Inspection Report Summary
Most inspections found no deficiencies, with the facility generally maintaining compliance with health, safety, and infection control standards. However, there were some serious issues in early 2023, including a substantiated complaint where staff failed to follow a resident’s care plan, resulting in choking and death, which led to a civil penalty. Other deficiencies involved incomplete medication records, maintenance concerns, and eviction procedure violations, but these were isolated and less severe. Several complaint investigations, including one about failure to provide a Do Not Resuscitate order and food quality concerns, were unsubstantiated. The most recent report from September 10, 2025, had no deficiencies, showing improvement and ongoing attention to safety and cleanliness.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 13
Capacity: 18
Deficiencies: 0
Sep 10, 2025
Visit Reason
The visit was a Case Management - Health Checks inspection conducted as an unannounced health and safety check of the facility.
Findings
No deficiencies were cited during the inspection; however, advisories were given regarding debris and items around the facility that needed removal by 09/19/2025 to maintain safety and cleanliness.
Report Facts
Residents currently cared for: 9
Staffing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the health and safety check. |
| Expectacio Vierra | Administrator | Observed facility conditions during the inspection. |
Inspection Report
Census: 15
Capacity: 18
Deficiencies: 0
Jun 24, 2025
Visit Reason
The visit was a Case Management - Other type of inspection conducted as a health and safety check focusing on overall safety including food supply, physical plant, and staffing.
Findings
No deficiencies were observed pursuant to Title 22 rules and regulations and Health and Safety Codes. Additional staffing was requested to meet the fall risk of three residents, and hospice resident reassessments were planned.
Report Facts
Fall risk residents: 3
Staffing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the health and safety check |
| Expectacio Vierra | Administrator/Director | Facility Administrator/Director |
Inspection Report
Census: 16
Capacity: 18
Deficiencies: 0
May 27, 2025
Visit Reason
The visit was a Case Management - Health Checks inspection to conduct a health and safety check of the facility, including overall safety, food supply, physical plant, and staffing.
Findings
No deficiencies were observed pursuant to Title 22 rules and regulations and Health and Safety Codes. An advisory was given for repair needed in the front men's bathroom, and additional evening staffing was requested to address the fall risk of three residents.
Report Facts
Residents at fall risk: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the health and safety check |
| Expectacio Vierra | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 10
Capacity: 18
Deficiencies: 0
Mar 13, 2025
Visit Reason
The inspection was an unannounced annual inspection visit conducted to ensure compliance with Title 22 regulations.
Findings
The facility was found to be in compliance with no deficiencies cited. The physical plant and common areas were clean and well maintained, with adequate food supply and functioning safety equipment. An advisory was given for not completing a fire drill for the quarter.
Report Facts
Water temperature: 112.5
Fire extinguisher check date: Feb 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the inspection and infection control domain tool |
| Lisa Rios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Monitoring
Census: 12
Capacity: 18
Deficiencies: 0
Jan 10, 2025
Visit Reason
Licensing Program Analyst Albert Johnson conducted a health and safety check and reviewed the infection control plan as part of a case management health check visit.
Findings
No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. The health and safety check included overall safety of the facility including food supply, physical plant, and staffing.
Report Facts
Invoice amount: 9500
Monthly payment: 950
Payment plan duration (months): 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the health and safety check and infection control plan review |
| Expectacio Vierra | Administrator | Facility administrator named in report header |
Inspection Report
Census: 12
Capacity: 18
Deficiencies: 0
Aug 20, 2024
Visit Reason
The visit was an unannounced case management visit conducted in response to civil penalties and the facility's request for a payment arrangement for an outstanding invoice.
Findings
The facility's request for a payment plan of $9,500 was approved, requiring monthly payments of $950 for 10 months starting September 1, 2024. Failure to comply will void the plan and require full payment.
Report Facts
Civil penalty amount: 9500
Monthly payment amount: 950
Payment plan duration (months): 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the case management visit and explained the purpose of the visit |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Expectacio Vierra | Administrator | Facility Administrator named in the report |
| Elenor Laurora | Met with Licensing Program Analyst during the visit |
Inspection Report
Monitoring
Census: 12
Capacity: 18
Deficiencies: 0
Jul 17, 2024
Visit Reason
The visit was an office meeting held to review the stipulation adopted on 07/10/2024 and discuss next steps, including monitoring compliance with the terms of the stipulation.
Findings
No violations were cited during this visit. The licensees and representatives expressed understanding of the stipulation and agreed to abide by its terms. Increased monitoring by CCLD was planned.
