Inspection Report Summary
Most inspections found no deficiencies, including the most recent report dated August 18, 2025, which had no deficiencies after a complaint investigation triggered by a death report. Earlier complaint investigations from 2024 and 2023 were largely unsubstantiated, with allegations about resident care, medication management, and staff presence not supported by evidence. The facility had some substantiated issues in April 2023 related to an outdated emergency disaster plan, vehicle safety, staff clearance, and incomplete training and personnel records. In June 2022, the facility was cited for overdue licensing fees totaling $1,857, but no health or safety concerns were noted at that time. Since then, the facility appears to have addressed these matters, showing improvement with clean annual inspections in December 2023 and December 2024.
Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 26
Capacity: 35
Deficiencies: 0
Aug 18, 2025
Visit Reason
The inspection was an unannounced Case Management visit regarding a death report received on 2025-08-15.
Findings
The Licensing Program Analyst conducted a tour of the facility for health and safety and did not find any health and safety concerns at the time of the visit. No deficiencies were cited.
Complaint Details
The visit was triggered by a death report complaint received on 2025-08-15. No deficiencies were found or cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Cabanas | Executive Director | Met with Licensing Program Analyst during the inspection and provided pertinent documentation. |
| Seo Jeon | Licensing Program Analyst | Conducted the unannounced Case Management visit and facility tour. |
| Rikesha Stamps | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 24
Capacity: 35
Deficiencies: 0
Dec 4, 2024
Visit Reason
An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing and regulatory requirements.
Findings
The facility was found to be clean, well-maintained, and compliant with infection control, physical plant, food service, care and supervision, and disaster preparedness requirements. No deficiencies were cited during the visit.
Report Facts
Staff members present: 6
Resident files reviewed: 3
Staff files reviewed: 6
Fire drill date: Nov 14, 2024
Hot water temperature: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Holm | Administrator | Met with Licensing Program Analyst during inspection |
| Seo Jeon | Licensing Program Analyst | Conducted the inspection visit |
| Rikesha Stamps | Licensing Program Manager | Named in report as Licensing Program Manager |
| Lauren Kabakoff | Administrator/Director | Facility Administrator/Director named in report header |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 35
Deficiencies: 0
May 17, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not supervise a resident resulting in multiple falls and that a resident's money was stolen.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews, observations, and record reviews indicated that the resident was a fall risk with regular checks and that there was no corroboration of theft of the resident's money. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of supervision leading to multiple falls and theft of resident's money. Evidence did not support the claims, and the resident was confirmed to be a fall risk with regular monitoring.
Report Facts
Capacity: 35
Census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Trout | Marketing and Resident Enrichment Director | Met with Licensing Program Analyst during investigation and provided information regarding allegations |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Allen Boeddeker | Administrator | Provided information regarding resident's fall risk and supervision |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 35
Deficiencies: 0
Mar 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-02-12 regarding staff not transporting residents to medical appointments, insufficient administrator presence, failure to follow residents' dietary plans, and lack of nurse availability.
Findings
The investigation included observations, interviews, and record reviews. The allegations were found to be unsubstantiated due to lack of preponderance of evidence. Residents and staff reported no issues with transportation, administrator presence, dietary plans, or nurse availability. The facility has six med techs covering all shifts.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included staff not transporting residents to medical appointments, insufficient administrator hours, failure to follow dietary plans, and no nurse availability. Interviews and records did not support these claims.
Report Facts
Facility capacity: 35
Census: 20
Number of med techs: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation |
| Lauren Kabakoff | Administrator | Facility administrator involved in investigation |
| Brian Lebeuf | Kitchen Manager / Head Chef | Interviewed regarding dietary plan allegations |
| Brian Trout | Marketing & Resident Enrichment Director | Provided information about med tech staffing |
| Lauren Vincent | Executive Director | Spoke with Licensing Program Analyst by phone during investigation |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 35
Deficiencies: 0
Mar 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was illegally evicting a resident without following proper eviction guidelines.
Findings
The investigation found that the resident was properly served with two 30-day eviction notices and was provided resources to find alternative housing. The complaint was determined to be unfounded and dismissed.
Complaint Details
The complaint alleged illegal eviction of a resident without proper 30-day notice and lack of assistance in finding alternative housing. The complaint was found to be unfounded based on observations, interviews, and record reviews.
Report Facts
Outstanding balance due: Resident had unpaid rent fees from September 2022 through March 2024
Eviction notices served: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lauren Vincent | Executive Director | Spoke with Licensing Program Analyst during investigation and assisted resident with housing resources |
| Brian Lebeuf | Kitchen Manager | Met with Licensing Program Analyst during the investigation and signed report |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 35
Deficiencies: 0
Mar 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not ensure a resident attended medical appointments, did not meet dietary needs, mismanaged medication, falsified records, and that the administrator was not present enough.
Findings
Based on observations, record reviews, and interviews with staff and residents, the allegations were found to be unsubstantiated due to lack of preponderance of evidence. Residents and staff reported no issues with medical appointments, dietary needs, medication management, or falsification of records, and the administrator's presence was deemed sufficient.
Complaint Details
The complaint investigation was unsubstantiated. The allegations included failure to ensure resident medical appointments, dietary needs, medication mismanagement, falsification of records, and insufficient administrator presence. Interviews and reviews did not support these claims.
