Inspection Report Summary
Most inspections found deficiencies related to resident care, supervision, and documentation, with several substantiated complaints involving neglect, failure to provide timely medical care, and inadequate supervision leading to serious injuries and even death. The facility received fines, including a $500 penalty in March 2025 for a transfer-related death and a total of $1,500 in civil penalties in 2021 for failure to provide proper care after insulin administration. Deficiencies often involved failure to meet individual care needs, medication administration errors, and retention of residents with serious health conditions without proper hospice care. The most recent report from September 3, 2025 substantiated neglect related to pressure injuries and failure to seek timely medical care, continuing a pattern of care and supervision issues. While some complaint investigations were unsubstantiated, the facility’s record shows ongoing challenges with resident care and safety without clear improvement over time.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 46
Capacity: 110
Deficiencies: 2
Sep 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of neglect and failure to seek timely medical care for Resident #1, who sustained multiple pressure injuries while in care at the facility.
Findings
The investigation substantiated that Resident #1 sustained three documented stage three pressure injuries due to neglect and lack of care. The facility failed to seek timely medical care, resulting in retaining a resident with prohibited health conditions without proper hospice admission or exception requests. Deficiencies related to observation and reporting were cited.
Complaint Details
The complaint was substantiated. Allegations included neglect/lack of care leading to Resident #1 sustaining multiple stage three pressure injuries and failure to seek timely medical care resulting in retaining a resident with a prohibited health condition. The investigation found sufficient evidence to support both allegations.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to regularly observe residents for changes and provide appropriate assistance, including reporting changes and notifying responsible persons. | Type A |
| Admission or retention of persons with prohibited health conditions, specifically stage 3 and 4 pressure injuries, without proper hospice care or exception. | Type A |
Report Facts
Pressure injuries sustained: 3
Capacity: 110
Census: 46
Plan of Correction Due Date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation and signed the report. |
| Patrice O'Grady | Administrator | Facility administrator involved in the investigation and exit interview. |
| Dennis Seng | Investigator | Conducted telephonic and in-person interviews and reviewed medical records during the investigation. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 110
Deficiencies: 1
Mar 26, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of neglect/lack of care leading to a questionable death and inadequate staffing to transfer a resident, resulting in a fall.
Findings
The investigation substantiated that Staff #1 failed to follow the resident's care plan requiring a 2-person transfer assist, resulting in the resident falling, sustaining a brain hemorrhage, and subsequently dying. A $500 immediate civil penalty was assessed. Another allegation regarding inadequate staffing to transfer the resident was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged neglect/lack of care leading to a questionable death when a resident fell during transfer using a Hoyer lift without the required 2-person assist, causing a brain hemorrhage and death. The allegation was substantiated. A second allegation of neglect/lack of supervision due to inadequate staffing to transfer the resident was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with the requirement for personal assistance and care as indicated in the pre-admission appraisal, specifically the 2-person transfer assist policy, resulting in resident injury and death. | Type A |
Report Facts
Civil penalty amount: 500
Number of residents present during inspection: 48
Total licensed capacity: 110
Number of care staff present at time of incident: 6
Number of LVNs present at time of incident: 1
Number of medication technicians present at time of incident: 1
Resident census on date of incident: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Patrice O'Grady | Administrator | Met with investigators during the inspection and provided information. |
| Keith Payne | Administrator | Facility Administrator named in the report. |
| Laura Garcia | Investigator | Conducted telephonic and in-person interviews as part of the investigation. |
| Laken Lacy | Interim Administrator | Interviewed during the initial complaint visit related to incident and death reports. |
Inspection Report
Annual Inspection
Census: 48
Capacity: 110
Deficiencies: 1
Mar 13, 2025
Visit Reason
Licensing Program Analysts conducted an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and health and safety standards.
Findings
The facility was generally found to be in compliance with regulations regarding physical plant conditions, food service, staff and resident files, infection control, and emergency plans. However, a deficiency was cited related to medication administration where medication counts for one resident did not match documentation, posing a potential health risk.
Deficiencies (1)
| Description |
|---|
| Counts for 2 of Resident #1's medications do not match and documentation does not reflect the discrepancy, posing a potential health risk. |
Report Facts
Resident rooms observed: 10
Staff files reviewed: 5
Resident files reviewed: 5
Residents interviewed: 5
Staff interviewed: 3
Medication review residents: 3
Remaining pills in bubble pack: 5
Remaining acetaminophen pills: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrice O'Grady | Administrator | Met with Licensing Program Analysts during inspection and agreed to review medication procedures |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection and signed the report |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 110
Deficiencies: 0
Mar 13, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that a resident was being held at the facility against their will.
Findings
The investigation found no sufficient evidence to substantiate the allegation. The resident has a diagnosis of dementia and moved into the facility on 2025-02-21. Interviews and observations confirmed the resident was not held against their will and had not attempted to exit the facility.
Complaint Details
The complaint alleged that Resident #1 was being held at the facility against their will. The allegation was deemed unsubstantiated due to insufficient evidence to prove the violation did or did not occur.