Report Facts
Capacity: 18
Census: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Expectacio Vierra | Administrator | Facility Administrator present during the meeting |
| Stephenie Doub | Regional Manager | Attended the office meeting |
| Lisa Rios | Licensing Program Manager | Attended the office meeting and signed the report |
| Albert Johnson | Licensing Program Analyst | Attended the office meeting and signed the report |
| Gilcy Opilas | Assistant Administrator | Attended the office meeting |
Inspection Report
Census: 12
Capacity: 18
Deficiencies: 0
Jul 11, 2024
Visit Reason
The visit was an unannounced case management visit to deliver an invite for an informal meeting scheduled for July 17, 2024, and to conduct a health and safety check of the facility.
Findings
No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. The health and safety check included overall safety of the facility, food supply, physical plant, and staffing.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the case management visit and explained the purpose of the visit. |
Inspection Report
Census: 11
Capacity: 18
Deficiencies: 0
Jun 5, 2024
Visit Reason
The inspection was a Case Management - Health Checks visit to conduct a health and safety check of the facility, including overall safety, food supply, physical plant, and staffing.
Findings
No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. The Licensee informed that the facility will not be sold and new staff has been hired to address staffing needs.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the health and safety check and spoke with Licensee. |
| Expectacio Vierra | Administrator | Licensee who spoke with Licensing Program Analyst and provided information about staffing and facility status. |
Inspection Report
Follow-Up
Census: 12
Capacity: 18
Deficiencies: 0
Mar 28, 2024
Visit Reason
The visit was a case management follow-up to review the 30-day eviction notice given to resident R1 and sent to the department.
Findings
The facility was informed that the eviction notice did not meet all requirements and needed to be amended. A sample notice was provided, and the facility was requested to resubmit the letter for approval. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the case management visit and met with the Administrator. |
| Expectacio Vierra | Administrator | Met with Licensing Program Analyst during the visit and responsible for revising the eviction notice letter. |
Inspection Report
Annual Inspection
Census: 12
Capacity: 18
Deficiencies: 0
Mar 12, 2024
Visit Reason
The inspection was an unannounced annual inspection visit conducted to ensure compliance with Title 22 regulations.
Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies cited. The physical plant, infection control, and safety equipment were all inspected and found to be satisfactory.
Report Facts
Water temperature: 112.5
Fire extinguisher last checked: Apr 20, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the annual inspection visit |
| Expectacio Vierra | Administrator | Facility administrator met during inspection |
Inspection Report
Census: 11
Capacity: 18
Deficiencies: 0
Dec 5, 2023
Visit Reason
The inspection was conducted as a Case Management - Health Checks visit to perform a health and safety check and review the infection control plan.
Findings
No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. The health and safety check included overall safety of the facility including food supply, physical plant, and staffing.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the health and safety check and reviewed the infection control plan. |
Inspection Report
Capacity: 18
Deficiencies: 0
Oct 31, 2023
Visit Reason
The visit was an unannounced case management inspection to ensure compliance with Health and Safety Code 1569.38 regarding the posting of licensing reports and disclosure to new residents.
Findings
The Licensing Program Analyst observed that the Accusation was properly posted in a location easily viewable by residents and visitors. The administrator confirmed that written notice was provided to existing residents within the required timeframe and mailed to responsible parties. The facility was found to be in compliance with the relevant Health and Safety Code.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Expectacion Vierra | Administrator | Met with Licensing Program Analyst and confirmed compliance with notice posting requirements. |
| Maja Jensen | Licensing Program Analyst | Conducted the unannounced visit and inspection. |
| Stephenie Doub | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 11
Capacity: 18
Deficiencies: 1
Oct 9, 2023
Visit Reason
An unannounced case management visit was conducted to issue a civil penalty related to a substantiated complaint investigation regarding failure to follow a resident's care plan and provide proper care.
Findings
The investigation found that a resident choked on a hot dog causing a full airway obstruction, resulting in serious bodily injury and death. The facility was cited for violations related to basic services and administrator qualifications, and a civil penalty was issued.
Complaint Details
The complaint investigation was initiated on October 27, 2022, alleging failure to follow the resident’s care plan and provide proper care. The complaint was substantiated on January 17, 2023.
