Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
3% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 20
Capacity: 679
Deficiencies: 0
Date: Oct 2, 2025
Visit Reason
The visit was an unannounced Case Management-Incident inspection to follow up on a suspected adult/elder physical abuse incident (SOC341) involving two residents from the independent living section of the facility.
Complaint Details
The visit was triggered by a complaint of suspected adult/elder physical abuse (SOC341). The complaint was cross-reported to law enforcement (case #SR250010503), Ombudsman, and CDPH. The incident involved two residents from the independent living section.
Findings
No deficiencies were observed or cited during the Case Management-Incident visit. The incident occurred in the Skilled Nursing Unit, which is outside the licensing jurisdiction, but responsible parties including law enforcement, Ombudsman, and CDPH were cross-reported.
Report Facts
Facility capacity: 679
Resident census: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Skillman | Health Care Administrator | Met with Licensing Program Analyst during inspection |
| Sharon Shnell-Hobbs | Director of Resident Health Services | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 379
Capacity: 679
Deficiencies: 0
Date: Jul 29, 2025
Visit Reason
An unannounced annual required inspection was conducted to evaluate compliance with licensing requirements at the facility.
Findings
The inspection found no deficiencies. The facility was compliant with safety, health, and care regulations, including fire safety, medication storage, and resident accommodations. Some staff had expired first aid/CPR certificates, resulting in a technical violation.
Report Facts
Residents in Assisted Living: 25
Residents in Memory Care: 7
Hospice waiver capacity: 40
Fire clearance capacity: 679
Staff files reviewed: 9
Resident files reviewed: 10
Staff without current 1st aid/CPR certificates: 5
Medication carts: 4
Water temperature range: 105
Water temperature range: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Keck | Executive Director/Administrator | Met with Licensing Program Analyst during inspection; administrator certificate expires 8/21/2025 |
| Sharon Shnell-Hobbs | Director of Resident Health Services | Met with Licensing Program Analyst during inspection and exit interview |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 15, 2025
Visit Reason
The inspection was conducted due to a complaint alleging sexual abuse by a Certified Nursing Assistant against a resident.
Complaint Details
The complaint involved an allegation by Resident 1 that CNA A sexually abused her on 4/13/25. The allegation was substantiated by interviews with staff and review of staffing assignments. The facility delayed reporting the allegation to the licensing agency as required.
Findings
The facility failed to immediately report an allegation of abuse made by Resident 1 on 4/13/25 to the California Department of Public Health until 4/15/25. This delay potentially left the resident vulnerable to further harm and delayed investigation and corrective actions.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and delayed reporting the results of the investigation to proper authorities. Resident 1's allegation of sexual abuse on 4/13/25 was not reported to the Department until 4/15/25.
Report Facts
Residents sampled: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in sexual abuse allegation |
| LN B | Licensed Nurse | Received abuse report from CNA A but failed to report to Administrator or DON |
| CNA C | Certified Nursing Assistant | Witnessed Resident 1's reaction and heard abuse allegation |
| Director of Nursing | Director of Nursing | Confirmed failure to report abuse allegation |
| Administrator | Administrator | Received delayed report of abuse allegation |
Inspection Report
Routine
Deficiencies: 15
Date: Feb 13, 2025
Visit Reason
Routine inspection of Spring Lake Village nursing home to assess compliance with health, safety, medication, infection control, and food service regulations.
Findings
The facility had multiple deficiencies including failure to meet residents' needs and preferences, medication errors, inadequate infection control practices, food safety violations, and improper storage and labeling of drugs and equipment. Staff training on Enhanced Barrier Precautions was lacking.
Deficiencies (15)
F 0558: The facility failed to reasonably accommodate the needs and preferences of residents 29 and 37, including call light accessibility and timely assistance with getting out of bed.
F 0584: Personal use items were stored in unlabeled wash basins and resident 18's basin was found on a roommate's bedside table, risking cross contamination.