Report Facts
Capacity: 110
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Patrice O'Grady | Administrator | Facility administrator interviewed during the investigation |
Document
Deficiencies: 0
Mar 13, 2025
Visit Reason
null
Findings
null
Inspection Report
Complaint Investigation
Census: 46
Capacity: 110
Deficiencies: 0
Jan 16, 2025
Visit Reason
The visit was a Case Management - Incident investigation regarding a self-reported incident involving a resident injury during transfer.
Findings
The investigation found no immediate health and safety hazards and insufficient evidence to determine that lack of care or supervision contributed to the resident's injury. No deficiencies were cited during the visit.
Complaint Details
The complaint involved Resident #1 who sustained an abrasion and subsequent fracture during a transfer. The fracture was not determined to be caused by improper transfer or lack of care.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the Case Management - Incident visit. |
| Laken Lacy | Regional Nurse Specialist | Interviewed during the visit and provided information about the incident. |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 110
Deficiencies: 0
Jan 16, 2025
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that facility employees failed to provide an appropriate level of supervision, resulting in a resident assaulting another resident and the resident sustaining injury.
Findings
The investigation found insufficient evidence to substantiate the allegation. Video footage and interviews showed that although the incident occurred, there was no prior history of aggressive behavior by the resident who assaulted another. Facility staff acted appropriately by reviewing the incident, communicating with medical providers, and implementing a 1:1 companion for the resident involved after the incident. No citations were issued.
Complaint Details
The complaint was unsubstantiated. The allegation involved failure to provide appropriate supervision leading to a resident assault and injury. The investigation included interviews, record reviews, and video footage analysis. Despite the incident, evidence was insufficient to prove the violation occurred.
Report Facts
Facility capacity: 110
Census: 46
Incident dates: Aug 28, 2024
Incident dates: Aug 23, 2024
Resident admission date: Jun 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laken Lacy | Regional Nurse Specialist / Interim Administrator | Met with Licensing Program Analyst during investigation and interviewed |
| Taylor Giunto | Regional Director of Operations | Interviewed telephonically during initial complaint visit |
| Douglas Real | Investigator | Continued the investigation and reviewed relevant reports |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 110
Deficiencies: 0
Jan 16, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that a resident was being financially abused while in care.
Findings
The investigation found insufficient evidence to corroborate the allegation of financial abuse. The resident has a conservator managing finances, and the facility staff and conservator confirmed no facility employees have access to the resident's funds or debit card. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that Resident #1 was being financially abused. Interviews with the resident, facility staff, and the resident's conservator, along with document review, revealed no evidence to support the allegation. The allegation was deemed unsubstantiated.
Report Facts
Deposit amount: 350
Capacity: 110
Census: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
| Laken Lacy | Regional Nurse Specialist | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 110
Deficiencies: 2
Dec 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 08/07/2023 regarding resident care and facility practices at Silverado Senior Living - Calabasas.
Findings
The investigation found insufficient evidence to substantiate most allegations including failure to address changes in resident condition, hygiene needs, room locking, linen provision, call system availability, and PRN medication administration. However, two allegations were substantiated: staff did not safeguard a resident's personal items, and staff failed to supervise the resident during meals, posing potential health and safety risks.
Complaint Details
The complaint investigation was triggered by allegations including failure to address a resident's condition change, hygiene neglect, locking resident in room, failure to provide clean linens, lack of call system, failure to provide PRN medication, failure to safeguard personal items, and failure to supervise resident during meals. The investigation concluded most allegations as unsubstantiated except for the safeguarding and supervision allegations which were substantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility staff neglected to supervise resident during meals, which posed a potential health and safety risk. | Type B |
| Facility staff did not properly safeguard residents' personal property, resulting in missing personal items. | Type B |
Report Facts
Capacity: 110
Census: 45
Deficiencies cited: 2
Plan of Correction Due Date: Jan 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Terri Weitzman | Administrator | Named in relation to resident care and facility management during investigation |
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation |
| Patrice O'Grady | Administrator | Met with Licensing Program Analyst during investigation visit |
Inspection Report
Annual Inspection
Census: 48
Capacity: 110
Deficiencies: 0
Oct 24, 2024
Visit Reason
The visit was an unannounced annual continuation inspection combined with a case management visit to ensure the facility is maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order effective from February 25, 2022 to February 24, 2025. The visit also addressed a legal non-compliance incident related to an allegation made by a resident's private companion.
Findings
The facility was found to be in compliance with regulations during the physical plant tour, food service inspection, medication review, staff and resident file review, and emergency disaster plan evaluation. No citations were issued. The allegation of sexual abuse was investigated with no evidence found, and coaching was provided to private companions on mandated reporting.
Complaint Details
The visit included review of an incident report related to an allegation of sexual abuse made by Resident #1's private companion, first observed in March 2024. The facility provided documentation including suspected abuse reports and medical records. Resident #1 was tested by a family member who is a medical professional, with no evidence of sexual abuse found. Resident #1 has dementia and was unable to verbalize concerns. Coaching on timely mandated reporting was provided to the private companions.
