Inspection Reports for Summerfield Memory Care of Redlands
1319 Brookside Ave, Redlands, CA 92373, United States, CA, 92373
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with many complaint investigations determined to be unsubstantiated. The facility’s annual inspections from June 2023 through June 2025 were clean, including the most recent annual inspection on June 4, 2025, which had no deficiencies. However, several complaint investigations between 2024 and 2025 substantiated issues related to staff neglect, including failure to perform first aid during a choking incident that resulted in a resident’s death in July 2021, delayed medical care for a resident with bruising, failure to call emergency services after a resident altercation, and improper restraint of a resident. These findings led to citations for resident rights violations, personnel competency, and immediate health and safety risks, including a $500 civil penalty assessed in October 2025. The pattern shows serious concerns in resident care and staff responsiveness in recent complaint investigations, although the facility has maintained compliance during routine annual inspections.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 47
Capacity: 75
Deficiencies: 2
Oct 29, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff neglect resulted in a resident's death following a choking incident on July 10, 2021.
Findings
The investigation substantiated the allegation that staff neglect resulted in the resident's death due to failure to perform first aid during the choking incident. The facility was cited for violations related to resident rights and personnel competency, posing an immediate health and safety risk.
Complaint Details
The complaint alleged that staff neglect resulted in a resident's death due to choking. The allegation was substantiated based on interviews, ambulance and hospital records, and staff statements. The resident exhibited signs of choking and distress, but staff failed to perform first aid. An Immediate Civil Penalty of $500 was assessed.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Violation of California Code of Regulations, Title 22, Section 87468.2(a)(8) - Residents' right to be free from neglect was not met as staff neglect resulted in resident death. | Type A |
| Violation of California Code of Regulations, Title 22, Section 87411(a) - Facility personnel were not competent as staff failed to perform first aid, posing a health and safety risk. | Type B |
Report Facts
Capacity: 75
Census: 47
Civil Penalty: 500
Plan of Correction Due Dates: Type A deficiency due 10/30/2025, Type B deficiency due 11/05/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rita Ortiz | Med Tech | Named in finding for failing to perform first aid during resident choking incident |
Inspection Report
Census: 45
Capacity: 75
Deficiencies: 0
Aug 14, 2025
Visit Reason
The visit was conducted for case management purposes related to the signing of an amended Complaint Investigation Report (LIC 9099) #18-AS-20220126121631.
Findings
The Licensing Program Analyst arrived to have the Resident Services Director sign the amended complaint investigation report. The report was signed by both parties and a copy was left with the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rashelle Wheaton | Resident Services Director | Met with during the visit and signed the amended Complaint Investigation Report. |
| Javier Prieto | Licensing Program Analyst | Arrived to the facility to have the amended Complaint Investigation Report signed. |
| Heidi Charette | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 75
Deficiencies: 1
Aug 8, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff were neglecting residents in care.
Findings
The investigation substantiated the allegation that staff neglected residents, specifically that emergency services were not called after a physical altercation between two residents, posing an immediate risk to resident safety.
Complaint Details
The complaint was substantiated. The allegation involved staff neglecting residents, specifically failure to respond appropriately to a physical altercation between residents and failure to call emergency services.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the physical safety of resident 1 (R1) and failure to call 911 per the family's request, posing an immediate risk to the health and safety of the resident in care. | Type A |
Report Facts
Capacity: 75
Census: 46
Deficiency due date: Aug 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edith Conchas | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation |
| Rachelle Wheaton | Resident Services Director | Met with investigators during the visit and received the exit interview |
| Heidi Charette | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 75
Deficiencies: 1
Jun 11, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-04-01 regarding staff not keeping the facility free of pests, staff mismanaging resident’s medication, and staff restraining a resident.
Findings
The investigation found the allegation of staff restraining a resident substantiated, with evidence that a staff member tied a resident in a wheelchair with a bedsheet, which violated regulations. The allegations of pest problems and medication mismanagement were found unsubstantiated based on observations, interviews, and documentation.
Complaint Details
The complaint investigation was initiated based on allegations received on 2025-04-01. The allegation that staff restrained a resident was substantiated. The allegations regarding pest problems and medication mismanagement were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff tied a resident in his wheelchair with a bedsheet, violating postural support regulations and posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
Resident interviews conducted: 7
Staff interviews conducted: 7
Medication audits: 4
Facility capacity: 75
Facility census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Charette | Executive Director | Met with Licensing Program Analyst and discussed the purpose of the visit; named in findings |
| Sarina Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
| Staff 1 (S1) | Staff member who restrained resident by tying him in wheelchair with bedsheet |
Inspection Report
Annual Inspection
Census: 45
Capacity: 75
Deficiencies: 0
Jun 4, 2025
Visit Reason
Licensing Program Analysts conducted an unannounced required annual inspection of the Residential Care Facility for the Elderly to assess compliance with licensing requirements.
Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies cited. The physical plant, food service, care and supervision, medical related services, and record reviews were all satisfactory.
Report Facts
Resident medications audited: 6
Staff files reviewed: 5
Resident files reviewed: 6
Hot water temperature readings: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Charette | Executive Director | Met with Licensing Program Analysts during the inspection and received the exit interview. |
| Sarina Ramirez | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Eldin Serrano | Licensing Program Analyst | Conducted the inspection. |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 75
Deficiencies: 0
May 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-04-21 regarding resident care concerns including unknown resident whereabouts, delayed assistance after a fall, and injuries sustained while in care.
Findings
The investigation found no evidence to support the allegations. Interviews with staff and residents indicated sufficient staffing and awareness of resident whereabouts. Documentation showed timely response to a resident fall with no evidence of prolonged neglect or injury related to the complaint. The allegations were deemed unsubstantiated.
Complaint Details
The complaint involved allegations that facility staff did not know a resident's whereabouts for an extended period, a resident did not receive assistance after falling for an extended period, and a resident sustained injuries (sun/heat blisters, head wound) while in care. The investigation concluded these allegations were unsubstantiated.
Report Facts
Facility capacity: 75
Resident census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Heidi Charette | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Danica J Turner | Administrator | Facility administrator named in the report |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 42
Capacity: 75
Deficiencies: 0
May 13, 2025
Visit Reason
The visit was conducted as a case management and other type of inspection to conduct additional interviews and have the Executive Director sign an amended complaint report related to Complaint Control Number 56-AS-20220310135429.
Findings
The Licensing Program Analyst arrived to conduct additional interviews and obtained signatures on an amended complaint report. No specific deficiencies or violations were detailed in the report.
Complaint Details
The visit was related to a complaint investigation identified by Complaint Control Number 56-AS-20220310135429. The report documents the signing of an amended complaint report but does not state substantiation status.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Charette | Executive Director | Met with during the inspection and signed the amended complaint report. |
| Javier Prieto | Licensing Program Analyst | Conducted the inspection and obtained signatures on the amended complaint report. |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 75
Deficiencies: 0
Mar 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 05/18/2021 regarding unexplained injuries to a resident, failure to follow reporting requirements, insufficient staffing, and improper staff training.
Findings
The investigation found all allegations to be unsubstantiated. The facility was observed to follow reporting requirements, was sufficiently staffed, and staff were properly trained. Residents interviewed were unable to respond due to cognitive impairment.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not enough evidence to prove the alleged violations occurred.
Report Facts
Capacity: 75
Census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becky Mann | Licensing Program Analyst | Conducted the complaint investigation |
| Heidi Charette | Administrator | Met with Licensing Program Analyst during the investigation |
| Nedra Brown | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 75
Deficiencies: 0
Dec 24, 2024
Visit Reason
An unannounced complaint investigation was conducted based on a complaint received on 2024-05-23 alleging that a resident developed a pressure injury while in care and that staff do not ensure resident care needs are being met.
Findings
The investigation found that Resident #1 was being treated for a stage 2 pressure injury and was repositioned every two hours according to the treatment plan. Interviews with staff and residents indicated consistent staff support and no concerns regarding care. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
Complaint was unsubstantiated. Although the allegation may have been valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur.
Report Facts
Capacity: 75
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paola Guerrero | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Jonathan Guzman | Facility Business Office Manager | Met with Licensing Program Analyst during the investigation and exit interview |
| Efren Malagon | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 50
Capacity: 75
Deficiencies: 0
May 18, 2024
Visit Reason
The visit was an unannounced required comprehensive annual inspection of the Residential Care Facility for Elderly (RCFE) to assess compliance with licensing regulations.
Findings
The facility was found to be operating within its licensed capacity, clean, in good repair, and maintaining safe conditions. No deficiencies were cited during the inspection, and all reviewed resident and staff files were in order.
Report Facts
Resident files reviewed: 4
Staff files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Delcie Mucha | Facility LVN | Met with Licensing Program Analyst during inspection and named in exit interview |
| Paola Guerrero | Licensing Program Analyst | Conducted the inspection and signed the report |
| Efren Malagon | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 75
Deficiencies: 1
Dec 14, 2023
Visit Reason
The visit was a Case Management Office Visit to address an amended complaint investigation related to an incident on 10/29/2022 involving a resident and staff interaction and the facility's failure to seek timely medical attention.