F 0656: The facility failed to implement care plans for residents 29 and 22, including lack of bedside fall mats and failure to elevate heels off the bed.
F 0686: Weekly skin assessments were not conducted or documented for resident 21's right heel pressure ulcer, risking delayed treatment.
F 0689: Shower disinfectant was stored in an unlocked container, risking unintentional access and harm.
F 0697: The facility failed to effectively manage pain for resident 200, resulting in unrelieved pain due to delayed medication administration.
F 0759: Medication error rate exceeded 5% with five errors observed, including improper administration of Pradaxa, Furosemide, Aspirin, Oxybutynin, and Potassium.
F 0760: Resident 36 received acetaminophen doses exceeding the prescribed maximum of 2,000 mg per day for several months, risking hepatotoxicity.
F 0761: Controlled drugs were discarded in an unsecured container and resident 29's oxygen humidifier bottle was undated, risking contamination and drug diversion.
F 0802: Kitchen staff failed competency testing for sanitizer levels in the 3-compartment sink, risking foodborne illness.
F 0812: Food safety violations included staff not wearing hair nets, damaged cutting boards, dented cans, dry goods stored on the floor, expired and unlabeled food items, and expired sanitizer.
F 0813: Resident personal foods in communal refrigerator were unlabeled and undated, risking consumption of expired food.
F 0814: One outside dumpster lacked a lid, risking pest attraction and foodborne illness.
F 0880: The facility failed to follow Enhanced Barrier Precautions for residents with indwelling devices, lacked signage, and had unlabeled equipment, risking infection transmission.
F 0945: The facility failed to provide mandatory infection control training on Enhanced Barrier Precautions to staff, risking spread of infections.
Report Facts
Medication error rate: 12.2
Sanitizer concentration: 1000
Residents affected: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Named in medication error findings related to improper administration of medications to Resident 14. |
| RN 5 | Registered Nurse | Named in findings related to Resident 29's call light and medication administration. |
| RN 6 | Registered Nurse | Named in medication error findings related to late administration of medications to Resident 199. |
| RN 10 | Registered Nurse | Named in infection control findings related to failure to wear gown when assisting Resident 14. |
| CNA 3 | Certified Nursing Assistant | Named in infection control findings related to failure to wear gown when changing catheter bags. |
| EC | Executive Chef | Named in food safety findings related to sanitizer testing and food handling. |
| IP/RN | Infection Preventionist Registered Nurse | Named in infection control findings and lack of staff training on Enhanced Barrier Precautions. |
| DSD | Director of Staff Development | Named in infection control findings and lack of staff training on Enhanced Barrier Precautions. |
Inspection Report
Complaint Investigation
Census: 357
Capacity: 679
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2025-01-30 alleging that staff did not ensure the facility was kept free of mold.
Complaint Details
Complaint was unsubstantiated and dismissed. The allegation was that staff did not ensure the facility was kept free of mold. Resident reported mold on 2025-01-26, management responded on 2025-01-27 with remediation and repairs. Resident expressed satisfaction with the timely response.
Findings
The investigation found that mold was present in the bathroom and laundry room of a resident's apartment, but the facility responded promptly with maintenance and remediation. The complaint was determined to be unfounded and dismissed, with no citations issued.
Report Facts
Complaint Control Number: 21
Capacity: 679
Census: 357
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation |
| William Keck | Administrator | Facility administrator met during investigation |
Inspection Report
Annual Inspection
Census: 430
Capacity: 679
Deficiencies: 2
Date: Aug 16, 2024
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to evaluate compliance with licensing regulations and facility safety standards.
Findings
The facility was found to have two main deficiencies: unlocked housekeeping/cleaning carts with accessible disinfectants posing a safety risk, and missing evacuation chairs at multiple stairwells. Other aspects such as resident and staff file reviews, emergency plans, infection control, and fire safety were compliant.
Deficiencies (2)
Two housekeeping/cleaning carts had numerous cleaners/disinfectants stored unlocked and accessible to residents, posing an immediate health and safety risk.