Report Facts
Facility capacity: 110
Resident census: 48
Staff files reviewed: 5
Resident files reviewed: 5
Medications reviewed: 3
Last fire extinguisher service date: Sep 19, 2024
Last emergency disaster drill date: Sep 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection and case management visit |
| Laken Lacy | Interim Administrator | Met with Licensing Program Analyst and discussed incident report |
| Tana McMillon | Administrator/Director | Named as facility administrator/director |
| Kristin Heffernan | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 110
Deficiencies: 0
Aug 27, 2024
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that a resident was financially abused while in care.
Findings
The investigation found insufficient evidence to support the allegation of financial abuse. Interviews and document reviews indicated that the resident was authorized to use their debit card with staff assistance, and the alleged unauthorized charge was a legitimate purchase by the resident.
Complaint Details
The complaint alleged fraudulent activity on Resident #1's debit card. The allegation was deemed unsubstantiated after interviews with staff, the resident, and the resident's conservator, as well as review of relevant documents.
Report Facts
Capacity: 110
Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report signature and oversight |
| Keith Payne | Administrator | Facility administrator mentioned in report header |
| Taylor Giunto | Regional Director of Operations | Interviewed during investigation |
| Laken Lacy | Interim Administrator | Interviewed during investigation |
Inspection Report
Annual Inspection
Census: 53
Capacity: 110
Deficiencies: 0
Mar 27, 2024
Visit Reason
The inspection was an unannounced required annual visit combined with addressing two self-reported Incident Reports.
Findings
The facility was found to be in compliance with Title 22 Regulations with no health or safety hazards observed. Kitchen appliances were operable, resident rooms and restrooms were clean and properly furnished, and common areas were well maintained. The annual inspection was not fully completed due to time constraints and will continue on a follow-up visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Urena | Licensing Program Analyst | Conducted the unannounced required annual visit and inspection. |
| Kendall Mesa | Administrator met with the Licensing Program Analyst during the inspection. |
Inspection Report
Census: 57
Capacity: 110
Deficiencies: 4
Aug 1, 2023
Visit Reason
The visit was an unannounced Case Management / Legal/Non-compliance inspection to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order effective from February 25, 2022 to February 24, 2025.
Findings
The inspection found several deficiencies including accessible razors posing immediate health and safety risks, failure to ensure a resident with dementia did not have access to personal care items, incidents of a resident leaving the facility unassisted resulting in injury, and incomplete documentation of PRN medication administration. Plans of correction were requested with due dates.
Severity Breakdown
Type A: 3
Type A (Deficiency Dismissed): 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Razors were observed accessible in Room 53, posing an immediate health and safety risk to residents in care. | Type A |
| One out of three residents with dementia was allowed to keep personal grooming and hygiene items despite evidence they could not safely manage them, posing an immediate health and safety risk. | Type A (Deficiency Dismissed) |
| Facility failed to ensure that Resident #4 did not leave the facility unassisted per physician report, posing an immediate health and safety risk. | Type A |
| Failure to document date, time, dosage, and resident response for PRN medication administration for two residents, posing an immediate health and safety risk. | Type A |
Report Facts
Residents with personal care items accessible: 3
Rooms observed: 8
Medication audit residents: 3
Incidents of resident leaving unassisted: 2
PRN medication administrations undocumented: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
| Terri Weitzman | Administrator | Facility Administrator met during inspection and involved in findings |
Inspection Report
Annual Inspection
Census: 55
Capacity: 110
Deficiencies: 2
May 22, 2023
Visit Reason
The visit was an unannounced required annual inspection to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order effective from February 25, 2022 to February 24, 2025.
Findings
The inspection included file reviews of five residents and five staff. Deficiencies were found related to incomplete personnel records for three staff members, including missing job applications, medical assessments, criminal record statements, and tuberculosis test results. These deficiencies pose potential health and safety risks to residents.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Personnel Requirements – Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician. This requirement was not met for three out of five staff (S1, S2, S3). | Type B |
| Criminal Record Clearance – All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement. This requirement was not met for two out of five staff (S1, S2). | Type B |
Report Facts
Staff files reviewed: 5
Resident files reviewed: 5
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and signed the report |
| Terri Weitzman | Administrator | Facility administrator met with the Licensing Program Analyst during the inspection |
| Kaitlyn Smith | Met with the Licensing Program Analyst during the inspection | |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 53
Capacity: 110
Deficiencies: 0
Feb 1, 2023
Visit Reason
The inspection was an unannounced required annual visit to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order effective from February 25, 2022 to February 24, 2025.
Findings
The facility was found to be in good condition with no deficiencies cited. Observations included operable kitchen appliances, clean and appropriately furnished resident rooms and restrooms, adequate infection control measures, and compliance with legal stipulations. Training documentation was reviewed but organization of files was recommended for easier verification.
Report Facts
Staff support group attendance: 12
Capacity: 110
Census: 53
Water temperature range: 107.6
Water temperature range: 112
Last audit date: 202212
Compliance audit date: Nov 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the unannounced required annual visit and authored the report |
| Akeema Matthew | Director of Health Services | Met with Licensing Program Analyst during the visit |
| Kaitlyn Smith | Director of Resident Family Services | Met with Licensing Program Analyst during the visit |
| Terri Weitzman | Administrator / Executive Director | Facility Administrator; unavailable during the visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 110
Deficiencies: 2
Nov 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 05/20/2022 concerning failure to communicate resident change of condition to hospice and staff not meeting resident's needs, among other complaints.
