Inspection Report Summary
Most inspections found no deficiencies, showing the facility generally maintained compliance with licensing regulations, infection control, and resident care standards. The most recent report from July 9, 2025, was a complaint investigation that found the allegation of an unsafe environment unsubstantiated. One notable deficiency occurred in January 2023 when a medication error was cited involving a resident receiving another resident’s medication to which they were allergic, posing an immediate health risk; this was an isolated incident with no fines or enforcement actions listed. Several other complaint investigations, including those related to infection control and resident care, were unsubstantiated. Recent reports have been consistently clean, indicating improvement and adherence to required protocols over time.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Capacity: 285
Deficiencies: 0
Jul 9, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-02-16 alleging that the facility does not provide a safe environment for residents.
Findings
The investigation found that the facility's main front door is locked from the outside at night but not from the inside, allowing residents to exit. Residents have key fobs to re-enter, and two side exit doors remain unlocked. Security staff may occasionally be away from the front desk. Based on these findings, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that the facility does not provide a safe environment because the main front door is locked at night and residents cannot exit, and security staff are not always available at the front desk. The allegation was found unsubstantiated.
Report Facts
Facility capacity: 285
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Teutschel | Evaluator | Conducted telephone interview and complaint investigation |
| Sondra Brakeville | Administrator | Facility administrator interviewed regarding complaint |
Inspection Report
Annual Inspection
Census: 285
Capacity: 285
Deficiencies: 0
Jun 4, 2025
Visit Reason
An unannounced required annual inspection visit was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and free from safety hazards. Staffing levels and training met requirements, resident care plans were comprehensive and up-to-date, medication administration followed policies, and health and safety protocols were in place. Overall, the facility complied with licensing regulations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sondra Brakeville | Administrator | Met with Licensing Program Analyst during inspection and acknowledged receipt of report. |
| Renita Hall | Licensing Program Analyst | Conducted the unannounced required annual inspection visit. |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Follow-Up
Census: 212
Capacity: 285
Deficiencies: 0
Jan 17, 2025
Visit Reason
The visit was an unannounced case management follow-up on an incident involving the death of a resident after an unwitnessed fall at the facility.
Findings
The facility acted appropriately and in compliance with applicable regulations regarding the incident. No deficiencies were cited during this visit, and appropriate safety measures were observed.
Report Facts
Resident age: 78
Incident date: Jan 10, 2025
Death report date: Jan 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renita Hall | Licensing Program Analyst | Conducted the unannounced case management visit and interview |
| Jessica Swaaley | Executive Director | Met with Licensing Program Analyst during the visit and discussed the incident |
| Sondra Brakeville | Administrator/Director | Interviewed regarding the incident and facility emergency protocols |
Inspection Report
Annual Inspection
Census: 285
Capacity: 285
Deficiencies: 0
Jun 19, 2024
Visit Reason
The inspection was an unannounced required 1-year annual visit to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and free from safety hazards. Staffing levels and training met regulatory requirements, resident care plans were comprehensive and up-to-date, medication administration was compliant, and health and safety protocols including infection control and emergency plans were properly followed. Overall, the facility complied with licensing regulations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sondra Brakeville | Administrator | Met with Licensing Program Analyst during inspection and acknowledged receipt of report. |
| Renita Hall | Licensing Program Analyst | Conducted the unannounced required 1-year annual visit. |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 220
Capacity: 285
Deficiencies: 0
Mar 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that resident care needs were not being met and that a resident was not given privacy, including a claim that a resident's bathroom was locked and inaccessible.
Findings
The investigation included interviews and records review and found that the bathroom was locked due to infection control protocols during a COVID-19 outbreak. Staff assisted residents with bathroom use and sanitization. There was insufficient evidence to substantiate the allegations regarding unmet care needs and lack of privacy.
Complaint Details
The complaint was unsubstantiated. Allegations included resident care needs not being met and lack of privacy due to locked bathroom access. Investigation found protocols in place for infection control and staff assistance. No evidence supported the allegations.
Report Facts
Capacity: 285
Census: 220
Bathroom locked duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Maureen Manzon | Assistant Director of Resident Care | Participated in exit interview and received report findings |
| Severino Doria | Director of Resident Care | Participated in exit interview and received report findings |
| Sondra Brakeville | Administrator | Confirmed bathroom locking due to infection control protocols |
Inspection Report
Census: 220
Capacity: 285
Deficiencies: 0
Mar 30, 2023
Visit Reason
Licensing Program Analyst Carmen Lopez conducted a visit to deliver findings for an investigation and to conduct a case management visit.
Findings
No deficiencies were cited during the visit. Technical advisories were given per Title 22, Division 6, Chapter 8 of the California Code of Regulations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Manzon | Assistant Director of Resident Care | Met during the visit and participated in the exit interview. |
| Severino Doria | Director of Resident Care | Met during the visit and participated in the exit interview. |
| Carmen Lopez | Licensing Program Analyst | Conducted the visit and delivered findings. |
| Rebecca Hedgecock | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 285
Deficiencies: 0
Jan 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not follow the infection control plan, specifically regarding COVID-19 protocols in the memory care unit.