Deficiencies (1)
| Description |
|---|
| Facility staff did not follow the resident’s care plan and failed to provide proper care, resulting in serious bodily injury. |
Report Facts
Civil penalty amount: 9500
Civil penalty amount: 10000
Resident ventilator days: 2
Days until resident death after ventilator removal: 5
Facility capacity: 18
Resident census: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report. |
| Expectacio Vierra | Administrator | Facility administrator involved in the inspection and cited in findings. |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 10
Capacity: 18
Deficiencies: 0
Aug 2, 2023
Visit Reason
The visit was a Case Management - Legal/Non-compliance meeting held to review previous engagements by the Department’s Technical Support Program (TSP) with the Licensee, focusing on care and supervision, record keeping, incident reporting, needs and service plans, and training requirements.
Findings
The report summarizes discussions and recommendations from TSP engagements addressing care and supervision improvements, record keeping challenges, and training documentation. No citations were issued during this visit, and quarterly visits will continue to ensure compliance.
Report Facts
Administrator coverage hours: 40
Number of TSP engagement meetings: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Expectacion Vierra | Licensee/Administrator | Participated in the meeting and discussed facility improvements |
| Liza King | Licensing Program Manager | Present at the meeting and signed the report |
| Maja Jensen | Licensing Program Analyst | Present at the meeting and signed the report |
Inspection Report
Routine
Census: 10
Capacity: 18
Deficiencies: 0
Jul 3, 2023
Visit Reason
The visit was an unannounced quarterly health and safety check conducted by Licensing Program Analyst Maja Jensen to assess the facility's compliance with health and safety regulations.
Findings
No deficiencies were cited during the visit. The analyst reviewed resident files, observed residents, checked food supplies, and confirmed that the facility met all regulatory requirements. Technical assistance was provided regarding special diets.
Report Facts
Resident files reviewed: 5
Residents observed: 10
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and provided technical assistance. |
| Expectacion Vierra | Licensee/Administrator | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Routine
Census: 12
Capacity: 18
Deficiencies: 1
Apr 11, 2023
Visit Reason
The visit was an unannounced quarterly case management health check conducted by Licensing Program Analyst Maja Jensen to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be sanitary with appropriate environmental conditions and sufficient staffing. However, a deficiency was cited because the lunch served did not match the written menu, posing a potential risk to residents' health, safety, and personal rights.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. This requirement was not met as the lunch served did not reflect what was listed on the menu. | Type B |
Report Facts
Staff on duty: 7
Days of perishable food observed: 2
Days of non-perishable food observed: 7
Plan of Correction Due Date: Apr 25, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and cited the deficiency. |
| Liza King | Licensing Program Manager | Supervisor overseeing the inspection. |
| Expectacio Vierra | Administrator | Facility administrator met during the inspection. |
Inspection Report
Annual Inspection
Census: 13
Capacity: 18
Deficiencies: 2
Feb 27, 2023
Visit Reason
The inspection was an unannounced required 1 year annual visit to assess compliance with regulations for the facility serving residents with Dementia.
Findings
The facility was generally found to be adequately furnished, safe, and compliant with environmental and safety standards. However, deficiencies were cited related to incomplete medication records and maintenance issues including piles of debris in the backyard posing potential risks to residents.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Incomplete and inaccurate Centrally Stored Medication and Destruction Records for Hydrocodone and other medications, posing potential risk to residents. | Type B |
| Maintenance and operation deficiencies due to piles of debris in the backyard, posing potential risk to residents. | Type B |
Report Facts
Capacity: 18
Census: 13
Plan of Correction Due Date: Mar 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and documented findings |
| Liza King | Licensing Program Manager | Supervisor overseeing the inspection |
| Larry Vierra | Licensee met with during inspection |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 18
Deficiencies: 2
Jan 17, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that facility staff did not follow care plan and neglect/lack of care resulting in death.
Findings
The investigation substantiated that facility staff did not follow the care plan for resident 1 (R1) by serving food not suitable for a soft diet, which led to R1 choking on a hot dog and subsequently dying. The facility failed to ensure R1 wore dentures and served appropriate food, posing an immediate risk to residents' health and safety.
Complaint Details
The complaint investigation was substantiated. The allegation that facility staff did not follow the care plan was confirmed based on evidence that R1 was served food not consistent with the required soft diet, resulting in choking and death. The neglect/lack of care resulting in death allegation was also substantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide soft food or chopped meats as required by care plan, posing immediate risk to residents. | Type A |
| Administrator failed to ensure provision of services with appropriate regard for residents' physical and mental well-being. | Type A |
Report Facts
Civil penalty amount: 500
Plan of Correction due date: Jan 18, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Expectacio Vierra | Administrator | Named in findings related to failure to ensure proper diet and care for resident. |
| Liza King | Licensing Program Manager | Oversaw licensing program related to the investigation. |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 18
Deficiencies: 0
Jan 17, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to an allegation that the facility failed to provide a Do Not Resuscitate (DNR) order to Emergency Medical Technicians (EMT).