Findings
The investigation substantiated that staff failed to notify hospice of a resident's change of condition in a timely manner and failed to meet the resident's needs, particularly in managing aggressive behaviors and medication administration. Several other allegations including staff leaving a resident in soiled clothing for extended periods, making inappropriate comments, and failure to prevent hazardous behaviors were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for failure to communicate resident change of condition to hospice in a timely manner and staff not meeting resident's needs. Other allegations such as staff leaving resident in soiled clothing for extended periods, making inappropriate comments, failure to prevent resident from eating hazardous objects, and failure to prevent inappropriate behaviors were unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to document and communicate resident changes to physician and responsible person timely, posing immediate health and safety risk. | Type A |
| Failure to provide basic services including personal assistance and care for residents exhibiting aggressive behaviors, posing immediate health and safety risk. | Type A |
Report Facts
Capacity: 110
Census: 54
Deficiencies cited: 2
Plan of Correction Due Date: Nov 18, 2022
Training Completion Due Date: Nov 29, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Census: 53
Capacity: 110
Deficiencies: 1
Nov 1, 2022
Visit Reason
The inspection was an unannounced Case Management-Legal Non-Compliance visit to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver and Order effective from February 25, 2022 to February 24, 2025.
Findings
The inspection found deficiencies related to medication documentation for residents, specifically that staff did not properly document the administration of PRN medications for three residents, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to document the date, time, dosage, and resident's response for PRN medication administration for three residents (R1, R2, R3), posing an immediate health and safety risk. | Type A |
Report Facts
Residents reviewed for medication audit: 5
PRN medication administrations documented incorrectly: 3
Census: 53
Total capacity: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the unannounced Case Management-Legal Non-Compliance inspection and medication audit |
| Terri Weitzman | Administrator | Facility administrator present during inspection |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 110
Deficiencies: 0
Sep 20, 2022
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that, due to lack of supervision, one resident assaulted another resident while in care.
Findings
The investigation found insufficient evidence to support the allegation of lack of supervision leading to the assault. The incident appeared isolated, and the facility intervened appropriately with behavior monitoring and interventions. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that Resident #1 was assaulted by Resident #2 due to lack of supervision. The investigation included interviews, document reviews, and staff statements. The allegation was unsubstantiated as the facility had taken appropriate actions and the police determined no intent to harm.
Report Facts
Complaint Control Number: 29
Complaint Control Number Full: 29-AS-20220603162155
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 49
Capacity: 110
Deficiencies: 0
Aug 30, 2022
Visit Reason
The visit was an unannounced Case Management-Legal Non-Compliance inspection to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order effective February 25, 2022 – February 24, 2025.
Findings
The facility was found to be in substantial compliance with regulations governing residential care for the elderly. Infection control protocols were observed, including COVID-19 guidance signage, staff wearing face coverings, and availability of hand sanitizer. The physical plant was clean and well maintained. Staffing and resident assessment requirements were met, and no deficiencies were cited at this time.
Report Facts
Capacity: 110
Census: 49
Hot water temperature: 113.1
Audit dates: 2
Audit upcoming dates: 2
Support group session duration: 2
Training hours: 6
Training hours per month: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Vida Gwinn | Administrator | Facility administrator mentioned in the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Kaitlyn Smith | Met with during the inspection | |
| Loren B. Shook | Member of licensee’s governing board who conducted a quarterly visit on August 9th |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 110
Deficiencies: 1
Jun 1, 2022
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that the licensee allowed an employee to work in the facility prior to obtaining criminal record clearance.
Findings
The investigation substantiated that two employees worked without valid criminal record clearance or had clearance status set to 'In Process', posing an immediate health and safety risk to residents. The licensee did not comply with the criminal record clearance requirements as per Title 22 of the California Code of Regulations.
Complaint Details
The complaint was substantiated. It alleged that the licensee allowed employees to work prior to obtaining criminal record clearance. The investigation confirmed this for two staff members.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain California criminal record clearance for two staff members prior to working in the facility, posing an immediate health and safety risk to residents. | Type A |
Report Facts
Capacity: 110
Census: 53
Deficiencies cited: 1
Plan of Correction due date: Jun 2, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Vida Gwinn | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation and agreed to corrective actions |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 53
Capacity: 110
Deficiencies: 3
Jun 1, 2022
Visit Reason
The visit was an unannounced Case Management-Legal Non-Compliance inspection to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order effective February 25, 2022 – February 24, 2025.
