Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
68% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
91% occupied
Based on a March 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Original Licensing
Census: 39
Capacity: 43
Deficiencies: 0
Date: Mar 12, 2026
Visit Reason
An unannounced pre-licensing inspection visit was conducted to evaluate the facility for licensing purposes.
Findings
The pre-licensing inspection was conducted and the report was reviewed with the Acting Administrator, Nick Catalano, with a copy provided to him. No deficiencies or violations are explicitly stated in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nick Catalano | Acting Administrator | Met with during the inspection and report review. |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced pre-licensing inspection visit. |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 38
Capacity: 43
Deficiencies: 0
Date: Jan 30, 2026
Visit Reason
An unannounced case management visit was conducted by Licensing Program Analyst Komal Curley to deliver a copy of an amended complaint report initially issued on January 8, 2026, and to review the report with the Acting Administrator.
Complaint Details
The visit was related to a complaint report initially issued on January 8, 2026. The amended complaint report was delivered during this visit.
Findings
The visit involved delivering and reviewing an amended complaint report with the Acting Administrator. No specific deficiencies or findings are detailed in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nick Catalano | Acting Administrator | Met with during the visit and involved in reviewing the complaint report. |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the amended complaint report. |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 43
Deficiencies: 1
Date: Jan 8, 2026
Visit Reason
An unannounced case management visit was conducted in response to an incident on 2025-12-18 where a resident was given the wrong medication by a med-tech.
Complaint Details
The visit was complaint-related due to an incident where Resident 1 was given the wrong medication by a med-tech. The med-tech notified the primary care physician and power of attorney, and in-service training was provided. The deficiency was substantiated as a Type B violation.
Findings
The med-tech administered another resident's medication to Resident 1 but corrected the error by providing the correct medication. An in-service training was provided to med-techs on 2025-12-23 by Affinity Hospice. A Type B deficiency was cited for failure to assist residents with self-administered medications as needed.
Deficiencies (1)
Failure to assist residents with self-administered medications as needed, resulting in a medication error where a resident was given another resident's medication.
Report Facts
Capacity: 43
Census: 39
Deficiency count: 1
Plan of Correction Due Date: Jan 15, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nick Catalano | Acting Administrator | Met with Licensing Program Analyst during the inspection and discussed the medication incident |
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| April Cowan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 43
Deficiencies: 0
Date: Jan 8, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not ensure the facility was free from pests.
Complaint Details
The complaint alleged that staff did not ensure the facility was free from pests. The allegation was found to be unfounded based on staff interviews and pest control documentation.
Findings
The investigation found no evidence of pests in the facility. Staff denied any sightings of cockroaches, bed-bugs, or mice, and pest control records showed no pest sightings. The allegation was determined to be unfounded.
Report Facts
Facility capacity: 43
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nick Catalano | Acting Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Census: 39
Capacity: 43
Deficiencies: 0
Date: Dec 10, 2025
Visit Reason
An unannounced case management visit was conducted in relation to an incident on 2025-11-20 where a resident bit into a bar of hand soap, causing lip swelling and requiring observation and notifications.
Findings
The investigation found that the incident was caused by a roommate's family member bringing in soap without notifying staff. Resident 1's service plan was updated to reflect new risk status. No citations were issued during the visit.
Report Facts
Incident date: Nov 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Curley | Licensing Program Analyst | Conducted the unannounced case management visit |
| Rose Ruiz | Resident Care Coordinator | Met with Licensing Program Analyst and discussed incident |
| Riley Tucker | Administrator/Director | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 43
Deficiencies: 0
Date: Aug 13, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not seek timely medical care for a resident.
Complaint Details
The complaint alleged that staff failed to seek timely medical care for a resident by not calling after-hour supportive care and causing a delay in chest x-ray treatment. The investigation found no preponderance of evidence to prove the alleged violations occurred, resulting in an unsubstantiated finding.