Findings
The facility was cited for failing to seek medical attention in a timely manner after a resident sustained significant bruising to their hands. Medical care was delayed by two days before appropriate action was taken.
Complaint Details
The complaint investigation was related to an incident on 10/29/2022 where staff failed to seek timely medical attention for a resident who had significant bruising on their hands. The investigation substantiated the allegation of delayed medical care.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to arrange or assist in arranging for medical care in a timely manner for a resident with bruised hands. | Type A |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Dec 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hedi Charette | Administrator | Facility administrator involved in the complaint investigation and exit interview |
| Bernadette Allen | Licensing Program Analyst | Conducted the investigation and visit |
| Karen Clemons | Licensing Program Manager | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 46
Capacity: 75
Deficiencies: 0
Jun 23, 2023
Visit Reason
An unannounced required annual visit was conducted to inspect the Residential Facility for the Elderly (RCFE) for compliance with licensing requirements.
Findings
The facility was found to be clean, in good repair, and operating in safe conditions with no deficiencies cited. Inspections included facility premises, kitchen, client bedrooms, shower rooms, safety equipment, medication storage and administration, staff and client records.
Report Facts
Client medications reviewed: 4
Staff files reviewed: 4
Client records reviewed: 4
Fire extinguisher service date: 2023
Fire and evacuation drill date: Apr 23, 2023
Facility temperature: 75
Refrigerator temperature: 39
Hot water temperature range in faucets: 105
Hot water temperature range in shower rooms: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Charette | Administrator | Met with Licensing Program Analyst during inspection |
| Magda Malcore | Licensing Program Analyst | Conducted the inspection and authored the report |
| Karen Clemons | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 75
Deficiencies: 0
Feb 28, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that facility staff handled a resident in a rough manner.
Findings
The investigation found no preponderance of evidence to support the allegation that facility staff handled the resident roughly. X-rays showed a right-hand fracture, but the circumstances and timing were not supported by witnesses or documentation. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that facility staff handled Resident #1 roughly, resulting in injuries. The investigation included review of medical records, facility files, reports, and interviews. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 75
Census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Hedi Charette | Administrator | Facility Administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 75
Deficiencies: 0
Jan 6, 2023
Visit Reason
Unannounced visit/investigation of a complaint received on 2022-08-08 regarding allegations of non-compliance with bathing and hygiene agreements, unmet resident needs resulting in bed sores, failure to inform POA of medical condition changes, and inadequate nutrition causing weight loss.
Findings
After reviewing documents, interviewing staff and residents' responsible parties, and observing records, the allegations were found to be unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.
Complaint Details
The complaint investigation was unsubstantiated, meaning although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur.
Report Facts
Staff interviewed: 12
Residents' responsible parties interviewed: 6
Facility capacity: 75
Facility census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on report |
| Delcie Mucha | Resident Service Director | Met with during investigation and discussed exit interview |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 75
Deficiencies: 0
Jan 4, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint received on 2022-09-21 regarding multiple allegations including residents' hygiene needs, cleanliness, withholding of personal items, and failure to provide a rate change notice.
Findings
Based on interviews with staff and outside parties, observations of the facility, and records reviewed, all six allegations were deemed unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unmet hygiene needs, unclean bathrooms, malodorous rooms, withholding of personal items, and failure to provide a rate change notice. Interviews and observations did not support these claims.
Report Facts
Capacity: 75
Census: 44
Number of staff interviewed: 7
Number of outside parties interviewed: 7
Number of allegations: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation |
| Hedi Charette | Administrator | Facility administrator met with during the investigation |
Inspection Report
Census: 44
Capacity: 75
Deficiencies: 0
Jan 4, 2023
Visit Reason
The visit was a Case Management - Other type of visit related to complaint number 56-AS-20220921101913, as indicated by the signing of LIC9099 and LIC9099-C forms.
Findings
The report documents the signing of complaint-related forms for complaint number 56-AS-20220921101913 on 01/04/2023. No specific findings or deficiencies are detailed in the report.
Complaint Details
The visit was related to complaint number 56-AS-20220921101913. No substantiation status or further complaint details are provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hedi Charette | Administrator | Met with during the visit and named in the report header. |
| Karen Clemons | Licensing Program Manager | Named in relation to the complaint forms. |
| Bernadette Allen | Licensing Program Analyst | Named in relation to the complaint forms. |
Inspection Report
Annual Inspection
Census: 46
Capacity: 75
Deficiencies: 0
Apr 19, 2022
Visit Reason
Licensing Program Analyst Javier Prieto made an unannounced visit to conduct an annual inspection with an emphasis on infection control.