Findings
The inspection found multiple deficiencies related to personnel records, including incomplete or missing job applications, health screenings, first aid certifications, and tuberculosis results for several staff members. The facility is required to maintain compliance with regulations governing residential care facilities for the elderly and to conduct ongoing audits, staff training, and resident assessments.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Four out of ten staff had job applications that were either incompletely filled out, blank, or missing. | Type B |
| Four staff needed health screenings and three staff required tuberculosis results, posing a potential health and safety risk. | Type B |
| Three staff lacked first aid certification on file. | Type B |
Report Facts
Staff records reviewed: 10
Staff with incomplete job applications: 4
Staff with incomplete health screenings: 4
Staff lacking first aid certification: 3
Staff requiring tuberculosis results: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and signed the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor and named in the report |
| Vida Gwinn | Administrator | Facility administrator met during inspection |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 110
Deficiencies: 1
Apr 19, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-04-12 regarding allegations of neglect and failure to meet residents' hygiene needs and other concerns.
Findings
The investigation substantiated that facility staff failed to meet Resident #1's hygiene needs, posing a potential health and safety risk. Other allegations including failure to safeguard resident's personal belongings, neglect of Resident #2, improper COVID-19 protocol, and visitation protocol violations were found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for failure to meet Resident #1's hygiene needs, supported by interviews and video surveillance. Other allegations were unsubstantiated based on interviews, record reviews, and evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to meet resident's hygiene needs as required by CCR 87464(f)(4) Basic Services. | Type B |
Report Facts
Capacity: 110
Census: 53
Plan of Correction Due Date: Apr 22, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
| Esther Chico-Gutierrez | Facility representative met during the investigation | |
| Vida Gwinn | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 55
Capacity: 110
Deficiencies: 0
Mar 8, 2022
Visit Reason
The inspection was an unannounced required annual visit with a specific emphasis on infection control practices and procedures, conducted due to active COVID-19 cases at the facility.
Findings
The facility was found to be in compliance with Title 22 Regulations with no immediate health or safety hazards observed. Infection control practices were reviewed, and the facility demonstrated adequate cleaning protocols, PPE supply, and staff adherence to COVID-19 safety measures. No deficiencies were cited at this time.
Report Facts
Capacity: 110
Census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and signed the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the inspection process |
| Kim Davis | Health Services Director | Facility representative met during the inspection and discussed infection control practices |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 110
Deficiencies: 0
Feb 1, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-03-05 regarding a scabies outbreak and failure to seek medical treatment for residents.
Findings
The investigation found insufficient evidence to substantiate the allegations. The facility had a confirmed scabies case which was treated in-house due to COVID-19 concerns, and residents received medical treatment including tele-health consultation and prescriptions. The local health department was notified and no deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a scabies outbreak and failure to seek medical treatment. The facility treated residents in-house after tele-health consultation and confirmed one case with a dermatologist. The local health department did not open a case due to only one confirmed case at the time.
Report Facts
Residents with rash observed: 5
Facility capacity: 110
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Taylor Giunto | Executive Director | Interviewed during investigation and involved in decision-making. |
| Kim Davis | Health Services Director | Met with Licensing Program Analyst during the inspection. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 110
Deficiencies: 1
Feb 1, 2022
Visit Reason
The inspection visit was conducted due to deficiencies observed during the investigation of a complaint regarding resident rashes and suspected scabies at the facility.
Findings
The facility failed to report the suspicion of scabies and/or rashes affecting at least five residents in February 2021 to Community Care Licensing. The facility treated residents in-house rather than sending them to the hospital due to COVID-19 concerns.
Complaint Details
The visit was complaint-related, triggered by complaint control #29-AS-20210305165753. The complaint involved at least five residents having rashes in February 2021, with suspicion of scabies. The complaint was substantiated by the investigation findings.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency within seven days of the occurrence of any incident threatening the welfare, safety, or health of any resident, specifically not reporting the presence of rashes on five residents in February 2021. | Type B |
Report Facts
Residents with rashes: 5
Capacity: 110
Census: 57
Plan of Correction Due Date: Feb 11, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 110
Deficiencies: 1
Nov 29, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that facility staff failed to provide proper care and supervision to Resident #1, resulting in the resident's death.
Findings
The Department changed the allegation status from Substantiated to Unsubstantiated after review and dismissed the $500 penalty. However, the Department found that facility staff failed to provide proper care and supervision to Resident #1, resulting in serious bodily injury, which will be addressed in a Case Management visit.
Complaint Details
The complaint was unsubstantiated. The initial finding of Substantiated on 01/31/2019 was overturned after appeal and further review. The allegation involved failure to provide proper care and supervision to Resident #1 resulting in death, but was changed to unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Facility staff failed to provide proper care and supervision to Resident #1 which resulted in serious bodily injury. |
Report Facts
Capacity: 110
Census: 58
Civil penalty: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Taylor Giunto | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Follow-Up
Census: 58
Capacity: 110
Deficiencies: 1
Nov 29, 2021
Visit Reason
The visit was an unannounced Case Management follow-up to a substantiated allegation of neglect/lack of care and supervision related to Resident #1 (R1). The purpose was to assess compliance following previous citations and penalties related to failure to provide proper care and supervision.
Findings
The facility was cited for failing to provide proper care to R1 after insulin administration, resulting in hospitalization and serious bodily injury. Civil penalties totaling $1,500 were assessed, including a repeat violation penalty. The allegation of neglect resulting in death was changed from substantiated to unsubstantiated and the prior $500 penalty was dismissed.