Findings
The investigation found that although there were concerns about delayed medical care and communication failures regarding a resident's chest x-ray, there was insufficient evidence to substantiate the allegation. The department determined the allegations to be unsubstantiated after reviewing documents, interviewing staff and a third party radiology company.
Report Facts
Facility capacity: 43
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit |
| Francis Macahilas | Dietary Supervisor | Met with the evaluator during the investigation |
| Joshua Lambengco | Administrator | Interviewed during the investigation |
Inspection Report
Annual Inspection
Census: 39
Capacity: 43
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
An unannounced annual visit was conducted by Licensing Program Analyst Komal Charitra to evaluate compliance with licensing requirements at the Silver Oaks facility.
Findings
The facility was generally well maintained with proper furnishings, safe dining areas, and secure storage of medications and chemicals. However, a deficiency was cited for the absence of non-skid mats in shower and bathtub floors, posing a potential safety risk.
Deficiencies (1)
No non-skid mats observed in shower and bathtub floors, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Perishable food days observed: 2
Non-perishable food days observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the inspection and authored the report |
| Rose Ruiz | Resident Care Coordinator | Met with Licensing Program Analyst during inspection |
| Joshua Lambengco | Administrator/Director | Facility administrator named in report header |
| April Cowan | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including staff mismanaging resident's medication and neglecting resident care.
Complaint Details
The complaint investigation was substantiated for the allegation of medication mismanagement. Other allegations including resident injuries due to staff neglect, improper cleaning, unclean bedding, unmet hygiene needs, presence of mold, and improper bedding were unsubstantiated.
Findings
The investigation substantiated the allegation that staff failed to ensure a resident took medications as prescribed due to the resident's behavior of hiding and spitting out medication. Other allegations regarding resident injuries, room cleanliness, bedding, hygiene, and mold were found to be unsubstantiated based on interviews, observations, and record reviews.
Deficiencies (1)
Facility failed to ensure Resident 1 took medications as prescribed, knowing the resident hides and spits out medication, posing an immediate health and safety risk.
Report Facts
Capacity: 43
Census: 43
Plan of Correction Due Date: Mar 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Lambengco | Administrator | Named in relation to findings and interviews during the complaint investigation |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation |
| April Cowan | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 43
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
An unannounced complaint investigation was conducted based on a complaint received on 2024-12-19 alleging that staff did not re-order a resident's medication timely, causing the resident to have seizures.
Complaint Details
The complaint alleged that staff did not re-order residents medication timely causing the resident to have seizures. The allegation was determined to be unsubstantiated after investigation.
Findings
The investigation reviewed medication records and interviews, finding that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation was unsubstantiated.
Report Facts
Capacity: 43
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Lambengco | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation |
| April Cowan | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 43
Deficiencies: 0
Date: Oct 22, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not ensure residents had incontinence supplies, did not follow COVID protocols, and did not meet resident needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included insufficient incontinence supplies, failure to follow COVID protocols during a September outbreak, and inadequate staffing. The facility was found to have sufficient supplies, followed COVID mitigation plans, and maintained adequate staffing.
Findings
The investigation found sufficient incontinence supplies, adherence to COVID protocols including isolation and masking, and adequate staffing levels. Based on interviews, observations, and documentation, the allegations were determined to be unsubstantiated.
Report Facts
Residents tested positive for COVID: 3
Staff interviewed: 6
Caregivers during AM and PM shifts: 4.5
Med-techs during shifts: 1
Caregivers during night shift: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Lambengco | Administrator | Met with Licensing Program Analyst during the complaint investigation and provided information on facility operations |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| April Cowan | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 43
Deficiencies: 1
Date: Sep 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to deliver findings regarding an allegation that facility staff did not dispense medications as prescribed.
Complaint Details
The complaint alleged that facility staff did not dispense medications as prescribed. The allegation was substantiated based on interviews, documentation review, and observations confirming medication was not administered as prescribed.
