Inspection Reports for Sparr Heights Estates Senior Living
2640 Honolulu Ave, Montrose, CA 91020, United States, CA, 91020
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with the facility generally maintaining clean, safe, and well-maintained conditions. Several complaint investigations were unsubstantiated, including serious allegations such as sexual abuse and inadequate care. One complaint investigation on September 15, 2022, was substantiated for medication errors involving improper patch application and unsecured medication storage, but no fines or enforcement actions were listed in the available reports. The most recent report from May 1, 2025, was a complaint investigation that found no deficiencies and unsubstantiated allegations. This suggests improvement since the last substantiated issues, with no recent serious concerns noted.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
0.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
53% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 70
Capacity: 131
Deficiencies: 0
Date: May 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not ensure adequate care and supervision to residents and that staff spoke inappropriately in front of a resident.
Complaint Details
The complaint involved two allegations: 1) staff did not ensure adequate care and supervision, specifically that a resident spent a night in a flooded room without checks until the next morning; 2) staff spoke inappropriately in front of a resident, including a claim that a staff member called the resident 'coo coo'. Both allegations were investigated through staff and resident interviews, record reviews, and physical plant tours. The allegations were found unsubstantiated.
Findings
The investigation found insufficient information to substantiate the allegations. Interviews, observations, and record reviews indicated that resident care and supervision were adequate, and no inappropriate staff behavior was confirmed. The resident involved had been moved out of the facility prior to the investigation.
Report Facts
Capacity: 131
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leizl De La Cerra | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation report |
| Ernest Lewis | Administrator | Facility administrator present during the investigation |
| Denise Gotto | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Annual Inspection
Census: 68
Capacity: 131
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
The inspection was a required one-year unannounced visit to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be in good condition with no health or safety hazards noted. Rooms were adequately furnished and clean, food storage and preparation areas were sanitary, and safety systems such as fire extinguishers and smoke detectors were properly maintained.
Report Facts
Fire extinguisher last inspection date: Jan 17, 2025
Hot water temperature: 109.6
Facility temperature: 73
Food stock duration - perishable: 2
Food stock duration - non-perishable: 7
Rooms inspected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the inspection and noted findings |
| Denise Gotto | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 131
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff sexually abused a resident and failed to report the incident to proper agencies.
Complaint Details
The complaint alleged that staff member S1 sexually abused resident R1 over a period of 3-6 months in 2022 and that the incident was not reported to authorities. Interviews with multiple staff, residents, and administrators revealed inconsistent and conflicting information, with no corroboration or complaints from residents or staff. The former executive director denied knowledge of the allegations and stated S1 resigned voluntarily to focus on school. Based on the investigation, the allegations were deemed unsubstantiated.
Findings
The investigation included interviews with staff, residents, and administrators and review of relevant documents. Conflicting statements and lack of corroborating evidence led to the determination that the allegations were unsubstantiated at this time.
Report Facts
Complaint Control Number: 31-AS-20230728111241
Number of staff interviewed: 6
Number of residents attempted to interview: 4
Complaint received date: 07/28/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Bill Heady | Executive Director | Met with investigator during visit and interviewed |
| Laarni Santiago | Investigator | Conducted the complaint investigation interviews |
| Ernest Lewis | Administrator | Facility administrator named in report header |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 131
Deficiencies: 0
Date: May 23, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not following proper reporting requirements and that resident care needs were not being met by facility staff.
Complaint Details
The complaint involved allegations of improper reporting by staff and unmet resident care needs. The allegations were deemed unsubstantiated based on interviews, record reviews, and documentation of incident reporting.
Findings
The investigation found that all twelve residents interviewed stated that staff were respectful and provided all needed care, with no complaints about care quality. The allegation regarding failure to report an altercation was unsubstantiated as the facility had submitted the required incident report and reported the incident to local law enforcement.
Report Facts
Residents interviewed: 12
Incident report date: May 22, 2023
Incident date: May 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Helen Kirkorian | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Ernest Lewis | Administrator | Facility administrator named in report header |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 131
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that the facility is unsafe for residents due to unsecured access ways and that residents are not provided proper medication assistance.