Complaint Details
The complaint alleged that facility staff failed to provide proper care and supervision to Resident #1, contributing to R1's death and failure to seek timely medical attention. The allegations were substantiated initially but later changed to unsubstantiated on November 29, 2021.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide proper care and supervision to Resident #1 after administering insulin, resulting in hospitalization and posing an immediate health and safety risk. | Type A |
Report Facts
Civil penalty amount: 9500
Civil penalty amount: 500
Civil penalty amount: 1000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Taylor Giunto | Executive Director | Met with Licensing Program Analyst during the visit and named in relation to findings |
| Ashley Smith | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as supervisor and licensing program manager in the report |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 110
Deficiencies: 1
Nov 29, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 11/04/2020 that residents sustained fractures while in care, staff restrained a resident, and failure to follow physician's orders for medical equipment.
Findings
The investigation substantiated that residents sustained numerous falls resulting in serious injuries due to lack of adequate care and supervision, including inconsistent use of hip protectors for Resident #1 and lack of fall prevention plans for Resident #2. The allegations that staff restrained Resident #2 and failed to follow physician's orders for medical equipment were unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding residents sustaining fractures due to falls and inadequate care. The allegations that staff restrained a resident and failed to follow physician's orders for medical equipment were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care, supervision, and services that meet individual needs, resulting in residents sustaining falls and serious injuries. | Type A |
Report Facts
Capacity: 110
Census: 58
Plan of Correction Due Date: Dec 1, 2021
Staff protocol review due date: Dec 6, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Taylor Giunto | Executive Director | Facility administrator met during investigation and exit interview |
| Dennis Douglas | Investigator | Assigned to the complaint investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 110
Deficiencies: 1
Sep 21, 2021
Visit Reason
An unannounced Case Management visit was conducted to follow up on a substantiated allegation of lack of supervision that resulted in injury to a resident.
Findings
The investigation substantiated that the facility failed to provide adequate care and supervision, leading to significant injuries and the death of Resident #1. The facility did not implement sufficient safety measures to manage Resident #2's repeated aggressive behavior, posing an immediate health and safety risk.
Complaint Details
The complaint alleged that on July 13, 2019, Resident #2 pushed Resident #1 causing serious injuries. The allegation was substantiated. Resident #1 was hospitalized and later died due to respiratory failure related to injuries sustained. Resident #2 had a history of aggressive behavior that was not adequately managed by the facility.
Deficiencies (1)
| Description |
|---|
| Violation of CCR Title 22, §87468.2(a)(4) regarding residents' rights to care, supervision, and services meeting their individual needs. |
Report Facts
Civil penalty amount: 14500
Civil penalty amount: 500
Civil penalty amount: 1000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Davis | Director of Healthcare Services | Met with Licensing Program Analyst during visit and acknowledged receipt of appeal rights. |
| Teresa Camara | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report header and signature sections. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 110
Deficiencies: 0
Sep 13, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-04-13 alleging that the facility does not provide a safe environment and that facility staff lack training.
Findings
The investigation found insufficient evidence to support the allegations that the facility does not provide a safe environment and that staff lack training. Staff were found to be trained properly and employ appropriate methods to manage aggressive resident behaviors related to dementia.
Complaint Details
The complaint alleged unsafe environment due to aggressive residents and lack of staff training. The allegations were investigated through staff interviews and records review. Both allegations were deemed unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 110
Census: 57
Training hours: 20
Dementia care training hours: 8
Additional training hours: 4
Staff files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Taylor Giunto | Administrator | Facility administrator interviewed during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 110
Deficiencies: 1
Sep 13, 2021
Visit Reason
An unannounced complaint investigation visit was conducted due to a complaint alleging residents sustained pressure injuries while in care.
Findings
The investigation substantiated that Resident #1 sustained a stage III pressure injury while in care, as the facility retained the resident with this injury without appropriate wound care prior to hospice assessment. Residents #2 and #3 also had pressure injuries but were receiving appropriate care under hospice supervision.
Complaint Details
The complaint alleged residents sustained pressure injuries while in care. The allegation was substantiated based on evidence that Resident #1 was retained with a stage III pressure injury without appropriate wound care prior to hospice care. Residents #2 and #3 had pressure injuries but were receiving appropriate care. The complaint investigation was conducted by Licensing Program Analyst Ashley Smith.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Persons who require health services for or have a health condition including stage 3 and 4 pressure injuries shall not be admitted or retained; the licensee retained Resident #1 with a stage III pressure injury, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 110
Census: 57
Deficiencies cited: 1
Plan of Correction Due Date: Sep 15, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Taylor Giunto | Executive Director | Met with Licensing Program Analyst during investigation and provided information about residents |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 110
Deficiencies: 0
Sep 13, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2020-11-16 regarding staff mismanagement of medication and failure to follow reporting requirements.
Findings
The investigation found insufficient evidence to substantiate the allegations of medication mismanagement and failure to follow reporting requirements. Medication audits and staff interviews revealed no discrepancies or errors, and the facility had submitted unusual incident reports as required.
Complaint Details
The complaint involved allegations that a former staff member was fired for multiple medication errors and narcotics theft, and that unusual incidents involving medication mismanagement were not properly reported. The investigation determined these claims to be unsubstantiated.