Findings
The investigation confirmed that the pharmacy only filled and sent the prescription antibiotic to the facility one time, and nurses observed on three dates that the medication was not dispensed as prescribed, posing an immediate health and safety risk. The allegation was substantiated.
Deficiencies (1)
Failure to develop and implement a plan for incidental medical and dental care, including assistance with self-administered medications, as required by CCR 87465(a)(4).
Report Facts
Capacity: 43
Census: 38
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joshua Lambengco | Administrator | Facility administrator met via facetime during investigation |
| Linda Mittelstadt | Activities Director | Report reviewed with activities director |
Inspection Report
Annual Inspection
Census: 37
Capacity: 43
Deficiencies: 0
Date: Jul 5, 2024
Visit Reason
An unannounced annual visit was conducted to evaluate the facility's compliance with licensing requirements and overall care standards.
Findings
The facility was found to be in good condition with no deficiencies cited. Resident rooms and common areas were well maintained, emergency drills were conducted quarterly, and records for residents and staff were complete and up to date.
Report Facts
Food supply duration: 2
Food supply duration: 7
Staff training hours: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Archer | Resident Care Coordinator | Met with Licensing Program Analyst during inspection |
| Grace Donato | Licensing Program Analyst | Conducted the inspection visit |
| Ollie Vance | Administrator | Facility administrator named in report |
Inspection Report
Census: 36
Capacity: 43
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
An unannounced case management incident visit was conducted following a report received on 2024-02-12 regarding a resident who died due to choking.
Findings
The investigation found that the resident was non-ambulatory, required no feeding assistance, and had a Do Not Resuscitate order. Staff had updated first aid training, and emergency services intervened as instructed. No deficiencies were cited during this visit.
Report Facts
Facility capacity: 43
Resident census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Lambengco | Executive Director | Met with Licensing Program Analyst during the visit |
| Bernadette Kang | Resident Care Coordinator | Met with Licensing Program Analyst during the visit |
| Grace Donato | Licensing Program Analyst | Conducted the unannounced case management incident visit |
| April Cowan | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 43
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that a resident sustained unexplained bruises while in care.
Complaint Details
The complaint alleged that a resident sustained unexplained bruises while in care. The allegation was unsubstantiated after interviews with staff, a witness, and the resident's doctor, as well as record reviews.
Findings
The investigation found that the resident is combative and hits staff during care, and bruises were caused by a visitor, not staff. Medical review indicated bruises could be related to aging or other medical issues. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 43
Resident census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bernadette Kang | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation |
| Ollie Vance | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 43
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not safeguard residents' personal belongings and that staff were not meeting residents' needs.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with responsible parties and observations. Allegations included staff not safeguarding residents' personal belongings and not meeting residents' needs. The department found insufficient evidence to prove the alleged violations occurred.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with responsible parties and observations during the visit indicated that missing items were either not a widespread issue or were found, and staff were observed interacting appropriately with residents. Therefore, the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 43
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bernadette Kang | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 43
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not mandated reporter certified.
Complaint Details
The allegation that staff were not mandated reporter certified was investigated and found to be unfounded based on interviews, record reviews, and information collected.
Findings
The investigation found that all staff had signed the mandatory reporting acknowledgment forms and that the allegation was unfounded, meaning it was false or without reasonable basis.
Report Facts
Capacity: 43
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joshua Lambengco | Executive Director | Met with Licensing Program Analyst during the investigation |
| Bernadette Kang | Resident Care Coordinator | Met with Licensing Program Analyst and provided information during the investigation |
| Ollie Vance | Administrator | Facility administrator named in the report |
Inspection Report
Census: 36
Capacity: 43
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
An unannounced case management visit was conducted following an incident report submitted on 2024-02-12 regarding a resident choking.
Findings
No deficiencies were cited during this visit. Pertinent documents were reviewed and the report was provided to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed pertinent documents. |
| Ollie Vance | Administrator | Met with Licensing Program Analyst during the visit. |
| Shayla Brewster | Resident Care Coordinator | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 43
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not providing the resident's authorized representative with a refund.
