Inspection Report Summary
Most inspections found deficiencies related primarily to medication management, staffing shortages, and resident care, including hygiene and assistance needs. Several complaint investigations were substantiated, revealing medication errors such as incorrect dosing and administering medications outside prescribed times, as well as insufficient staffing that delayed response to resident calls and affected care quality. The facility also faced issues with personal rights violations and refund policies in earlier reports, along with some immediate health and safety risks due to staff working without proper clearance or association. The most recent report from October 22, 2025, was clean with no deficiencies noted, indicating improvement since prior findings. Several complaint investigations were unsubstantiated, showing that not all concerns led to citations.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 96
Capacity: 140
Deficiencies: 0
Oct 22, 2025
Visit Reason
The inspection was a required 1-year unannounced annual visit to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with operational, physical plant, safety, staffing, resident records, activities, food service, incidental medical services, and disaster preparedness requirements. No deficiencies were noted during the exit interview.
Report Facts
Staff count: 48
Administrator count: 1
Hospice residents: 4
Fire extinguisher inspection date: Oct 14, 2025
Sprinkler system certification date: May 19, 2025
Administrator certificate expiration: Jun 23, 2026
Certificate of liability expiration: Oct 1, 2026
Food perishables storage duration: 2
Food non-perishables storage duration: 7
Freezer temperature: 0
Refrigerator temperature: 40
Last disaster drill date: Oct 21, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sanjuana Enriquez | Administrator | Met with Licensing Program Analyst during inspection |
| Melisa Rankin | Licensing Program Analyst | Conducted the 1-year required annual visit |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 140
Deficiencies: 1
Aug 5, 2025
Visit Reason
The visit was a Case Management - Incident visit conducted to issue deficiencies related to a medication error discovered during a complaint visit.
Findings
The facility did not follow the physician's order when medication was given outside the prescribed time frame, specifically administering a PRN Tramadol at 9:55 am instead of at bedtime as ordered, posing a potential health and safety risk to the resident.
Complaint Details
The visit was triggered by a complaint regarding a medication error involving Resident 1, where medication was administered outside the prescribed time frame. The complaint was substantiated based on interviews and record reviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not comply with the requirement to assist residents with self-administered medications as needed, giving medication outside the prescribed time frame. | Type B |
Report Facts
Capacity: 140
Census: 89
Plan of Correction Due Date: Sep 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sanjuana Enriquez | Administrator | Met with Licensing Program Analyst during the visit |
| Melisa Rankin | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 0
Aug 5, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not prevent a resident from sustaining multiple falls and that staff administered medication not prescribed to a resident.
Findings
The investigation found the allegations unsubstantiated based on record reviews and staff interviews. The resident experienced three unwitnessed falls within a 24-hour period, and medication was administered outside the prescribed time, but no preponderance of evidence proved violations occurred.
Complaint Details
The complaint involved two allegations: 1) staff did not prevent a resident from sustaining multiple falls, and 2) staff administered medication not prescribed to the resident. Both allegations were found unsubstantiated after investigation.
Report Facts
Facility capacity: 140
Number of incidents: 3
Medication administration time: 9.55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Sanjuana Enriquez | Administrator | Facility administrator met during investigation |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 140
Deficiencies: 0
Mar 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were violating residents' personal rights by not allowing a resident to leave the facility unassisted when requested.
Findings
The investigation found that the resident had a diagnosis of dementia and the facility staff followed regulations by redirecting residents at risk for elopement and supervising them if they insisted on leaving. There was insufficient evidence to substantiate the allegation, so it was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff were violating residents' personal rights by preventing a resident from leaving the facility unassisted. The allegation was unsubstantiated after review of medical records and interviews with staff and residents.
Report Facts
Capacity: 140
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joanna Casillas | Administrator | Met with Licensing Program Analyst during the investigation |
| Vanessa Vazquez | Wellness Director | Met with Licensing Program Analyst during the investigation |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 88
Capacity: 140
Deficiencies: 0
Oct 3, 2024
Visit Reason
The inspection was a required 1-year unannounced annual visit to evaluate the facility's compliance with licensing and operational standards.
Findings
The facility was found to be in compliance with infection control, physical plant safety, operational requirements, staffing, personnel records, resident records, food service, incidental medical services, and disaster preparedness. No deficiencies were cited during the inspection.
