of a complaint regarding failure to report a positive COVID-19 case and maintenance issues within the facility.
Findings
The facility failed to report a positive COVID-19 case to Community Care Licensing and Local Public Health. Additionally, maintenance deficiencies were found including a broken shower head fixture holder and a clogged P-trap in resident apartments.
Complaint Details
Investigation of complaint (15-AS-20220428123317) regarding failure to report a positive COVID-19 case and maintenance issues.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The shower head holder fixture in a resident apartment was broken and the P-trap in the kitchen sink of another apartment was clogged, posing potential personal rights risks. | Type B |
| Failure to report the positive case of COVID-19 to Community Care Licensing and Local Public Health. | Type B |
Report Facts
Capacity: 90
Census: 62
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert Castro | Executive Director | Confirmed failure to report COVID-19 case |
| Lisa Lostica | Senior Business Office Manager | Met during inspection and provided report copy |
| Alicia Delmundo | Licensing Program Analyst | Conducted inspection and investigation |
| Bennett Fong | Licensing Program Manager | Supervisor of licensing program |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 90
Deficiencies: 3
May 4, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a water leak, lack of grab bars in a resident's bathroom, and the facility not being maintained at a comfortable temperature.
Findings
The investigation substantiated the allegations, finding water leaks in multiple apartments and hallways, a missing grab bar in a resident's shower, and uncomfortable temperatures in the dining area and residents' apartments due to non-functioning heaters.
Complaint Details
The complaint investigation was substantiated based on interviews, inspections, and record reviews. Allegations included water leaks, missing grab bars, and uncomfortable temperatures. The facility was found non-compliant with Title 22 California Code of Regulations sections 87303(a), 87303(e)(4), and 87303(b).
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Water leaking from bathroom ceiling and bedroom ceiling in one resident's apartment; sink faucet leaking in another apartment; water damage in third floor hallway ceiling posing safety risks. | Type B |
| Resident's shower room missing a grab bar, posing potential safety risk. | Type B |
| Facility not maintained at a comfortable temperature; heaters in residents' apartments and dining area not working, posing health and personal right risks. | Type B |
Report Facts
Capacity: 90
Census: 62
Deficiencies cited: 3
Plan of Correction Due Date: May 18, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Delmundo | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bennett Fong | Licensing Program Manager | Oversaw the complaint investigation |
| Lisa Lostica | Senior Business Office Manager | Facility representative who met with the Licensing Program Analyst during inspection |
| Gilbert M Castro | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 90
Deficiencies: 2
Apr 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident sustaining a fracture while in care and failure to provide proper notification of eviction to the resident's representative.
Findings
The investigation substantiated that a resident sustained a fractured spine after multiple falls and that the facility failed to reassess the resident's care needs. It was also substantiated that the facility did not provide proper eviction notification to the resident's representative. One allegation regarding failure to notify about rate increases was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that a resident sustained a fracture while in care and that the facility failed to provide proper eviction notification. The allegation regarding failure to notify about rate increases was unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to conduct reassessment or update Appraisal Needs and Services Plan after resident's multiple falls and dementia diagnosis. | Type A |
| Failure to issue a 30-day eviction notice to resident's representative and refusal to take resident back from skilled nursing facility. | Type B |
Report Facts
Civil penalty amount: 500
Capacity: 90
Census: 59
Plan of Correction Due Date: Apr 19, 2022
Plan of Correction Due Date: Apr 25, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Catherine Lin | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Lisa Lostica | Senior Business Office Manager | Interviewed during investigation and involved in findings discussion. |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 90
Deficiencies: 1
Apr 18, 2022
Visit Reason
The visit was a case management visit conducted while delivering complaint investigation findings related to a resident's multiple falls and lack of reassessment documentation.
Findings
The investigation found that a resident diagnosed with Dementia had multiple falls between 09/2019 and 02/2020, but the facility did not conduct reassessment or update the resident’s Appraisal Needs and Services Plan. Staff were unaware of the resident’s Dementia diagnosis. A deficiency was cited for failure to meet reappraisal requirements.
Complaint Details
The visit was complaint-related, investigating multiple falls of resident R1 and lack of reassessment documentation. The deficiency was substantiated and cited.
Deficiencies (1)
| Description |
|---|
| Failure to update the pre-admission appraisal and conduct reassessments to document changes in the resident's condition following multiple falls. |
Report Facts
Deficiency Type: Type B deficiency cited under Section 87463(a) Reappraisals
Plan of Correction Due Date: POC due date is 04/25/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Catherine Lin | Licensing Program Analyst | Conducted the case management visit and complaint investigation |
| Bennett Fong | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
| Lisa Lostica | Senior Business Office Manager | Met with Licensing Program Analyst during the visit |
Inspection Report
Routine
Census: 58
Capacity: 90
Deficiencies: 0
Apr 14, 2022
Visit Reason
Unannounced infection control inspection conducted as a required 1-year visit to assess compliance with infection control standards.
Findings
The facility was found to have adequate infection control measures including proper PPE use, sufficient food supply, visitor screening, and posted hygiene policies. No deficiencies were cited during the visit.
Report Facts
PPE supply duration: 30
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert Castro | Administrator | Met with Licensing Program Analyst during inspection |
| Gregory Clark | Licensing Program Analyst | Conducted the infection control inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 90
Deficiencies: 0
Mar 15, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not regularly observe residents for change in condition.
Findings
The investigation found no preponderance of evidence to substantiate the allegation. The facility experienced a brief power outage affecting the call button system, but staff provided increased monitoring and bells to residents requiring higher care. No deficiencies were cited and technical assistance was provided.
Complaint Details
The complaint was unsubstantiated due to lack of sufficient evidence. The reporting party requested to remain anonymous.
Report Facts
Capacity: 90
Census: 59
Power outage duration (minutes): 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert Castro | Administrator | Met with Licensing Program Analysts during investigation and provided information about the power outage and resident monitoring |
| Leslie Ibo | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 90
Deficiencies: 0
Oct 7, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding multiple allegations including resident fracture, medication mishandling, hygiene issues, and food service adequacy.
Findings
The investigation found no evidence to substantiate the allegations. Staff responded timely to call buttons, medication refills were handled properly, hygiene and housekeeping schedules were maintained, and food service was adequate. No deficiencies were cited during the visit.
Complaint Details
The complaint investigation was unsubstantiated based on lack of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 90
Census: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ibo | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
| Gerald Castro | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Capacity: 90
Deficiencies: 1
Aug 13, 2021
Visit Reason
The inspection visit was a case management visit conducted in response to an AWOL incident report involving a resident who was found outside the facility after leaving through a fire exit door.
Findings
The facility was found to have deficiencies related to the care of a resident diagnosed with dementia, which is not appropriate for the facility's design. This posed an immediate health and safety risk to persons in care.
Complaint Details
The visit was triggered by a complaint incident report of a resident with dementia who left the facility through a fire exit door and was found by police walking on the street. The complaint was substantiated by the findings.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet personal rights of residents by not providing safe, healthful, and comfortable accommodations, specifically related to caring for a resident with dementia in a facility not designed for such care. | Type A |
Report Facts
Capacity: 90
Deficiency count: 1
Plan of Correction Due Date: Aug 16, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gilbert Castro | Executive Director | Met during the visit and involved in the incident report |
| Leslie Ibo | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection |
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