Complaint Details
The allegation that staff were not providing the resident's authorized representative with a refund was investigated and found to be unfounded.
Findings
The investigation found the allegation to be unfounded after interviews and file reviews revealed that the facility was reviewing the refund due to an overpayment and had already sent a check to the resident's authorized representative.
Report Facts
Capacity: 43
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ollie Vance | Administrator | Met with Licensing Program Analyst during the investigation |
| Shayla Brewster | Resident Care Coordinator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 43
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-12-22 alleging that staff did not ensure changes in a resident's condition were brought to the attention of a physician.
Complaint Details
The complaint alleged that staff did not ensure changes in a resident's condition were brought to the attention of a physician. The allegation was found to be unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found that the allegation was unfounded. Records showed correspondence between the resident care coordinator, administrator, and physician, including physician adjustments to medication, indicating the concern was addressed appropriately.
Report Facts
Capacity: 43
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ollie Vance | Administrator | Met with Licensing Program Analyst during the investigation |
| Shayla Brewster | Resident Care Coordinator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 43
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were unable to communicate with residents due to a language barrier.
Complaint Details
The complaint alleged that staff were unable to communicate with residents due to a language barrier. The investigation found no preponderance of evidence to prove the alleged violation occurred, and the complaint was unsubstantiated.
Findings
The allegation was found to be unsubstantiated. The Licensing Program Analyst observed Spanish-speaking caregivers attempting to communicate with residents using basic sign language and noted efforts by the facility to hire more English-speaking caregivers. Interviews and record reviews indicated staffing and communication were improving.
Report Facts
Capacity: 43
Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ollie Vance | Administrator | Met with Licensing Program Analyst during the investigation |
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation |
| April Cowan | Supervisor | Supervisor overseeing the investigation |
| Shayla Brewster | Resident Care Coordinator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Census: 35
Capacity: 43
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
An unannounced visit was conducted by Licensing Program Analyst Grace Donato to perform case management and deliver an immediate exclusion letter to exclude a staff member who previously worked at the facility.
Findings
The Licensing Program Analyst delivered an immediate exclusion letter to the facility administrator regarding a staff member. The letter was reviewed by the administrator, and the report was discussed and provided to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the unannounced visit and delivered the immediate exclusion letter. |
| Ollie Vance | Administrator | Reviewed the immediate exclusion letter and met with the Licensing Program Analyst. |
| Shayla Brewster | Resident Care Coordinator | Met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 43
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff spoke inappropriately to residents in care.
Complaint Details
The allegation that staff spoke inappropriately to residents was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found the allegation to be unfounded after interviews with staff and residents, who reported no inappropriate language or behavior by the staff member in question.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation |
| Ollie Vance | Administrator | Facility administrator present during the investigation |
| Shayla Brewster | Resident Care Director | Met with Licensing Program Analyst during the investigation |
| Jackie Jin | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 43
Deficiencies: 0
Date: Oct 6, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff mishandled a resident's medications and were not properly administering medications.
Complaint Details
The complaint alleged mishandling and improper administration of medications, specifically concerns about underdosing and delayed medication refills. The complaint was found to be unfounded.
Findings
The investigation found that the facility had sufficient medication supply and administered the correct dosage as per doctor's orders. The allegations were determined to be unfounded based on interviews, records review, and medication counts.
Report Facts
Medication bottles received: 6
Facility capacity: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation |
| Ollie Vance | Administrator | Met with evaluator during investigation |
| Shayla Brewster | Resident Care Coordinator | Met with evaluator during investigation |
| Jackie Jin | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 43
Deficiencies: 0
Date: Sep 1, 2023
Visit Reason
An unannounced complaint investigation was conducted following allegations including staff negligence causing multiple resident falls, failure to feed or give drink to a resident, and staff not allowing a resident to have a visitor.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff negligence causing multiple falls with injury, failure to feed or hydrate a resident, and banning a visitor. Evidence and interviews did not support these claims.