Complaint Details
The complaint investigation was unsubstantiated based on observations, interviews with residents, staff, and maintenance personnel, and review of relevant records. No evidence supported the allegations of unsecured access ways or medication errors.
Findings
The investigation found that the access ways in the Memory Care Unit were secured with all safety protocols in place, and no issues were reported by maintenance staff. Interviews with residents and medication staff revealed no medication errors or late medication passes, leading to the allegations being deemed unsubstantiated.
Report Facts
Residents interviewed: 6
Medication staff interviewed: 2
Capacity: 131
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Agard | Licensing Program Manager | Oversaw the complaint investigation |
| Tracy Waite | Interim Administrator | Met with investigators during the visit |
Inspection Report
Annual Inspection
Census: 58
Capacity: 131
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
An unannounced required 1-year inspection was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean and well-maintained with appropriate safety measures in place, including operational smoke detectors, carbon monoxide detectors, and fire extinguishers. Medication carts were secured, and no deficiencies were issued during this inspection.
Report Facts
Food supply duration: 2
Food supply duration: 7
Hot water temperature: 120
First aid kits: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the inspection and authored the report |
| Naira Margaryan | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Helen Kirkorian | Business Office Manager | Met with the Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 131
Deficiencies: 0
Date: Oct 9, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-05-19 regarding residents' hygiene needs not being met, failure to seek medical attention for a resident, and failure to administer medication.
Complaint Details
The complaint involved allegations that residents' hygiene needs were not met, staff did not seek medical attention for a resident with a toe fungal infection, and staff failed to give prescribed medication. The investigation found these allegations unsubstantiated.
Findings
The investigation found that the resident's hygiene needs were met unless refused, medical attention was sought with documented communication with the podiatrist, and medication was administered as prescribed. Therefore, all allegations were deemed unsubstantiated.
Report Facts
Complaint received date: May 19, 2021
Facility capacity: 131
Facility census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Veronica Sanchez | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation |
| Carmy C Jerome | Administrator | Facility administrator named in the report |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 131
Deficiencies: 2
Date: Sep 15, 2022
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations that staff did not follow doctor's orders and that medications were accessible to a resident in care.
Complaint Details
Complaint investigation was substantiated based on evidence including photo documentation and record reviews confirming medication errors and improper medication storage.
Findings
The investigation substantiated that staff failed to follow physician's orders by applying two medication patches instead of one on Resident #1, and that prescription medication was accessible to the resident in their room, posing immediate health and safety risks.
Deficiencies (2)
Licensee did not abide by Resident #1's physician's order regarding medication patch application.
Licensee failed to keep prescription medication in central medication storage, making it accessible to Resident #1.
Report Facts
Capacity: 131
Census: 64
Deficiencies cited: 2
Plan of Correction Due Date: Sep 16, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| Ernest Lewis | Executive Director | Facility representative met during investigation and agreed to corrective actions |
| Carmy C Jerome | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 131
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained a bruise while in care.
Complaint Details
The complaint alleged that on 02/17/2022, Resident #1 sustained a bruise while in care. Staff interviews and review of photos indicated the injury was likely self-inflicted scratches. The allegation was unsubstantiated.
Findings
Based on inspection, observation, interviews, and record review, there was insufficient information to support the allegation. The injury appeared to be scratches caused by the resident scratching their own face, and no health and safety issues were noted. The complaint was deemed unsubstantiated.
Report Facts
Complaint Control Number: 31-AS-20220314112215
Facility Capacity: 131
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Ernest Lewis | Administrator | Met with Licensing Program Analyst during the visit |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 131
Deficiencies: 0
Date: Sep 11, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff did not seek medical attention for a resident and did not notify the responsible party of the resident's injury.
Complaint Details
The complaint involved two allegations: staff did not seek medical attention for resident #1 and staff did not notify the responsible party of the resident's injury. Both allegations were investigated through staff interviews and record reviews and were found to be unsubstantiated.
Findings
The investigation found insufficient information to support the allegations. Staff did seek medical attention for the resident and notified the responsible party within 24 hours. The allegations were deemed unsubstantiated.