Report Facts
Full time staff: 49
Administrators: 1
Residents on hospice: 3
Non-ambulatory residents: 46
Bedridden residents: 1
Fire extinguisher inspection date: Oct 20, 2023
Carbon monoxide detector test date: Oct 3, 2024
Sprinkler system test date: May 31, 2024
Food perishables supply: 2
Food non-perishables supply: 7
Disaster drill date: Aug 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanna Enriquez | Administrator | Met with Licensing Program Analyst during inspection |
| Erika Miller | Licensing Program Analyst | Conducted the 1-year required annual visit |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 140
Deficiencies: 1
Oct 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 08/09/2024 regarding inadequate medication administration for pain management, insufficient assistance during mealtime, and failure to reposition residents.
Findings
The investigation found the allegation of failure to provide pain medication unsubstantiated due to lack of preponderance of evidence. However, allegations regarding inadequate assistance during mealtime and failure to reposition residents were substantiated, resulting in staff termination and citation of regulatory violations.
Complaint Details
The complaint investigation was triggered by allegations that facility staff did not provide medication for pain management to a resident, did not provide adequate assistance during mealtime, and failed to reposition residents. The pain medication allegation was unsubstantiated, while the assistance and repositioning allegations were substantiated. Staff member S2 was terminated due to failure to perform duties.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Additional Personal Rights of Residents ... care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. | Type B |
Report Facts
Capacity: 140
Census: 90
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erika Miller | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
| Amy Bowman | Wellness Director | Interviewed during investigation and provided information on facility policies |
| Sanjuana Enriquez | Administrator | Interviewed during investigation |
| Staff 1 | Identified resident needing assistance with meals and described incident | |
| Staff 2 | Staff member terminated for failure to assist and reposition residents |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 140
Deficiencies: 0
Jun 10, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not provide proper notification of rate increases and that facility staff did not communicate with the authorized representative.
Findings
The investigation found insufficient evidence to substantiate the allegations. Documentation showed that 60-day notifications of rate increases were sent via First Class Mail, and interviews indicated no failure in communication by staff. The complaint was determined to be unsubstantiated.
Complaint Details
The complaint involved two allegations: 1) staff did not provide proper notification of rate increases, and 2) facility staff did not communicate with the authorized representative. Both allegations were found unsubstantiated based on interviews and documentation reviewed.
Report Facts
Capacity: 140
Census: 94
Complaint Control Number: 29-AS-20240520154222
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sanjuana Enriquez | Administrator | Met with Licensing Program Analyst during the investigation and involved in communication regarding allegations |
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 140
Deficiencies: 0
Jun 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to allegations that staff did not dispense resident’s medication according to doctor’s orders and did not ensure the resident received contracted amenities.
Findings
The investigation found insufficient evidence to substantiate the allegations. Medication administration records showed the resident received prescribed medications as ordered, and the issue with contracted amenities related to TV service incompatibility was addressed with temporary solutions and family communication.
Complaint Details
The complaint involved two main allegations: 1) Staff did not dispense Resident 1's pain medication as prescribed, including refusal to give medication when requested. 2) Staff did not ensure the resident received contracted amenities, specifically related to TV service interruption and incompatibility after a service update. Both allegations were found unsubstantiated based on interviews, medication records, and facility documentation.
Report Facts
Census: 94
Total Capacity: 140
Complaint Control Number: 29-AS-20240524153030
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sanjuana Enriquez | Administrator | Met during investigation and involved in findings discussion |
| Melisa Rankin | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation report |
| Amy Bowman | Designee | Met during investigation and involved in findings discussion |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 140
Deficiencies: 3
Feb 2, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including staff mismanagement of resident medication, inadequate staffing to meet residents' needs, failure to follow admissions agreement, and facility cleanliness issues.
Findings
The investigation substantiated all allegations: a medication error where a resident received three times the prescribed dose of Warfarin; insufficient staffing levels causing neglect and inadequate care; failure to fully comply with admissions agreement regarding housekeeping, grooming, and shower assistance; and facility cleanliness issues with stained dining room tablecloths. A technical violation and a $250 civil penalty for a repeat violation were issued.