Findings
Based on interviews, record reviews, and observations, the allegations were found to be unsubstantiated. Staff were found to follow proper feeding and hydration protocols, residents were allowed visitors without restriction, and only two falls were reported for the resident in question with appropriate protocols followed.
Report Facts
Facility capacity: 43
Number of falls reported: 2
Number of staff interviewed: 6
Number of family members interviewed: 4
Number of residents interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation |
| Ollie Vance | Administrator | Facility administrator involved in the investigation |
| Shayla Brewster | Resident Care Coordinator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Capacity: 43
Deficiencies: 0
Date: Sep 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff do not ensure residents' bathing needs are met, the facility is dirty, and staff are not administering medications according to physician's instructions.
Complaint Details
The complaint investigation was triggered by allegations regarding inadequate bathing, facility cleanliness, and medication administration. After review of records, interviews, and observations, the allegations were found to be unsubstantiated due to lack of evidence supporting the claims.
Findings
The investigation found all allegations to be unsubstantiated. Residents were observed to be well groomed and clean, the facility was found to be clean with housekeeping logs showing frequent cleaning, and medication administration records showed compliance with physician instructions.
Report Facts
Facility capacity: 43
Bathroom cleaning frequency: 93
Bathroom cleaning frequency per day: 3
Medication passes: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation |
| Ollie Vance | Administrator | Facility administrator interviewed during investigation |
| Shayla Brewster | Resident Care Coordinator | Interviewed during the investigation |
Inspection Report
Annual Inspection
Census: 34
Capacity: 43
Deficiencies: 1
Date: Aug 23, 2023
Visit Reason
An unannounced annual visit was conducted to evaluate the facility's compliance with regulatory requirements and overall care standards.
Findings
The facility was generally found to be in good repair with adequate supplies and safety measures. However, three out of four resident medication records were not properly logged, posing a potential health and safety risk. The facility promptly updated the records and was required to submit a plan of correction.
Deficiencies (1)
Three out of four resident records showed medications not logged, which poses a potential health, safety, or personal rights risk to persons in care.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Aug 30, 2023
Hot water temperature: 112
Food supply duration: 2
Food supply duration: 7
Resident records reviewed: 5
Staff records reviewed: 5
Residents interviewed: 4
Staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Evaluator | Conducted the inspection and signed the report |
| Jackie Jin | Supervisor | Supervisor overseeing the inspection |
| Ollie Vance | Administrator | Facility administrator present during the inspection |
| Shayla Brewster | Resident Care Coordinator | Met with the licensing evaluator during the inspection |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 43
Deficiencies: 0
Date: Aug 23, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff do not prevent residents from being physically abused by other residents and that staff do not inform residents' authorized representatives of incidents as required.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff failing to prevent resident-to-resident physical abuse and failing to inform authorized representatives of incidents. Interviews with family members and staff, along with record reviews, showed that staff do intervene and authorized representatives are notified appropriately.
Findings
The investigation found that staff do intervene to prevent physical abuse among residents and that authorized representatives are informed of incidents as required. Based on interviews with family members and staff, as well as record reviews, the allegations were determined to be unsubstantiated due to lack of evidence.
Report Facts
Capacity: 43
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ollie Vance | Administrator | Facility administrator met during the investigation |
| Shayla Brewster | Resident Care Coordinator | Met during the investigation and provided information |
| Jackie Jin | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 43
Deficiencies: 0
Date: Jul 31, 2023
Visit Reason
An unannounced case management incident investigation visit was conducted in response to an incident involving missing narcotic medications discovered on 07/25/2023.
Complaint Details
The complaint involved missing narcotic medications discovered during a narcotics count. The staff member identified as the main suspect admitted to taking the narcotics. The police were involved, and the staff member was terminated. No citations were issued.