Report Facts
Capacity: 131
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Naira Margaryan | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Veronica Sanchez | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation |
| Erika Hughes | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 131
Deficiencies: 0
Date: Sep 11, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations regarding residents' clothes being dirty and missing.
Complaint Details
The complaint investigation was unsubstantiated based on observations, record reviews, and staff interviews regarding allegations of dirty and missing clothes for Resident #1.
Findings
The investigation found that the allegations were unsubstantiated. Resident #1's clothes were observed to be clean and tidy, and no complaints about missing clothes were confirmed. Staff reported that residents' clothes are laundered once a week and families are advised to label clothes to avoid mixing.
Report Facts
Capacity: 131
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Named in report signature |
| Veronica Sanchez | Resident Care Coordinator | Met with during the investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 131
Deficiencies: 0
Date: Aug 20, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2020-11-24 regarding staff not cleaning resident rooms, insufficient staffing, and call lights not being answered timely.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with residents and staff, observations of clean rooms, and no evidence supporting the allegations of insufficient staffing or delayed call light responses.
Findings
The investigation found that residents reported rooms were cleaned daily and general cleaning was done weekly, staffing was sufficient to meet residents' needs according to residents and staff interviewed, and call lights were answered within a reasonable time. Therefore, the allegations were deemed unsubstantiated.
Report Facts
Residents interviewed: 9
Rooms observed: 12
Care staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Lizette Halili | Staff | Met with Licensing Program Analyst during the investigation. |
| Carmy C Jerome | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 131
Deficiencies: 0
Date: Aug 17, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2020-11-24 regarding insufficient clean linens and malodorous resident rooms.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included insufficient clean linens and malodorous resident rooms, both of which were not supported by observations or interviews.
Findings
The investigation found sufficient linens in stock and clean linens in all twelve rooms visited. No foul odors or carpet stains were observed in the rooms inspected. The allegations were deemed unsubstantiated based on observations and interviews.
Report Facts
Rooms visited: 12
Complaint received date: Nov 24, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Ernest Lewis | Executive Director | Met with investigators and provided information during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 131
Deficiencies: 0
Date: Jul 7, 2022
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff were not providing resident's medication as prescribed, a resident was left in a soiled diaper for an extended period, and a resident was not being provided medical attention in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated based on staff interviews, medication administration record review, and observations. Allegations regarding medication administration, diaper care, and timely medical attention were not supported by evidence.
Findings
Based on interviews, record review, and observation, all allegations were found to be unsubstantiated. Medication was administered as prescribed except for documented exceptions, residents' diapers were changed regularly, and medical attention was provided timely with palliative care involvement.
Report Facts
Capacity: 131
Census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernest Lewis | Executive Director | Met with Licensing Program Analyst during investigation |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 55
Capacity: 131
Deficiencies: 0
Date: Feb 17, 2022
Visit Reason
An unannounced required 1-year infection control inspection was conducted to assess compliance with COVID-19 prevention protocols and overall facility conditions.
Findings
The facility was found to be in compliance with infection control measures, including proper signage, PPE stock, and screening procedures. Common areas, resident rooms, and safety equipment were inspected and found adequate. No deficiencies were issued at this time.
Report Facts
Food supply duration: 2
Food supply duration: 7
Hot water temperature: 120
Fire extinguisher last serviced: 2021
Medication carts observed: 1
First aid kits: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernest Lewis | Executive Director | Met with Licensing Program Analyst during inspection |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the inspection |
| Naira Margaryan | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 131
Deficiencies: 0
Date: Jun 30, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that facility staff over-medicated a resident.
Complaint Details
The complaint alleged that facility staff over-medicated a resident. The investigation found the allegation unsubstantiated based on interviews, record review, and observation.
Findings
The investigation included staff interviews and record reviews, which showed that medication administration matched documentation and the resident had no adverse reactions. The allegation was found to be unsubstantiated.
Report Facts
Facility capacity: 131
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Fountain | Operations Specialist | Met with the Licensing Program Analyst during the investigation |
| Carmy C Jerome | Administrator | Facility administrator named in the report |
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