Complaint Details
The complaint investigation was substantiated. Allegations included medication mismanagement where a resident received an overdose of Warfarin; inadequate staffing leading to neglect of residents; failure to follow admissions agreement regarding housekeeping and personal care; and facility cleanliness issues. Interviews with staff, residents, and document reviews supported these findings.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Staff did not properly assist resident with medications and issued incorrect dose posing immediate health and safety risk. | Type A |
| Staffing levels were insufficient at all times to meet resident needs, posing potential health and safety risk. | Type B |
| Staff did not properly assist residents with showers or have a system to make up missed showers, posing potential health and safety risk. | Type B |
Report Facts
Civil penalty amount: 250
Capacity: 140
Census: 95
Plan of Correction due date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation and signed the report. |
| Vanessa Vazquez | Wellness Coordinator | Met with Licensing Program Analyst during the investigation and provided information about medication error and staffing. |
| Sanjuana Enriquez | Administrator | Facility Administrator involved in interviews and discussions regarding staffing and care issues. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 140
Deficiencies: 2
Feb 2, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including staff not meeting a resident's hygiene needs and charging for services not rendered.
Findings
The investigation substantiated that staff did not properly assist a resident with showers and lacked a system to make up missed showers, posing a potential health and safety risk. The facility issued refunds for missed showers. Another allegation regarding adherence to the admission agreement about cable services was found unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding staff not meeting resident’s hygiene needs and charging for services not rendered. The allegation about staff not adhering to the admission agreement related to cable services was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff did not properly assist resident with showers or have a system to make up missed showers, posing a potential health and safety risk. | Type B |
| Facility charged fees without clear specification and delayed refunding missed shower charges, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 140
Census: 95
Refunded missed showers: 3
Plan of Correction Due Date: Feb 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
| Sanjuana Enriquez | Administrator | Facility administrator interviewed regarding findings |
| Vanessa Vazquez | Wellness Coordinator | Met with Licensing Program Analyst during inspection |
| Maintenance Director | Interviewed regarding cable service issues | |
| Medtech | Interviewed regarding shower refusals and procedures |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 140
Deficiencies: 1
Feb 2, 2024
Visit Reason
A Case Management - Incident visit was conducted to issue deficiencies related to a medication error that the facility self-reported, involving a staff member administering the wrong medication to a resident.
Findings
The facility failed to properly assist residents with medications, resulting in an incorrect dose being given that posed an immediate health and safety risk. Staff involved were retrained and disciplinary action was taken. A civil penalty for a repeat violation was assessed.
Complaint Details
The visit was triggered by an incident report received on 01/27/2024 regarding a medication error on 01/21/2024 where Staff 1 prepared two different medications simultaneously and administered the wrong one to Resident 1. The resident was monitored closely for respiratory depression and declined ER transfer. Staff 1 was written up and retrained.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement a plan for incidental medical and dental care, specifically not properly assisting residents with medications and issuing an incorrect dose. | Type A |
Report Facts
Civil penalty amount: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the Case Management - Incident visit and issued the report. |
| Kelly Burley | Licensing Program Manager | Supervisor named in the report. |
| Vanessa Vazquez | Wellness Coordinator | Met with Licensing Program Analyst during the visit. |
| Sanjuana Enriquez | Administrator | Facility Administrator involved in the visit. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 140
Deficiencies: 0
Feb 2, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff made an inappropriate comment towards a resident.
Findings
The allegation that staff called a resident with dementia 'pathetic' was investigated and deemed unsubstantiated. Technical assistance was provided to the administrator to review staff communication and residents' personal rights.
Complaint Details
The complaint alleged that staff made an inappropriate comment towards a resident with dementia by calling them 'pathetic' for needing assistance. After investigation, the allegation was found unsubstantiated.
Report Facts
Capacity: 140
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and issued the report |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 94
Capacity: 140
Deficiencies: 0
Sep 7, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced annual continuation visit to evaluate the facility's compliance with Title 22 Regulations and ensure there are no health and safety hazards.
Findings
The facility was found to be in compliance with regulations, with clean and operable kitchen appliances, sufficient food supplies, well-maintained common areas, operational safety equipment, clean and sanitary restrooms, and adequate infection control policies and supplies. No deficiencies were noted.