Twelve out of twenty-eight stairwells lacked the required evacuation chairs, posing an immediate health and safety risk.
Report Facts
Capacity: 679
Census: 430
Deficiencies cited: 2
Stairwells lacking evacuation chairs: 12
Stairwells total: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bill Keck | Administrator | Met with LPAs during inspection and participated in exit interview |
| Dan Skillman | Skilled Nursing Administrator (back-up RCFE Administrator) | Met with LPAs during inspection |
| Sharon Shnell-Hobbs | Director of Resident Health Services | Met with LPAs during inspection and toured facility |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 679
Deficiencies: 0
Date: May 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-02-02 regarding allegations of fraudulent billing at the facility.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove that the alleged abuse (fraudulent billing) occurred.
Findings
The investigation found that a glitch in the facility's electronic billing system caused billing errors, which have since been addressed with affected residents either credited or billed appropriately. There was no evidence of ill intent or malice, and the complaint was determined to be unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caitlynn Felias | Evaluator | Conducted the complaint investigation. |
| Christina Hadley | Investigated the allegations into possible violations of continuing care statutes. | |
| Daniel Skillman | Administrator | Met with during the investigation. |
| Sharon Shnell-Hobbs | Director of Health Services | Met with during the investigation. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 679
Deficiencies: 0
Date: May 10, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that staff refused to administer medication to a resident.
Complaint Details
The complaint alleged that staff refused to administer medication, including Morphine and Lorazepam, to Resident 1 on multiple dates in December 2023. The investigation found no preponderance of evidence to prove the alleged violations occurred, resulting in an unsubstantiated finding.
Findings
The investigation reviewed medication administration records and observations, concluding that the allegation was unsubstantiated as the facility administered medications appropriately and the resident declined medication when offered.
Report Facts
Facility capacity: 679
Resident census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bill Keck | Executive Director | Met with Licensing Program Analyst during investigation |
| Dan Skillman | Health Care Administrator | Met with Licensing Program Analyst during investigation |
| Caitlynn Felias | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 679
Deficiencies: 0
Date: Apr 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-02-02 regarding allegations of personal rights violations related to fraudulent billing.
Complaint Details
The complaint involved allegations of personal rights violations due to fraudulent billing. The complaint was found to be unsubstantiated.
Findings
The investigation found that the facility experienced a glitch in their electronic billing system which caused billing errors. The issue was addressed, residents were credited or billed appropriately, and there was no evidence of ill intent or malice. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 679
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Hadley | Evaluator | Conducted the complaint investigation |
| Allison Nakatomi | Licensing Program Manager | Named in report signature section |
| Jeanie Pressey | Administrator | Facility administrator named in report |
Inspection Report
Annual Inspection
Census: 380
Capacity: 679
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
The inspection was conducted as a Case Management - Annual Continuation visit to review compliance with licensing requirements.
Findings
No deficiencies were cited during the Case Management-Annual Continuation. Staff files, medication orders, and resident records were found appropriate. First Aid Certificates were not available for viewing and were requested.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanie Pressey | Administrator | Named as facility administrator. |
| Sharon Hobbs | Health Services Director | Met with during inspection. |
| Daniel Skillman | Back-up Administrator | Met with during inspection and greeted LPAs. |
| Thai Waanasna | RN Supervisor | Directed LPAs during inspection. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection. |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection. |
Inspection Report
Annual Inspection
Census: 380
Capacity: 679
Deficiencies: 2
Date: Aug 21, 2023
Visit Reason
The inspection was an unannounced Required 1 Year Inspection conducted to evaluate compliance with licensing regulations at Spring Lake Village facility.
Findings
The facility was found to be clean, well-maintained, and compliant with safety and health standards. One medication cart was found unlocked, and the Emergency Disaster Plan lacked the Community Care Licensing phone number, both issues were addressed with education. No deficiencies were cited during this inspection.
