Inspection Report Summary
Most inspections found no deficiencies, with the facility consistently meeting licensing requirements for safety, cleanliness, staffing, and infection control. The most recent report from March 28, 2025, was perfect, showing full compliance with no issues noted. One isolated deficiency appeared in April 2023 when a staff member lacked required infection control training, but this was promptly addressed with a corrective plan. Several complaint investigations, including those in June 2023 and April 2024, were unsubstantiated after thorough review. Overall, the facility’s record shows stable compliance with no serious enforcement actions or fines reported.
Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 62
Capacity: 104
Deficiencies: 0
Mar 28, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with all applicable regulations, including fire safety, food storage, and medication security. No issues or concerns were observed during the visit.
Report Facts
Hospice waiver residents: 12
Fire extinguisher last service date: Mar 5, 2025
Fire alarm inspection date: Mar 5, 2025
Last fire drill date: Mar 8, 2025
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Zuletta | Administrator | Met with Licensing Program Analyst during the inspection and was informed of the purpose of the visit. |
| Janette Romero | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
Inspection Report
Capacity: 104
Deficiencies: 0
Jan 17, 2025
Visit Reason
An unannounced collateral visit was conducted to collect records and conduct interviews at the facility.
Findings
No immediate health or safety concerns were observed during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Zuletta | Executive Director | Met with during the visit and exit interview. |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced collateral visit. |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 104
Deficiencies: 0
Apr 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-11-19 alleging that the licensee did not accord a resident safe accommodations and did not safeguard the resident's personal property.
Findings
The investigation found that staff followed policy regarding safe accommodations and that the resident's personal property was accounted for and returned. Based on interviews and records review, the allegations were unsubstantiated.
Complaint Details
The complaint was unsubstantiated after investigation. Three witnesses verified staff compliance with safe accommodations, and resident's personal property was confirmed accounted for and returned by staff OS1.
Report Facts
Complaint Control Number: 08-AS-20211119083204
Capacity: 104
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Michael Zuletta | Administrator | Facility administrator met during the investigation and exit interview |
| John Rante | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 60
Capacity: 104
Deficiencies: 0
Mar 12, 2024
Visit Reason
An unannounced annual required visit was conducted to evaluate compliance with licensing regulations for the memory care facility.
Findings
The inspection found the facility to be clean, well-maintained, and adequately staffed with no regulation violations observed. Infection control, physical plant, food service, care and supervision, record keeping, health-related services, and disaster preparedness were all found to be in compliance.
Report Facts
Staff files reviewed: 5
Resident files reviewed: 5
Disaster drill date: Feb 16, 2024
Visit time began: 1430
Visit time completed: 1800
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Zuletta | Administrator In Training | Met during inspection and exit interview |
| Shanyn Chapman | Family Ambassador Dementia Care Specialist | Met during inspection |
| Jacqueline Shaw Ross | Licensing Program Analyst | Conducted the inspection |
| Jazmond D Harris | Licensing Program Manager | Named in report header |
Inspection Report
Census: 62
Capacity: 104
Deficiencies: 0
Oct 20, 2023
Visit Reason
The visit was an unannounced collateral visit conducted to interview a resident.
Findings
The Licensing Program Analyst met with the Executive Director and conducted an exit interview. A copy of the report and Licensee Rights were provided to the Executive Director.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kellie Pacheco-Smith | Executive Director | Met with Licensing Program Analyst during the visit and received the report and Licensee Rights. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced collateral visit and interview. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 104
Deficiencies: 0
Jun 12, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not provide proper care for a resident, including leaving the resident without clothes and not providing clean linens.
Findings
The investigation included interviews with staff and a resident, and review of pertinent documents. The allegations were found to be unsubstantiated or unfounded due to lack of preponderance of evidence and conflicting resident recollections.
Complaint Details
The complaint involved allegations that staff left a resident pantless on a urine-covered mattress without a sheet and smeared feces in the resident's bathroom and room. The resident reported removing their own pants and not seeking staff assistance. Staff observed the resident unclothed from the waist down but the resident was previously observed fully clothed on a sheeted mattress 30 minutes prior. The complaint was unsubstantiated due to insufficient evidence.
Report Facts
Staff interviewed: 3
Resident interviewed: 1
Complaint received date: Jun 7, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation |
| Cheryl Goodrich | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Kellie Smith | Executive Director | Met with LPAs during the investigation |
| Tana McMillon | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 65
Capacity: 104
Deficiencies: 1
Apr 13, 2023
Visit Reason
An unannounced annual required visit was conducted to evaluate compliance with licensing regulations and facility operations.
Findings
The facility was generally found to be clean, well-maintained, and adequately staffed with proper emergency and disaster preparedness. However, one staff member was found to lack infection control training, which was documented as a deficiency with a plan of correction due by 04/14/2023.
Deficiencies (1)
| Description |
|---|
| One staff member did not have infection control training as required by the Infection Control Plan. |
Report Facts
Staff files reviewed: 5
Resident files reviewed: 5
Plan of Correction Due Date: Apr 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kellie Smith | Administrator | Met with Licensing Program Analysts during the inspection and involved in deficiency discussion. |
| Janira Arreola | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Joel Esquivel | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 53
Capacity: 104
Deficiencies: 0
May 24, 2022
Visit Reason
The inspection was an unannounced annual inspection with emphasis on infection control conducted by the Licensing Program Analyst.
Findings
The facility was found to be in compliance with infection control measures, including appropriate COVID-19 postings, sufficient hygiene supplies, PPE availability, and staff training. No deficiencies were observed during the visit.
Report Facts
Capacity: 104
Census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the annual inspection |
| Shanyn Chapman | Family Ambassador | Met with Licensing Program Analyst during inspection |
Inspection Report
Original Licensing
Census: 53
Capacity: 104
Deficiencies: 0
Mar 2, 2021
Visit Reason
An announced Pre-Licensing and Component III inspection visit was conducted due to a change of ownership and initial licensing of the facility.
Findings
The facility was found to have appropriate safety features including a sprinkler system, secured perimeter, and functioning smoke and carbon monoxide detectors. The kitchen and food service areas were clean and compliant with regulations. No activities were taking place due to COVID-19 social distancing protocols. The facility maintains locked medication rooms with 24/7 LVN care and locked resident and staff records.
Report Facts
Water temperature: 107
Thermostat temperature: 103
Licensed capacity: 104
Current census: 53
Number of rooms: 46
Perishable food supply: 7
Non-perishable food supply: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kellie Pacheco-Smith | Administrator | Met with Licensing Program Analyst during inspection and acknowledged receipt of documents |
| Adam Hamer | Licensing Program Analyst | Conducted the Pre-Licensing and Component III inspection visit |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report |
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