Most inspections found no deficiencies, showing the facility generally met licensing and safety standards over time. The most recent report from July 15, 2025, was clean with no issues noted. Earlier reports included a substantiated deficiency in November 2024 for failing to promptly notify authorities when a resident went missing, which posed a potential safety risk. A prior minor medication management issue was found in July 2023 involving an unlisted medication on the administration record. Several complaint investigations were unsubstantiated, and overall, the facility’s compliance appears to have improved, with recent inspections free of deficiencies.
The Licensing Program Analyst conducted an unannounced required annual inspection of the facility on 07/15/2025.
Findings
The facility was found to be in compliance with licensing requirements, including fire clearance, emergency preparedness, and resident care standards. No issues or concerns were observed during the visit.
Report Facts
Staff present: 2Fire extinguisher last serviced: Jun 25, 2025Certificate of liability insurance expiration: Dec 12, 2025Last emergency disaster drill: Jun 30, 2025
Employees Mentioned
Name
Title
Context
Janette Romero
Licensing Program Analyst
Conducted the inspection and authored the report
Daphne Drapeau
Administrator
Facility administrator present during the inspection
The visit was an unannounced case management inspection to address a deficiency observed during the investigation of a complaint regarding a missing resident.
Findings
The facility failed to timely notify the missing resident's responsible party and local law enforcement after the resident was discovered missing, posing a potential health, safety, and personal rights risk.
Complaint Details
The visit was triggered by complaint control number 18-AS-20220826154813 regarding the failure to timely report a missing resident to responsible parties and law enforcement. The deficiency was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
The licensee did not ensure 911 was contacted immediately after staff discovered Resident #1 was missing at 8:00 AM; local law enforcement was not contacted until 11:12 AM.
Type B
Report Facts
Census: 6Total Capacity: 6Plan of Correction Due Date: Nov 11, 2024
Employees Mentioned
Name
Title
Context
Janette Romero
Licensing Program Analyst
Conducted the case management visit and authored the report
Daphne Drapeau
Administrator
Facility administrator met with Licensing Program Analyst during inspection
An unannounced complaint investigation visit was conducted in response to allegations that a resident sustained multiple injuries and went missing due to lack of supervision by facility staff.
Findings
The investigation found that the resident was able to leave the facility unassisted and did not require overnight supervision. There was no preponderance of evidence to prove the alleged violations occurred, and the allegations were unsubstantiated.
Complaint Details
The complaint involved allegations that Resident #1 sustained multiple injuries and went missing due to lack of supervision. The investigation included records review, interviews, and observations. The allegations were found unsubstantiated due to lack of evidence.
The inspection was an unannounced Required Annual Inspection conducted to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in compliance with no Title 22, Division 6 Regulation violations observed or cited. The physical plant, medications, food service, and care & supervision met regulatory standards.
Report Facts
Staff on site: 2
Employees Mentioned
Name
Title
Context
Ali Naghibi
Administrator
Met with Licensing Program Analyst during inspection and participated in exit interview
Venus Mixson
Licensing Program Analyst
Conducted the inspection and reviewed facility records
The visit was an unannounced required annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing regulations.
Findings
The facility was found generally clean, well-maintained, and compliant with safety requirements; however, a deficiency was noted regarding medication management where a medication (Ferosul) was on hand but not listed on the Medication Administration Record (MAR). Staff and client records were complete and emergency drills were conducted quarterly.
Deficiencies (1)
Description
The facility had Ferosul medication on hand but did not have said medication on the MAR list.
Report Facts
Capacity: 6Census: 5POC Due Date: Jul 21, 2023
Employees Mentioned
Name
Title
Context
Elizabeth Rivera
Administrator
Facility Administrator present during inspection and exit interview
The visit was an unannounced case management health and safety inspection conducted in conjunction with complaint 18-AS-20220826154813.
Findings
No imminent health or safety concerns were observed, no deficiencies were cited, and the facility was found to have sufficient staff, food, and medication supplies.
Complaint Details
The visit was conducted in response to complaint 18-AS-20220826154813. No immediate threats to health, safety, or welfare were found, and no deficiencies were cited.
The visit was an unannounced required annual inspection with emphasis on infection control.
Findings
The Licensing Program Analyst observed sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead responsible for tracking COVID-19 cases and maintaining PPE and cleaning supplies.
Employees Mentioned
Name
Title
Context
Ali Naghibi
Administrator
Met with Licensing Program Analyst during inspection and discussed infection control practices.
Venus Mixson
Licensing Program Analyst
Conducted the inspection and made observations regarding infection control.
An unannounced annual required licensing inspection was conducted to verify compliance with statutes, regulations, and infection control practices, including COVID-19 mitigation measures.
Findings
The facility was found to be in compliance with all relevant regulations and infection control practices, including COVID-19 mitigation. No deficiencies were observed during the visit.
Employees Mentioned
Name
Title
Context
Ali Naghibi
Administrator
Met with Licensing Program Analyst during inspection and participated in exit interview.
Adam Hamer
Licensing Program Analyst
Conducted the unannounced annual inspection and authored the report.
Denise Powell
Licensing Program Manager
Named as Licensing Program Manager on the report.
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