Deficiencies (2)
One out of seven medication carts was unlocked, posing a risk of resident access to medications.
Community Care Licensing phone number was missing from the Emergency Disaster Plan document.
Report Facts
Capacity: 679
Census: 380
Fire Extinguishers last charged: 2023
Water temperature: 118
Water temperature: 108
Emergency disaster drill date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Hobbs | Health Services Director | Met with LPAs and involved in education regarding medication cart security and emergency plans |
| Daniel Skillman | Back-up Administrator | Greeted LPAs and granted access to the facility |
Inspection Report
Census: 440
Capacity: 679
Deficiencies: 0
Date: Jul 25, 2023
Visit Reason
The inspection was an unannounced Case Management-Incident Inspection conducted to review a resident's file and interview the resident in care.
Findings
No deficiencies were observed or cited during the Case Management-Incident Inspection. An exit interview was conducted and a copy of the report was provided to the Executive Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanie Pressey | Executive Director | Met with Licensing Program Analyst during inspection and named in report. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident Inspection. |
| Hope DeBenedetti | Licensing Program Manager | Named in the report. |
Inspection Report
Routine
Census: 49
Deficiencies: 6
Date: Apr 7, 2023
Visit Reason
Routine inspection to assess compliance with regulatory standards including care planning, medication administration, activities program, food safety, and waste management.
Findings
The facility had multiple deficiencies including failure to review and revise care plans for pressure injury and fall prevention, failure to document a large bruise, insufficient activities staff limiting outdoor activities, a medication administration error, unsanitary conditions in food storage areas, and improper storage of kitchen waste.
Deficiencies (6)
F 0657: The facility failed to review and revise care plans quarterly and as needed for Residents 31 and 37, placing them at risk for pressure injuries and falls.
F 0658: The facility failed to assess and document a large bruise on Resident 12, potentially resulting in an unrecognized safety issue.
F 0679: The facility failed to provide sufficient activities staff to support outdoor activities for Residents 17, 19, 35, and 38, depriving them of fresh air and outdoor activities.
F 0760: The facility failed to administer medication as ordered to Resident 26, potentially causing dizziness, drowsiness, or nasal symptoms.
F 0812: The facility failed to ensure walk-in refrigerator and freezer floors were clean, resulting in unsanitary food storage areas.
F 0814: The facility failed to properly store kitchen waste as dumpster lids did not close properly and trash compactor was left open, risking infestation.
Report Facts
Resident falls: 10
Activities staff hours required: 378
Activities staff hours worked: 209
Bruise size: 8.5
Bruise width: 6.5
Medication tablets administered: 2
Medication tablets ordered: 1
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Registered Nurse | Administered incorrect medication dose to Resident 26 |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan revisions and medication administration |
| Management Staff D | Verified unsanitary conditions in kitchen and improper waste storage | |
| Licensed Staff B | Reviewed Resident 12's bruise documentation and charting | |
| Licensed Staff C | Notified doctor and family about Resident 12's bruise | |
| Unlicensed Staff A | Assisted Resident 12 and unaware of bruise cause | |
| Activities Director | Activities Director | Provided activities schedule and staffing information |
| Administrator | Administrator | Provided activities staff timesheets |
| Registered Dietitian | Registered Dietitian | Interviewed about kitchen inspections and audits |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 679
Deficiencies: 0
Date: Jun 24, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the facility was not allowing indoor visitations.
Complaint Details
The complaint alleged that the facility was not allowing indoor visitations. The complaint was investigated and found to be unfounded and dismissed.
Findings
The investigation found that the facility required visitors to test for COVID before entering and did not allow unvaccinated visitors indoors even with a negative test. The facility had been following stricter visitation guidelines due to a COVID outbreak. Based on interviews and observations, the complaint was determined to be unfounded and dismissed.