Report Facts
Facility capacity: 140
Resident census: 94
Fire extinguisher service date: Sep 9, 2022
Last disaster drill date: Aug 31, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanna Enriquez | Administrator | Met with Licensing Program Analyst during inspection |
| Jenny Olson | Licensing Program Analyst | Conducted the annual continuation visit |
| Kelly Burley | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Annual Inspection
Census: 94
Capacity: 140
Deficiencies: 1
Sep 6, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced required annual visit to the facility to review compliance with licensing regulations.
Findings
The inspection found that resident and staff records were complete, medications were properly stored and labeled, but two staff members were found not associated with the facility, posing an immediate health and safety risk. The administrator corrected this issue during the visit.
Deficiencies (1)
| Description |
|---|
| Two staff were not associated to the facility, which poses an immediate health and safety risk to persons in care. |
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Care staff interviewed: 2
Staff not associated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sanjuana Enriquez | Administrator | Facility administrator involved in the inspection and correction of deficiencies |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 140
Deficiencies: 1
Jun 15, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-02-24 regarding incomplete records provided to an authorized representative and alleged medication errors.
Findings
The investigation substantiated that staff did not provide complete records to the authorized representative despite multiple requests, posing a potential health, safety, or personal rights risk. The allegation that staff dispensed wrong medications was unsubstantiated due to insufficient evidence, but medication training was recommended.
Complaint Details
The complaint alleged that staff did not provide complete records to the authorized representative and that facility staff dispensed wrong medications to a resident. The records allegation was substantiated, while the medication error allegation was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not comply with the requirement to store active and inactive records properly and failed to make confidential information available to the resident's authorized representative upon request. | Type B |
Report Facts
Capacity: 140
Census: 94
Plan of Correction Due Date: Jun 22, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation report |
| Sanjuana Enriquez | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 140
Deficiencies: 2
Jun 15, 2023
Visit Reason
The visit was conducted as a Case Management - Deficiencies inspection in conjunction with a complaint investigation to issue citations for deficiencies observed during the complaint investigation.
Findings
Deficiencies were found related to medication management, including missing quantity information for certain medications in the Centrally Stored Medication and Destruction Record and failure to properly assist residents with medication administration, posing health and safety risks.
Complaint Details
The complaint investigation was triggered by an incident report received on 3/9/23 regarding Resident 2 noticing that residents' Alendronate medication needed a refill, which was not properly administered for the month of March.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility Centrally Stored Medication and Destruction Record (CSMDR) records for Resident #1 were missing the quantity for Vitamin C and Hydrochlorothiazide. | Type B |
| Facility did not follow doctors' orders and properly assist resident with medication, posing an immediate health and safety risk. | Type A |
Report Facts
Deficiencies cited: 2
Medication doses missed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit and complaint investigation. |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection. |
| Joanna Enriquez | Administrator | Facility administrator met during the inspection. |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 140
Deficiencies: 1
May 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-02-24 regarding incorrect refunds and charging residents for services not needed.
Findings
The allegation that the facility did not issue a correct refund was substantiated, with evidence of duplicate tray charges and a refund issued after the complaint. The allegation that the facility charged a resident for services not needed was unsubstantiated, as the facility provided care based on assessments and refunded charges for discontinued services.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility did not issue a correct refund due to duplicate tray charges. The allegation that the facility charged a resident for services not needed was unsubstantiated after review of care assessments and billing adjustments.
Severity Breakdown
Technical Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not issue a correct refund for duplicate tray charges. | Technical Violation |
Report Facts
Refund amount: 987
Capacity: 140
Census: 94
Charge amounts: 300
Charge amounts: 438
Charge amounts: 528
Charge amounts: 546
Charge amounts: 450
Charge amounts: 285
Charge amounts: 90
Charge amounts: 300
Charge amounts: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and issued findings |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation report |
| Sanjuana Enriquez | Administrator | Facility administrator involved in investigation |
| Amy Bowman | Wellness Director | Interviewed during investigation and provided information on resident care |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 0
Apr 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not inform the authorized representative of a change in a resident's living arrangement.
Findings
The investigation found that Resident 2 moved into Resident 1's apartment without staff knowledge or permission, but staff acted quickly to rectify the situation once aware. Based on interviews and evidence, the allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that the facility did not inform the authorized representative of a change in living arrangement involving two residents. The allegation was found to be unsubstantiated after investigation.