Findings
The facility was observed to have proper infection control measures including signage, hand hygiene supplies, cleaning provisions, and PPE use. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the annual inspection and made observations regarding infection control. |
| Danica J Turner | Administrator | Facility administrator mentioned in the report header. |
| Kelley Lara | Met with the Licensing Program Analyst during the inspection. | |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 75
Deficiencies: 0
Mar 14, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-03-10 regarding lack of an administrator, overmedication of residents, and insufficient staffing.
Findings
The investigation found that the Executive Director has been in position for over three years with a designated substitute, medication administration records showed no discrepancies or overmedication, and the facility was fully staffed with residents and staff confirming adequate care. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on the investigation findings that refuted the allegations of no administrator, overmedication, and lack of staff.
Report Facts
Number of residents' Medical Administration Records reviewed: 11
Facility capacity: 75
Resident census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Heidi Charette | Executive Director | Interviewed during investigation and named in findings |
Inspection Report
Complaint Investigation
Capacity: 75
Deficiencies: 0
Mar 2, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of lack of supervision resulting in a resident sustaining injuries while in care.
Findings
The Licensing Program Analyst conducted interviews with staff and the resident, toured the facility, and found no evidence of injuries or lack of care. The facility was clean and free from clutter. The allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with multiple staff members and the resident, as well as observations made during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report. |
| Melissa Talley | Memory Care Director | Met with the Licensing Program Analyst during the investigation. |
| Danica J Turner | Administrator | Facility administrator named in the report. |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 75
Deficiencies: 0
Jan 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation regarding allegations that residents were not being changed timely, admitted without a physician's report, without a Hoyer lift, without a medication list, not being showered timely, and that the facility was not sufficiently staffed to meet residents' needs.
Findings
The investigation found the facility to be clean and free of obstructions, with sufficient staff and proper documentation for residents. There was not enough evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated due to lack of sufficient evidence to prove the alleged violations occurred.
Report Facts
Capacity: 75
Census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Trish McCraken | Business Office Manager | Met with the Licensing Program Analyst during the investigation |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 75
Deficiencies: 0
Sep 22, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including neglect resulting in death of a resident, inadequate staffing, temperature control issues, uncleared adults working in the facility, and lack of signaling systems in resident rooms.
Findings
The investigation found all allegations to be unsubstantiated based on interviews, observations, and records review. The resident's death was attributed to COPD complications with no evidence of neglect. Staffing levels were adequate, temperature was maintained comfortably, all staff were properly cleared, and resident rooms had signaling systems.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included neglect resulting in death, inadequate staffing, temperature issues, uncleared adults working, and lack of signaling systems. Evidence did not support these allegations.
Report Facts
Capacity: 75
Census: 39
Staff count per shift: 4
Staff count per shift: 6
Facility temperature: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Danica Turner | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 75
Deficiencies: 0
Mar 17, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 08/24/2020 regarding resident care concerns including residents left in soiled diapers, inadequate personal protective equipment for staff, and residents' clothing not changed daily.
Findings
The investigation included interviews and record reviews which found that staff are required to check and change residents' diapers regularly, adequate personal protective equipment is provided and mandatory for staff, and residents' clothing is changed daily or as needed. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents left in urine and feces-soaked diapers for extended periods, staff not provided adequate personal protective equipment, and residents' clothing not changed daily. Interviews with staff and review of records did not support these allegations.
Report Facts
Capacity: 75
Census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danica Turner | Administrator | Facility administrator met during investigation and involved in exit interview |
| Natalie Gayoso | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Karen Clemons | Licensing Program Manager | Manager overseeing the licensing program for this investigation |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 75
Deficiencies: 0
Feb 1, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a questionable death and development of pressure injuries while in care.
Findings
The investigation found the allegation of questionable death to be unfounded with no evidence of neglect by facility staff. The allegation regarding pressure injuries was unsubstantiated, meaning there was insufficient evidence to prove neglect caused the injuries.
Complaint Details
The complaint involved allegations of a questionable death of Resident #1 due to neglect and that the resident developed pressure injuries while in care. The investigation included review of medical records, interviews, and facility file review. The questionable death allegation was found to be unfounded, and the pressure injury allegation was unsubstantiated.
Report Facts
Facility capacity: 75
Census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Licensing Program Analyst | Investigator who conducted the complaint investigation and delivered findings |
| Danica Turner | Administrator | Facility administrator met during the investigation |
| Efren Malagon | Licensing Program Manager | Manager overseeing the licensing program related to this investigation |
Loading inspection reports...