Report Facts
Capacity: 679
Census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the complaint investigation |
| Dan Skillman | Skilled Nursing Administrator | Met with Licensing Program Analyst during investigation |
| Kimberley Mota | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 31
Capacity: 679
Deficiencies: 0
Date: Jun 17, 2022
Visit Reason
The inspection was a Required-1 Year unannounced inspection focused on infection control practices and procedures at the facility.
Findings
No deficiencies were cited during the inspection. The facility was found to be in good repair with proper infection control measures including visitor screening, staff testing, and secured medication and toxin storage.
Report Facts
Fire extinguisher inspection date: Jan 11, 2022
Evacuation drill date: Jun 16, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Shnell-Hobbs | Director of Resident Health Services | Met with Licensing Program Analyst during inspection and discussed infection control plan |
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the Required-1 Year inspection |
Inspection Report
Annual Inspection
Census: 33
Capacity: 679
Deficiencies: 0
Date: Jul 16, 2021
Visit Reason
An unannounced Required – 1 Year inspection was conducted to evaluate compliance with licensing regulations for the assisted living and memory care facility.
Findings
The facility was found to be clean, well-maintained, and compliant with infection control measures including PPE use and vaccination rates. No deficiencies were cited during this inspection. Some guidance was provided regarding visitor screening and updating the mitigation plan for visitation.
Report Facts
Residents in assisted living: 24
Residents in memory care: 9
Fire extinguisher last inspection date: Jan 20, 2021
Last emergency drill date: Jul 12, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Shnell-Hobbs | Director of Resident Health Services | Met with Licensing Program Analysts during inspection and discussed visitor screening and infection control |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 28, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements for nursing home care, including care planning, medication administration, restorative nursing services, staff competency, medication storage, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to update care plans for new diagnoses, medication administration errors, inadequate restorative nursing services, improper tuberculin skin test procedures, medication storage without physician orders, incomplete pneumococcal vaccination tracking, and broken window screens in resident rooms.
Deficiencies (7)
F 0656: The facility failed to update and revise the care plan for Resident 15's new diagnosis of pneumonia and antibiotic treatment after hospital return on 2/5/2020.
F 0658: The facility failed to follow medication administration policy for Resident 110 by administering Diltiazem without verifying the correct dosage in the Medication Administration Record.
F 0688: The facility failed to provide restorative nursing services as ordered for Resident 1, resulting in missed sessions and potential decline in range of motion and mobility.
F 0726: Licensed nurses were not competent in following physician orders for tuberculin skin tests for Residents 42, 19, and 35, including premature repeat testing and inconsistent recording of results.
F 0761: The facility stored medications for Resident 5 in the medication cart without a physician's order, risking administration without proper authorization.
F 0883: The infection control program failed to track pneumococcal vaccination status for Residents 29 and 47, risking unvaccinated residents and incomplete documentation.
F 0921: The facility failed to ensure window screens were intact in 11 resident rooms, allowing potential entry of insects and posing a nuisance or health risk.
Report Facts
Residents sampled: 16
Residents sampled: 7
Residents sampled: 15
Residents sampled: 15
Residents affected: 11
Rooms affected: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse R | Licensed Nurse | Interviewed regarding Resident 15's condition and hospital transfer |
| Licensed Nurse S | Licensed Nurse | Reported Resident 15's return with pneumonia diagnosis |
| Licensed Nurse F | Licensed Nurse | Interviewed about care plan updates for Resident 15 |
| Director of Staff Development | DSD | Provided training and oversight information for care planning, TST competency, and restorative nursing |
| Licensed Nurse A | Licensed Nurse | Observed medication administration for Resident 110 and interviewed about MAR discrepancies |
| Nurse Supervisor C | Nurse Supervisor | Assisted with vaccination record tracking and documentation |
| Director of Nursing | DON | Interviewed about medication storage and vaccination documentation |
| Director of Maintenance H | Director of Maintenance | Interviewed about window screen repairs and maintenance procedures |
| Maintenance Staff I | Maintenance Staff | Performed window screen repairs |
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