Report Facts
Facility capacity: 140
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Burley | Licensing Program Manager | Named in report signature section |
| Sanjuana Enriquez | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Capacity: 140
Deficiencies: 2
Jan 19, 2023
Visit Reason
An unannounced Case Management - Deficiencies visit was conducted due to a COVID-19 outbreak at the facility and repeated failures to timely report cases and submit incident reports as required by regulation.
Findings
The facility failed to submit required COVID-19 incident reports within the mandated timeframes multiple times, resulting in a $250 civil penalty for a repeat violation. Deficiencies were cited related to late reporting of incidents and epidemic outbreaks.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to submit a written report within seven days of the occurrence of specified events, posing a potential health, safety or personal rights risk to persons in care. | Type B |
| Failure to report an epidemic outbreak within 24 hours, posing a potential health, safety or personal rights risk to persons in care. | Type B |
Report Facts
Civil penalty amount: 250
Days late for resident incident reports: 6
Days late for staff incident reports: 13
Days late for late incident report: 1
Days late for late COVID reporting: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanna Enriquez | Administrator | Met with Licensing Program Analyst during inspection and named in report regarding reporting deficiencies |
| Jeannette Olson | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager in report |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 140
Deficiencies: 1
Oct 28, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that facility staff were making medical decisions for residents, making false statements, and not providing emergency information timely to emergency medical personnel.
Findings
The allegation that facility staff made medical decisions for residents was substantiated, specifically regarding forcing a resident to go to the hospital against their wishes. The allegation that staff made false statements was unsubstantiated due to insufficient evidence. The allegation that emergency information was not provided timely was also unsubstantiated, though recommendations were made to improve processes and organization.
Complaint Details
The complaint investigation was substantiated regarding the facility forcing a resident to hospital against their wishes. The allegation of false statements by staff was unsubstantiated. The allegation of untimely provision of emergency information was unsubstantiated but recommendations were made.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents were not given the right to reject medical care, violating personal rights under CCR 87468.1(a)(16). | Type B |
Report Facts
Capacity: 140
Census: 102
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and issued final findings |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation report |
| Joanna Enriquez | Administrator | Facility administrator met during inspection |
| Sanjuana Enriquez | Administrator | Named as facility administrator in report header |
| Wellness Director | Interviewed regarding resident transport policy and emergency personnel interactions |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 140
Deficiencies: 2
Oct 28, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2022-10-04 regarding allegations that the facility did not meet a resident's care needs and did not follow refund policy.
Findings
The investigation substantiated that the facility failed to meet Resident 1's care needs, including inadequate showering and toileting assistance, and did not provide a 40% refund as required by the refund policy. Another allegation regarding failure to follow the admissions agreement related to transportation was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for allegations that the facility did not meet Resident 1's care needs and did not follow refund policy. The allegation that the facility did not follow the admissions agreement regarding transportation was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not meet resident's needs as identified in the pre-admission appraisal, posing a potential health and safety risk. | Type B |
| Facility did not provide a 40 percent refund as required by the admission agreement and health and safety code. | Type B |
Report Facts
Capacity: 140
Census: 102
Deficiencies cited: 2
Refund percentage: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
| Joanna Enriquez | Administrator | Facility administrator interviewed during investigation and named in findings |
Inspection Report
Annual Inspection
Census: 95
Capacity: 140
Deficiencies: 1
Aug 31, 2022
Visit Reason
The inspection was a required unannounced 1-year infection control annual visit to the facility conducted on 08/31/2022.
Findings
The facility demonstrated compliance with infection control policies including screening, PPE use, social distancing, and training. However, two staff members were found working without being properly associated with the facility, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Two out of 40 staff were not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care. | Type A |
Report Facts
Staff not associated to facility: 2
Total staff reviewed: 40
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Bowman | Wellness Director | Met with Licensing Program Analyst during inspection and responsible for infection control. |
| Jeannette Olson | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection. |
| Sanjuana Enriquez | Administrator | Facility administrator who agreed to associate staff by the plan of correction due date. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 140
Deficiencies: 0
Aug 2, 2022
Visit Reason
The visit was an Informal Conference conducted to discuss multiple complaints received and deficiencies cited for Santa Maria Terrace.