Findings
The investigation found that memory care residents were quarantined by sections as required, staff trainings on COVID-19 protocols were confirmed, and the facility followed its COVID-19 infection control plan. The allegation was found to be unsubstantiated.
Complaint Details
The complaint alleged that staff did not follow infection control plan related to COVID-19 positive residents not quarantining in the memory care unit. The allegation was found to be unsubstantiated.
Report Facts
Capacity: 285
Census: 178
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hamilton | Licensing Program Analyst | Conducted the complaint investigation |
| Sondra Brakeville | Executive Director | Met with Licensing Program Analyst during the investigation |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 217
Capacity: 285
Deficiencies: 1
Jan 12, 2023
Visit Reason
The visit was conducted in response to a self-reported incident on 2022-11-01 where a resident was administered medication to which they were allergic.
Findings
A deficiency was cited for a medication error where Resident 1 was given another resident's medication, posing an immediate health risk. The facility staff had current criminal record clearances and residents appeared appropriate for care.
Complaint Details
The visit was complaint-related due to a self-reported medication error incident involving Resident 1. The deficiency was substantiated and cited.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical & Dental Care Services. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Resident 1 being administered another resident's medication to which they were allergic, posing an immediate health risk. | Type A |
Report Facts
Residents in care: 217
Total capacity: 285
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sondra Brakeville | Administrator/Executive Director | Met during the visit and involved in exit interview |
| Kayla Hilario | Licensing Program Analyst | Conducted the inspection visit |
| John Rante | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 219
Capacity: 285
Deficiencies: 0
May 23, 2022
Visit Reason
The visit was an unannounced case management inspection regarding two self-reported incidents involving resident falls and injuries submitted to Community Care Licensing.
Findings
The Licensing Program Analyst toured the facility, interviewed staff, and reviewed records, finding no deficiencies during the visit.
Complaint Details
The visit was triggered by two incidents: Resident #1 fell and sustained an injury on 2022-05-07 and was hospitalized, returning with hospice care; Resident #2 fell and sustained an injury on 2022-05-13 and was hospitalized. Both incidents were self-reported to Community Care Licensing.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vicky Williamson | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Sondra Brakeville | Executive Director | Met with Licensing Program Analyst to discuss the purpose of the visit. |
| Jessica Swaaley | Business Office Manager | Participated in exit interview and received a copy of the report. |
| Diana Lopez | Director of Resident Care | Met with Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 219
Capacity: 285
Deficiencies: 0
May 23, 2022
Visit Reason
The inspection was an unannounced required 1-year visit to evaluate the facility's compliance with licensing and infection control requirements.
Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation measures, and no deficiencies were observed during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sondra Brakeville | Administrator / Executive Director | Met with Licensing Program Analyst during the inspection and discussed the purpose of the visit. |
| Diana Lopez | Assistant Director of Resident Care | Conducted facility tour with Licensing Program Analyst. |
| Jessica Swaaley | Business Office Manager | Participated in exit interview and received a copy of the report. |
Inspection Report
Census: 205
Capacity: 285
Deficiencies: 0
Jan 18, 2022
Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan including disinfection, testing, vaccination, screening protocols, and use of personal protective equipment (PPE).
Findings
During the visit, no deficiencies were cited. The team interviewed the Business Office Manager and conducted a walk-through of the facility, concluding with a debriefing.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Swaaley | Business Office Manager | Interviewed during the visit and involved in debriefing. |
| Carmen Lopez | Licensing Program Analyst | Conducted the on-site HAI assessment visit. |
| Jennifer West | COVID-19 Site Assessment Nurse | Conducted the on-site HAI assessment visit. |
| Rebecca Hedgecock | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 137
Capacity: 285
Deficiencies: 0
Jun 15, 2021
Visit Reason
An unannounced annual required licensing inspection was conducted to verify compliance with statutes, regulations, and other written requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation strategies, and no deficiencies were observed during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sondra Brakeville | Executive Director | Met with Licensing Program Analyst during inspection and named in report. |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection and authored the report. |
| John Rante | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Census: 137
Capacity: 285
Deficiencies: 0
Jun 15, 2021
Visit Reason
An unannounced case management visit was conducted regarding two incident reports involving resident falls and injuries.
Findings
Both incidents were appropriately addressed by the facility, all required notifications were made, and no deficiencies were issued during the visit.
Report Facts
Incident dates: Incidents occurred on 2021-05-15 and 2021-06-02
Resident census: 137
Facility capacity: 285
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sondra Brakeville | Executive Director | Met during visit and named in report |
| Dennis Prejusa | Director of Resident Care | Met during visit and named in report |
| Natasha Persaud | Licensing Program Analyst | Conducted the inspection visit |
| John Rante | Licensing Program Manager | Named in report |
Inspection Report
Census: 150
Capacity: 285
Deficiencies: 0
Jan 22, 2021
Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.
Findings
During the visit, no deficiencies were issued. A walk-through of the facility was conducted and a debriefing was held with the Executive Director and Assistant Director.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sondra Brakeville | Executive Director | Interviewed and participated in the walk-through and debriefing during the visit. |
| Severino Doria | Assistant Director | Interviewed and participated in the walk-through and debriefing during the visit. |
Loading inspection reports...