Report Facts
Capacity: 35
Census: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation |
| Lauren Kabakoff | Administrator | Named as administrator and involved in investigation |
| Brian Lebeuf | Kitchen Manager | Met with during investigation and received report |
| Lauren Vincent | Executive Director | Interviewed by phone regarding allegations |
| Brian Trout | Marketing & Resident Enrichment Director | Interviewed regarding allegations and denied falsification |
| Nisha Henson | Med Tech | Stated no issues with medication administration |
| Jazmond D Harris | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 35
Deficiencies: 0
Jan 30, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that a resident sustained unexplained bruising while in care and that staff did not safeguard the resident's personal property.
Findings
The investigation found insufficient information to substantiate the allegations regarding unexplained bruising and loss of the resident's wallet and glasses. The complaint was deemed unsubstantiated due to lack of evidence.
Complaint Details
The complaint was unsubstantiated. Allegations included unexplained bruising on Resident One and loss of Resident One's wallet and glasses. Interviews and record reviews did not provide sufficient evidence to prove the allegations.
Report Facts
Capacity: 35
Census: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Martinez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lauren Kabakoff | Interim Administrator | Met with Licensing Program Analyst during the investigation |
| Allen Boeddeker | Administrator | Interviewed regarding resident bruising allegation |
Inspection Report
Annual Inspection
Census: 23
Capacity: 35
Deficiencies: 0
Dec 11, 2023
Visit Reason
Licensing Program Analyst Janira Arreola conducted a required annual unannounced visit to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in good condition with no deficiencies cited. Observations included proper infection control measures, a clean and safe physical plant, adequate food service supplies, complete staff and client records, proper medication storage and labeling, and an up-to-date emergency and disaster plan.
Report Facts
Fire drill date: Sep 21, 2023
Hot water temperature: 108.3
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Kabakoff | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Janira Arreola | Licensing Program Analyst | Conducted the annual inspection visit |
| Rikesha Stamps | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 17
Capacity: 35
Deficiencies: 5
Apr 20, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-04-12. The investigation addressed multiple allegations including lack of a current emergency disaster plan, facility vehicle disrepair, uncleared adults working at the facility, inaccurate resident and employee records, and inadequate staff training.
Findings
The investigation substantiated several allegations: the facility did not have a current emergency disaster plan, the facility vehicle was in disrepair (fire extinguisher unsecured), uncleared adults were working without proper fingerprint clearance, resident and employee records were incomplete or inaccurate, and staff training documentation was insufficient with some expired CPR/First Aid certifications. Other allegations such as improper storage of flammable liquids, administrator presence, cleanliness, excess trash, and unsafe environment were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations including lack of a current emergency disaster plan, facility vehicle disrepair, uncleared adults working at the facility, incomplete resident and employee records, and inadequate staff training. Other allegations such as improper storage of flammable liquids, insufficient administrator presence, cleanliness issues, excess trash, and unsafe environment were unsubstantiated.
Severity Breakdown
Type A: 4
Type B: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility did not have a current emergency disaster plan with updated forms and accurate staff listings. | Type A |
| Facility vehicle fire extinguisher was not secured and could roll around. | Type A |
| An employee (S1) worked without obtaining proper fingerprint clearance. | Type A |
| Staff files lacked documentation of required training; CPR/First Aid certification expired for one staff member. | Type A |
| Personnel records were incomplete and missing verification of required staff training and orientation. | Type B |
Report Facts
Facility capacity: 35
Census: 17
Staff files reviewed: 5
Resident files reviewed: 7
Total staff: 15
Volunteers: 10
Plan of Correction due dates: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Kabakoff | Executive Director | Met with during inspection; involved in escorting uncleared staff off premises |
| Shannon Hundley | LVN/Assistant Executive Director | Greeted Licensing Program Analyst and involved in escorting uncleared staff off premises |
| Javina George | Licensing Program Analyst | Conducted the complaint investigation |
| Joel Esquivel | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 35
Deficiencies: 1
Jun 22, 2022
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding overdue licensing fees at the facility.
Findings
The inspection found that the facility had overdue licensing fees totaling $1,857.00 for the year 2021 and subsequent late fees. No other health and safety concerns were observed during the inspection.
Complaint Details
Complaint #18-AS-20220621091121 was investigated. The deficiency related to overdue licensing fees was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to pay all applicable and accrued licensing fees, including annual fees and late fees for 2021, constituting grounds for denial or forfeiture of a license. | Type A |
Report Facts
Overdue licensing fees: 1857
Census: 23
Total capacity: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Dunning | Administrator | Named in relation to the deficiency and exit interview. |
| Crystal Colvin | Licensing Program Analyst | Conducted the inspection and cited the deficiency. |
| Joel Esquivel | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 23
Capacity: 35
Deficiencies: 0
Nov 9, 2021
Visit Reason
Licensing Program Analyst Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control.
Findings
The inspection found sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead responsible for tracking COVID-19 cases, maintaining PPE supplies, and staff training on infection control.
Report Facts
COVID-19 positive cases in quarantine: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nisha Henson | Medical Technician | Met with Licensing Program Analyst during inspection and discussed infection control practices |
| Jesse Gardner | Licensing Program Analyst | Conducted the annual inspection |
Loading inspection reports...