Findings
The conference addressed issues including staffing, meeting residents' needs (such as showering, diapering, and call buttons), incontinence supplies, physical plant conditions, reporting, and COVID-19 protocols. The Administrator was informed about the potential for further administrative actions.
Complaint Details
The visit was complaint-related, discussing multiple complaints and deficiencies cited. The Administrator was notified that further citations could lead to probation or formal non-compliance plans and possible administrative action.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanna Enriquez | Administrator | Met during the Informal Conference and discussed regarding facility issues and administrative actions. |
| Amy Bowman | Wellness Director | Met during the Informal Conference and discussed as back-up designee for Administrator absence. |
| Kelly Burley | Licensing Program Manager | Conducted the Informal Conference and discussed issues and administrative process. |
| Jeannette Olson | Licensing Program Analyst | Present at the Informal Conference. |
Inspection Report
Census: 97
Capacity: 140
Deficiencies: 1
Jul 11, 2022
Visit Reason
An unannounced case management visit was conducted to issue a deficiency related to late reporting of incident reports that were submitted after the required 7-day timeframe.
Findings
The facility was cited for repeatedly submitting incident reports late, with multiple incidents reported beyond the 7-day requirement, posing potential health, safety, and personal rights risks to residents.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit incident reports within seven days of occurrence on multiple occasions. | Type B |
Report Facts
Days late for incident reports: 16
Days late for incident reports: 14
Days late for incident reports: 10
Days late for incident reports: 9
Days late for incident reports: 8
Days late for incident reports: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the unannounced case management visit and issued the deficiency |
| Kelly Burley | Licensing Program Manager | Supervisor overseeing the inspection |
| Amy Bowman | Wellness Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 140
Deficiencies: 2
Jul 11, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to complaints received on 2021-09-09 regarding staff not maintaining residents' hygiene and not providing assistance to residents.
Findings
The investigation substantiated that staff did not maintain resident hygiene as Resident 1 was not showered twice weekly as required, and staff did not provide timely assistance to residents, with many call pendant alerts unanswered or delayed. However, the allegation that lack of assistance resulted in a fall was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not maintain residents' hygiene and did not provide timely assistance to residents, with evidence including shower refusals, delayed or unanswered call pendant responses, and insufficient staffing. The allegation that lack of assistance resulted in a fall was unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Personnel Requirements - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. | Type A |
| Basic Services - Facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal, either directly or through outside resources. | Type B |
Report Facts
Call pendant presses: 60
Calls answered within 15 minutes: 24
Calls answered within 16-29 minutes: 12
Calls answered within 30-45 minutes: 4
Calls unanswered: 20
Civil penalty: 250
Days without shower: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the unannounced complaint investigation visit and issued final findings. |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Amy Bowman | Wellness Director | Met with during the investigation and interviewed regarding resident care. |
| Sanjuana Enriquez | Administrator | Facility Administrator who agreed to submit updated staffing schedule and implement plan of correction. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 140
Deficiencies: 2
Jul 11, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2022-06-16 regarding residents' diapering needs not being met and inadequate hygiene supplies at the facility.
Findings
The investigation substantiated that residents were not changed frequently enough during the night shift, resulting in soaked clothing and bedding, and that hygiene supplies such as briefs and wipes were not adequately stocked, causing delays in resident care.
Complaint Details
The complaint was substantiated based on interviews, record review, photographs, and staff statements. Issues included residents being soaked with urine and fecal matter due to infrequent diaper changes during the night shift and inadequate hygiene supplies for hospice residents, causing delays in restocking briefs and wipes.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. | Type A |
| Failure to ensure equipment and supplies necessary for personal care and maintenance of adequate hygiene practice were readily available to each resident. | Type B |
Report Facts
Census: 97
Total Capacity: 140
Deficiency Type A Due Date: Jul 12, 2022
Deficiency Type B Due Date: Jul 22, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
| Amy Bowman | Wellness Director | Interviewed during investigation; involved in addressing diapering and hygiene supply issues |
| Sanjuana Enriquez | Administrator | Facility administrator who agreed to create a plan to ensure timely restocking of incontinence care products |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 140
Deficiencies: 1
Jun 6, 2022
Visit Reason
An unannounced complaint investigation was conducted due to allegations including staff not responding to residents' calls for help, failure to assist with hygiene needs, medication mismanagement, overcharging residents, and lack of dignity in resident treatment.