Findings
The investigation confirmed that a staff member (S1) admitted to taking the missing narcotics, which were from two different residents on hospice care. The narcotics were not returned, but no doses were missed. The facility notified families and hospice agencies, refilled the medications, terminated the staff member, and reported the incident to the police.
Report Facts
Capacity: 43
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the investigation |
| John Calandra | Licensing Program Analyst | Conducted the investigation |
| Shayla Brewster | Resident Care Coordinator | Interviewed during the investigation and notified families and hospice agencies |
| Ollie Vance | Administrator | Assisted in locating missing narcotics and reviewed video footage |
| Cara Smith | Supervisor | Supervisor overseeing the report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 43
Deficiencies: 0
Date: Jul 17, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were unable to effectively communicate with residents in care.
Complaint Details
The complaint alleged that staff were unable to effectively communicate with residents. After investigation, the allegation was unsubstantiated as staff followed proper protocols and no incidents of communication failure were recalled.
Findings
The investigation included interviews with staff and attempted resident interviews. It was found that staff follow protocols for reporting incidents and communicating with residents, including those who do not speak English. The allegation was deemed unsubstantiated due to lack of evidence that the incident occurred.
Report Facts
Capacity: 43
Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation |
| Shayla Brewster | Resident Care Director | Met with evaluator during investigation |
| Jackie Jin | Supervisor | Supervisor overseeing the investigation |
| Ollie Vance | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 43
Deficiencies: 1
Date: May 19, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on incident reports submitted regarding aggressive behaviors by Resident 1 (R1).
Complaint Details
The visit was complaint-related, triggered by multiple incidents involving Resident 1 exhibiting aggressive behaviors towards other residents. The complaint was substantiated by observations and file review.
Findings
The facility failed to reassess Resident 1 after five incidents of aggressive behavior and did not develop an individualized needs and service plan to address these behaviors. Documentation of frequent checks was also lacking.
Deficiencies (1)
Failure to update pre-admission appraisal and conduct reassessments after significant changes in resident's condition, specifically after R1's aggressive incidents.
Report Facts
Number of aggressive incidents by Resident 1: 5
Facility capacity: 43
Resident census: 34
Plan of Correction due date: May 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the inspection and evaluation |
| Shayla Brewster | Resident Care Coordinator | Interviewed during the inspection and involved in care coordination |
| Ollie Vance | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 43
Deficiencies: 0
Date: May 12, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to address allegations including staff failing to prevent residents from being harmed by another resident, failure to provide a safe and comfortable environment, short staffing, and failure to safeguard residents' personal belongings.
Complaint Details
The complaint investigation was unsubstantiated for most allegations and unfounded for the allegation that a resident sustained an injury while in care. The reporting party's concerns were investigated through interviews and observations, with no evidence found to support the claims.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and family interviews indicated that behaviors such as grabbing and touching are common among dementia residents and staff intervene appropriately. The facility was found to be fully staffed and residents' personal belongings are safeguarded. The allegation of a resident sustaining an injury was found to be unfounded.
Report Facts
Capacity: 43
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ollie Vance | Administrator | Met with Licensing Program Analyst during the complaint investigation and provided information regarding allegations |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Cara Smith | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 43
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
An unannounced case management visit was conducted regarding an elopement incident that occurred on 04/18/2023.
Complaint Details
Visit was triggered by a complaint related to a resident elopement incident on 04/18/2023. No deficiencies were cited.
Findings
The resident eloped and was found outside the facility after 10 minutes due to a door not being properly shut. The facility updated its policy on door access codes, installed a camera, and conducted staff training. No deficiencies were cited during the visit.
Report Facts
Incident duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the unannounced case management visit |
| Jackie Jin | Licensing Program Manager | Conducted the unannounced case management visit and supervisor |
| Shayla Brewster | Resident Care Coordinator | Met with evaluators during the visit |
| Ollie Vance | Administrator | Facility administrator present during the visit and report review |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 43
Deficiencies: 0
Date: Mar 27, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were forcing COVID-19 free residents to isolate in their rooms and not providing activities for residents in care.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included forced isolation of COVID-19 negative residents and lack of activities for residents. Interviews with the administrator and staff indicated these allegations were not supported by evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The administrator and staff denied the claims, stating COVID negative residents were allowed normal activities and COVID positive residents were isolated with precautions. Activities were provided to both COVID positive and negative residents by the Activities Director and caregivers.