Report Facts
Capacity: 110
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and medication audit |
| Taylor Giunto | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Follow-Up
Census: 56
Capacity: 110
Deficiencies: 4
Aug 23, 2021
Visit Reason
The visit was an unannounced Case Management follow-up to a substantiated allegation of neglect/lack of care and supervision related to Resident #1 (R1).
Findings
The licensee failed to monitor R1 after insulin administration and failed to seek timely medical care after R1 was found unresponsive, substantiating the allegations of neglect and lack of proper care. A civil penalty was issued for serious bodily injury related to these violations.
Complaint Details
The complaint alleged that facility staff failed to provide proper care and supervision to Resident #1, contributing to R1's death, and failed to seek timely medical attention. These allegations were substantiated.
Deficiencies (4)
| Description |
|---|
| Failure to provide R1 with proper care and supervision relating to assistance with activities of daily living. |
| Failure to obtain timely medical attention for R1 by failing to call 9-1-1 immediately upon finding R1 in an unresponsive state. |
| Not having competent staff to ensure R1 was monitored and ate after receiving insulin, and subsequently failing to contact emergency services for R1 in a timely manner. |
| Administrator not providing staff with appropriate training to ensure R1 was afforded appropriate care and supervision. |
Report Facts
Civil penalty amount: 9500
Immediate civil penalty amount: 500
Insulin units administered: 6
Additional insulin units administered: 2
Blood glucose reading: 274
Blood glucose reading: 146
Insulin units administered: 6
Insulin units administered: 7
Time alarm sounded: 1345
Time 9-1-1 called: 1433
Time emergency arrived: 1438
Time resident pronounced deceased: 1440
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Taylor Giunto | Executive Director | Met with Licensing Program Analyst during the visit and signed report acknowledging appeal rights. |
| Ashley Smith | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 110
Deficiencies: 1
Aug 23, 2021
Visit Reason
The visit was an unannounced complaint investigation initiated due to an allegation that, due to lack of care and supervision, Resident #1 sustained injuries after being pushed by Resident #2 on 07/13/2019.
Findings
The investigation substantiated the allegation that Resident #1 was pushed by Resident #2 resulting in serious injuries and eventual death. The facility staff were aware of Resident #2's aggressive behaviors but failed to implement adequate safety measures to manage these behaviors, posing a risk to residents.
Complaint Details
The complaint was substantiated. Resident #1 was pushed by Resident #2 causing serious injuries including a stable burst fracture of the first cervical vertebra, acute respiratory failure, fractures, contusions, and lacerations. Resident #1 was admitted to the emergency room and later passed away. Resident #2 had a documented history of aggressive behaviors. The facility failed to implement adequate safety measures despite awareness of these behaviors.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care, supervision, and services sufficient to meet residents' individual needs, resulting in Resident #1 sustaining multiple injuries due to lack of care and supervision. | Type A |
Report Facts
Civil penalty amount: 500
Capacity: 110
Census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation report. |
| Taylor Giunto | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation. |
| Dennis Douglas | Investigator | Conducted interviews and reviewed documentation during the investigation. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 110
Deficiencies: 0
Jul 2, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-05-20 regarding residents being locked inside their rooms, insufficient staffing, residents not having access to their rooms, and inadequate supervision of residents.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Residents were not locked inside their rooms as they could release locks from inside, and some doors no longer locked. Staffing levels were adequate with a new staggered schedule providing sufficient coverage. Residents had access to their rooms either by key or staff assistance, and supervision was deemed adequate.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents locked inside rooms, insufficient staffing, residents lacking access to rooms, and inadequate supervision. Interviews, observations, and schedule reviews found no evidence to support these claims.
Report Facts
Staff to resident ratio: 7
Staff to resident ratio: 10
Facility capacity: 110
Resident census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Taylor Giunto | Executive Director | Met with Licensing Program Analyst during investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 110
Deficiencies: 0
Jul 2, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2020-11-04 regarding resident care, facility maintenance, and safety concerns.
Findings
All allegations including unmet showering and incontinence needs, presence of vermin, fire safety noncompliance, and resident elopement attempts were investigated and found to be unsubstantiated based on interviews, observations, and documentation review.
Complaint Details
The complaint included allegations that staff were not meeting residents' showering and incontinence needs, the facility had vermin, was not maintained in conformity with fire safety regulations, and that residents eloped from the facility. The investigation found insufficient evidence to substantiate any of these claims, deeming all allegations unsubstantiated.
Report Facts
Capacity: 110
Census: 50
Complaint received date: Nov 4, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Taylor Giunto | Executive Director | Facility administrator interviewed during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 51
Capacity: 110
Deficiencies: 0
Jun 14, 2021
Visit Reason
The inspection was an unannounced required annual visit with a specific emphasis on infection control practices and procedures.
Findings
The facility was found to be in compliance with Title 22 Regulations, with no deficiencies cited. The kitchen, bedrooms, restrooms, and common spaces were all in good condition, and infection control policies and procedures were deemed adequate.