Findings
The investigation substantiated that staff did not respond timely to residents' call buttons, posing an immediate health and safety risk due to inadequate staffing. Other allegations regarding hygiene assistance, medication mismanagement, overcharging, and dignity were found unsubstantiated based on interviews and record reviews.
Complaint Details
The complaint investigation was substantiated regarding staff not responding timely to residents' calls for help. Other allegations including failure to assist with hygiene needs, medication mismanagement, overcharging, and lack of dignity were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide necessary services, resulting in inadequate staff to respond to call buttons, posing an immediate health and safety risk. | Type A |
Report Facts
Resident calls answered in less than 10 minutes: 32
Resident calls answered in 10-20 minutes: 28
Resident calls answered in 21-45 minutes: 11
Resident calls never responded to: 25
Residents interviewed stating staff do not respond timely: 10
Residents interviewed stating they have no issues receiving hygiene services: 7
Residents interviewed stating they were treated with dignity: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
| Sanjuana Enriquez | Administrator | Facility administrator involved in interviews and plan of correction |
| Vanessa Vazquez | Wellness Coordinator | Met with during the investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 140
Deficiencies: 3
Jun 6, 2022
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 03/28/2022 regarding multiple allegations including staff not following COVID-19 protocols, delayed response to resident calls, inadequate staffing, water leaks in resident bathrooms, facility disrepair, and accessible electrical conduit.
Findings
The investigation substantiated several allegations including failure to follow COVID-19 visitor protocols, delayed staff response to resident calls, inadequate staffing levels, water leaks in resident bathrooms, and facility disrepair posing health and safety risks. The allegation regarding accessible electrical conduit was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations including staff not following COVID-19 protocols, delayed response to resident calls, inadequate staffing, resident bathroom water leaks, and facility disrepair. The allegation regarding electrical conduit accessibility was unsubstantiated.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs. | Type A |
| Water supplies and plumbing fixtures were not properly maintained, allowing water to leak to the apartment below. | Type A |
| Facility was not clean, safe, sanitary, and in good repair at all times, specifically resident room was not clean and sanitary upon move-in. | Type B |
Report Facts
Resident census: 94
Total capacity: 140
Resident calls: 7
Staff response under 15 minutes: 3
Staff response 15 minutes or longer: 4
Residents with dementia: 29
Residents unable to leave facility unassisted: 55
Residents on hospice: 6
Residents who wander: 12
Residents needing two-person assistance: 1
Residents needing transfer assistance: 10
Bedridden residents: 5
Non-ambulatory residents: 43
Incontinent residents: 16
Residents requiring restroom assistance: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
| Sanjuana Enriquez | Administrator | Facility administrator involved in interviews and corrective plans |
| Vanessa Vazquez | Wellness Coordinator | Met with Licensing Program Analyst during investigation |
| Staff 1 | Mentioned as working alone on a day with inadequate staffing |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 140
Deficiencies: 0
Mar 10, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not providing authorized representatives with resident records and were not returning authorized representatives' calls or emails.
Findings
The investigation found that the facility did not collect or hold residents' vaccination cards but logged vaccination data within facility records. The facility stated they would release medical documents to authorized representatives. Attempts to contact the reporting party were unsuccessful, and based on interviews and records reviewed, the allegations were deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not providing authorized representatives with resident records and not returning calls or emails. The facility confirmed no contact was made by authorized representatives requesting records, and attempts to reach the reporting party failed.
Report Facts
Capacity: 140
Census: 87
Complaint Control Number: 29-AS-20211019091255
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kelly Burley | Licensing Program Manager | Conducted the unannounced complaint visit to issue final findings |
| Amy Bowman | Wellness Director | Interviewed during the investigation |
| Sanjuana Enriquez | Administrator | Provided information regarding vaccination cards and facility records |
Inspection Report
Complaint Investigation
Capacity: 140
Deficiencies: 0
Mar 10, 2022
Visit Reason
An unannounced complaint investigation was conducted based on allegations that the facility was not following its Admission Agreement on refunds and that facility staff did not keep residents' rooms clean.
Findings
The investigation found the allegations unsubstantiated. Residents and staff interviews, as well as record reviews, indicated no issues with refunds or room cleanliness. The facility complied with service requests and maintained cleanliness standards.