Report Facts
Capacity: 43
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ollie Vance | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cara Smith | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 43
Deficiencies: 1
Date: Mar 22, 2022
Visit Reason
The visit was conducted as a complaint investigation due to concerns about failure to seek timely medical attention for a client and deficiencies related to documentation.
Complaint Details
During complaint investigation, a deficiency of the CA Code of Regulations, Title 22 was observed. The complaint involved failure to seek timely medical attention and inadequate documentation for client #1.
Findings
The facility failed to seek timely medical attention for client #1 who was diagnosed with a UTI after a delay in reporting symptoms and treatment. Additionally, staff observations, communication, and treatment were not documented due to staff shortage, violating resident record requirements.
Deficiencies (1)
Failure to document staff observations, communication, and treatment for client #1 regarding unusual vaginal discharge and related symptoms, posing a potential health, safety, or personal rights risk.
Report Facts
Capacity: 43
Census: 38
Plan of Correction Due Date: Mar 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Rubio | Administrator | Facility administrator present during inspection |
| Audrey Jeung | Licensing Evaluator | Licensing evaluator conducting the inspection |
| Julio Montes | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 43
Deficiencies: 1
Date: Mar 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident sustained unexplained injuries while in care, facility staff failed to meet the resident's hygiene needs, and staff failed to report the incident to the resident's authorized representative.
Complaint Details
The complaint investigation was unannounced and based on allegations received on 01/23/2020. The investigation was conducted by Evaluator Audrey Jeung. The allegations included unexplained injuries, failure to meet hygiene needs, and failure to report incidents to the resident's authorized representative. The failure to seek timely medical attention was substantiated, while other allegations were unsubstantiated.
Findings
The investigation found that it could not be proven that the resident sustained unexplained injuries due to staff neglect, and the allegations regarding hygiene needs were unsubstantiated. However, the allegation that the facility failed to seek timely medical attention was substantiated, as staff delayed reporting the resident's pain and bruises to the physician, posing a potential risk to the resident's health and safety.
Deficiencies (1)
Facility failed to seek timely medical attention
Report Facts
Capacity: 43
Census: 38
Plan of Correction Due Date: Mar 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Evaluator | Conducted the complaint investigation and signed the report |
| Nancy Rubio | Administrator | Facility administrator met during the investigation |
| Julio Montes | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 27
Capacity: 43
Deficiencies: 0
Date: Dec 14, 2021
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and infection control practices.
Findings
The facility was found to have appropriate infection control measures, proper storage of medications and sharps, and maintained social distancing in dining areas. A recommendation was made to cover trash cans with lids in bathrooms. Several documents were requested to be submitted by 12/21/21.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Rubio | Administrator | Met with Licensing Program Analyst during inspection and provided screening log documentation. |
| Adriana Garcia | Resident Care Coordinator | Greeted Licensing Program Analyst during inspection. |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced annual inspection. |
| Julio Montes | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 43
Deficiencies: 0
Date: Sep 2, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the authorized representative did not receive a copy of the admission agreement and that the administrator did not refund the authorized representative.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.
Findings
The investigation found that the responsible party did receive a hardcopy of the admission agreement via mail and that the facility had a 30-day written termination policy. The allegations were determined to be unfounded as the resident moved out earlier than the 30-day notice period and the December payment was made in advance.
Report Facts
Capacity: 43
Census: 31
Complaint received date: Apr 16, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nancy Rubio | Administrator | Facility administrator met during investigation |
| Julio Montes | Supervisor | Supervisor overseeing the investigation |
Viewing
Loading inspection reports...