Report Facts
Capacity: 110
Census: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Taylor Giunto | Administrator | Met with Licensing Program Analyst during inspection |
| Ashley Smith | Licensing Program Analyst | Conducted the inspection |
| Marisol Villa | Assistant Administrator | Accompanied Licensing Program Analyst during physical plant tour |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 110
Deficiencies: 0
Jun 7, 2021
Visit Reason
The inspection was conducted as a Case Management investigation regarding a self-reported incident involving two residents found engaging in sexual intercourse in a resident room.
Findings
The investigation found no immediate health and safety concerns during the visit. Additional investigation was needed, and no citations were issued on the date of the visit.
Complaint Details
The visit was complaint-related due to a self-reported incident involving Resident #1 and Resident #2 engaging in sexual intercourse in a resident room on 11/14/2020. No citations were issued and no immediate health and safety concerns were observed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Taylor Giunto | Administrator | Met with Licensing Program Analysts during the investigation and was involved in interviews and facility tour. |
| Aja Richardson | Licensing Program Analyst | Conducted the Case Management inspection and investigation. |
| Salia Walker | Licensing Program Analyst | Conducted the Case Management inspection and investigation. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 52
Capacity: 110
Deficiencies: 0
May 19, 2021
Visit Reason
The visit was a Case Management - Other type conducted to review the Accusation dated 5/13/2021 and to provide information regarding Health and Safety Code 1569.38 about posting and notification requirements.
Findings
The Licensing Program Analyst reviewed and discussed the contents of the Accusation with the facility Administrator and provided relevant regulatory information. An exit interview was conducted and signatures were obtained.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Taylor Giunto | Executive Director | Met with Licensing Program Analyst during the visit and discussed the Accusation. |
| Ashley Smith | Licensing Program Analyst | Conducted the Case Management - Other visit and reviewed the Accusation. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 110
Deficiencies: 3
Mar 30, 2021
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations received on 08/13/2020 regarding lack of supervision causing resident injuries, failure to seek timely medical attention, and failure to meet a resident's incontinent needs.
Findings
The investigation substantiated all allegations: the facility failed to provide adequate supervision resulting in multiple injuries to Resident #1; failed to seek timely medical attention for Resident #1's abdominal pain, which was later diagnosed as gallstones; and failed to meet Resident #1's incontinent care needs due to staffing shortages and resident resistance. The facility lacked sufficient protocols and training to manage aggressive behaviors and did not call 9-1-1 when requested by family.
Complaint Details
The complaint was substantiated. Resident #1 sustained multiple unexplained injuries due to lack of supervision, the facility failed to seek timely medical attention for Resident #1's abdominal pain, and failed to meet Resident #1's incontinent needs. Staff interviews and document reviews supported these findings.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide care, supervision, and services that meet individual needs, resulting in multiple injuries due to lack of supervision. | Type A |
| Failure to immediately telephone 9-1-1 in an imminent threat to resident's health, including apparent life-threatening medical crisis. | Type A |
| Failure to ensure incontinent residents are kept clean and dry and facility remains free of odors from incontinence. | Type A |
Report Facts
Census: 55
Total Capacity: 110
Deficiencies cited: 3
Plan of Correction Due Date: Apr 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
| Taylor Giunto | Administrator / Executive Director | Facility administrator involved in interviews and findings |
| Jose Santana | Investigator | Community Care Licensing Division Investigator assigned to the case |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 110
Deficiencies: 0
Jan 25, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that Resident #1 was assaulted by another resident resulting in injury on 12/15/2020.
Findings
The investigation found insufficient evidence to support the claim that Resident #1 was assaulted due to lack of supervision. The incident was deemed isolated, and no deficiencies were cited.
Complaint Details
The complaint alleged that Resident #1 was assaulted by Resident #2 on 12/15/2020 resulting in injury. Interviews and records review indicated the incident was unwitnessed, residents apologized to each other shortly after, and no additional injuries or supervision issues were found. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 29520210104155928
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Taylor Giunto | Executive Director | Met with Licensing Program Analyst during investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 110
Deficiencies: 0
Jan 25, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility was unsanitary, specifically that fecal matter was observed and not cleaned for over an hour.
Findings
The investigation found insufficient evidence to support the allegation that the facility was unsanitary. The facility appeared clean during a virtual tour, and staff interviews indicated regular cleaning and prompt housekeeping response. The allegation was deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint was unsubstantiated based on the investigation findings. The allegation was that the facility was unsanitary, but evidence did not support this claim.
Report Facts
Capacity: 110
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit |
| Taylor Giunto | Administrator | Facility representative met during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 110
Deficiencies: 0
Jan 25, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/25/2020 regarding unmet toileting and personal hygiene needs of residents and unsanitary conditions in the facility.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff were found to check residents every two hours for toileting needs, assist with personal hygiene, and maintain cleanliness despite some residents refusing care. The facility appeared clean and sanitary during the virtual tour.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not meeting toileting needs, personal hygiene needs, and the facility not being kept clean and sanitary. Interviews and observations did not support these claims.
Report Facts
Capacity: 110
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Taylor Giunto | Administrator | Facility representative met during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
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