Complaint Details
The complaint involved two allegations: 1) the facility not following its Admission Agreement on refunds, specifically overcharging Resident 1 for bathing and medication assistance and for a month of care after moving out; 2) facility staff not keeping residents' rooms clean. Both allegations were investigated through interviews with residents and staff, review of records including admission agreements and care plans, and observations. The findings were unsubstantiated.
Report Facts
Capacity: 140
Residents interviewed: 7
Resident 1 move-out notice: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeannette Olson | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation and issued final findings |
| Sanjuana Enriquez | Administrator | Provided statements regarding resident care and billing practices |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 140
Deficiencies: 0
Dec 2, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 03/31/2020 regarding inappropriate staff behavior and lack of respect towards residents.
Findings
The investigation found the allegations unsubstantiated. Interviews with staff and residents confirmed no verbal abuse or disrespectful treatment occurred. Residents expressed satisfaction with the care and respect they received.
Complaint Details
The complaint alleged that facility staff spoke inappropriately to residents and did not treat residents with respect. After interviews with staff and residents, both allegations were deemed unsubstantiated.
Report Facts
Residents interviewed: 9
Staff interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Arien Diaz | Licensing Program Analyst | Conducted the complaint investigation and interviews. |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Sanjuana Enriquez | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 140
Deficiencies: 1
Nov 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 08/28/2020 alleging that staff did not ensure a resident received insulin and did not provide adequate food service.
Findings
The allegation that staff did not ensure a resident received insulin was substantiated due to a communication failure resulting in a resident not receiving insulin one morning. The allegation that staff did not provide adequate food service was unsubstantiated, with residents reporting satisfaction with food quality and quantity.
Complaint Details
The complaint investigation was substantiated regarding the failure to ensure a resident received insulin due to lack of communication among staff. The allegation regarding inadequate food service was unsubstantiated based on resident interviews and observations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure medications were given as prescribed for resident 1, posing an immediate health and safety risk. | Type A |
Report Facts
Residents interviewed: 9
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Arien Diaz | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Sanjuana Enriquez | Administrator | Facility administrator named in report |
| Vanessa Vazquez | Met with during inspection | |
| Staff 1 | Staff member involved in insulin administration incident |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 140
Deficiencies: 1
Sep 30, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-07-30 regarding multiple allegations including medication errors, inadequate supervision, and other resident care concerns.
Findings
The investigation substantiated the allegation that staff administered another resident's medication to a resident, confirming a medication error. All other allegations including inadequate supervision, assistance with showers, food quality and quantity, functioning pendants, provision of linens, housekeeping services, and charging for services not received were deemed unsubstantiated based on interviews, observations, and record reviews.
Complaint Details
The complaint investigation was substantiated for the allegation that staff administered another resident's medications to a resident (medication error involving resident R1 on 2020-05-16). Other allegations including lack of supervision, inadequate shower assistance, food quality and quantity, malfunctioning pendants, lack of linens, inadequate housekeeping, and improper charges were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by the licensee not ensuring that the resident received the prescribed medication. | Type A |
Report Facts
Capacity: 140
Census: 81
Deficiency count: 1
Plan of Correction Due Date: Oct 4, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sanjuana Enriquez | Administrator | Named in relation to medication error finding and facility management |
| Arien Diaz | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Kelly Burley | Licensing Program Manager | Manager overseeing the licensing program and report |
Inspection Report
Annual Inspection
Census: 85
Capacity: 140
Deficiencies: 1
Aug 31, 2021
Visit Reason
An unannounced one-year infectious control annual visit was conducted to perform a facility risk assessment and review compliance with infection control and staff clearance requirements.
Findings
The facility was found to have submitted a mitigation plan and addressed infection control requirements satisfactorily. However, a deficiency was cited for an individual working without CDSS clearance, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| An individual was working without CDSS clearance, having an inactive status on the Guardian and LIS roster, which poses an immediate health, safety or personal rights risk to persons in care. | Type A |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sanjuana Enriquez | Administrator | Met with Licensing Program Analyst during inspection and involved in facility tour and compliance discussion |
| Toan Luong | Licensing Program Analyst | Conducted the inspection and issued citation |
| Kelly Burley | Licensing Program Manager | Supervisor named in report |
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