Findings
The investigation found that Resident 1 (R1) had conflicting Physician Orders for Life-sustaining Treatment (POLST) forms, and that resuscitation efforts and full medical treatment were provided in accordance with the latest POLST. There was no evidence that the DNR was withheld from EMTs, and the allegation was unsubstantiated.
Complaint Details
The complaint alleged the facility failed to provide DNR to EMT. The investigation included review of medical records, death certificate, AMR report, and interviews with family members, residents, staff, and the administrator. The allegation was found to be unsubstantiated.
Report Facts
Facility capacity: 18
Census: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Liza King | Licensing Program Manager | Oversaw the complaint investigation |
| Expectacio Vierra | Administrator | Facility administrator met during investigation and provided records |
Inspection Report
Complaint Investigation
Census: 9
Capacity: 18
Deficiencies: 1
Aug 15, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of illegal eviction and a separate allegation regarding the quality of food served at the facility.
Findings
The allegation of illegal eviction was substantiated based on the licensee's admission that a resident was not permitted to return to the facility without an eviction notice. The allegation regarding food quality was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for illegal eviction where the licensee admitted that a resident was not allowed to return to the facility without an eviction notice. The food quality allegation was unsubstantiated due to insufficient evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a 30-day written eviction notice as required by CCR 87224(a). | Type B |
Report Facts
Civil penalty amount: 250
Capacity: 18
Census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Expectacio Vierra | Administrator | Interviewed during investigation and admitted to eviction procedure issues |
Inspection Report
Census: 14
Capacity: 18
Deficiencies: 0
Mar 10, 2022
Visit Reason
The visit was an unannounced case management visit conducted by the Licensing Program Analyst to assess compliance of the facility.
Findings
The facility was found to be in compliance with no deficiencies cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elenor Laurora | Caregiver | Met with Licensing Program Analyst during the case management visit. |
Inspection Report
Annual Inspection
Census: 15
Capacity: 18
Deficiencies: 0
Mar 4, 2022
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with Title 22 regulations and infection control requirements.
Findings
No deficiencies were observed during the visit. The facility was found to be clean, well-maintained, and compliant with infection control protocols including COVID-19 mitigation measures.
Report Facts
Water temperature: 112.5
Fire extinguisher check date: Apr 20, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bruce Jacobs | Licensing Program Analyst | Conducted the inspection and infection control domain tool |
| Expectacio Vierra | Administrator | Facility administrator met during inspection and received report |
Inspection Report
Follow-Up
Census: 13
Capacity: 18
Deficiencies: 1
Oct 14, 2021
Visit Reason
Unannounced case management visit to conduct a follow-up on an incident report submitted to the Department.
Findings
The investigation found that Resident one (R1) was moved out on the third day of admission without proper eviction notice. Staff were not trained to provide appropriate care for R1's known behaviors prior to admission, and the licensee failed to issue the required 60-day eviction letter and did not send a 3-day eviction letter request to CCLD for approval.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Eviction Procedures: Licensee evicted a resident without written notice, violating Section 87224(a)(1) through (5), posing potential health, safety, and personal rights risks. | Type B |
Report Facts
Capacity: 18
Census: 13
Plan of Correction Due Date: Oct 29, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Boothe | Licensing Program Analyst | Conducted the follow-up inspection and investigation |
| Liza King | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
| Expectacio Vierra | Administrator | Facility Administrator met during the inspection |
Inspection Report
Complaint Investigation
Census: 12
Capacity: 18
Deficiencies: 0
Sep 22, 2021
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report submitted regarding a resident moving out of the facility.
Findings
No deficiencies were observed or cited during the visit. Additional information is needed to conclude the investigation, and a follow-up visit will be conducted.
Complaint Details
The visit was triggered by an incident report received on 2021-09-20 concerning Resident one (R1) moving out of the facility. The investigation is ongoing and additional information is required.
Report Facts
Census: 12
Total Capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Boothe | Licensing Program Analyst | Conducted the case management visit and investigation |
Inspection Report
Annual Inspection
Census: 11
Capacity: 18
Deficiencies: 0
Aug 26, 2021
Visit Reason
The visit was an unannounced annual inspection conducted to ensure compliance with Title 22 regulations at the facility.
Findings
The inspection found no deficiencies. The facility was observed to be clean, well-maintained, and compliant with infection control protocols including COVID-19 mitigation measures.
Report Facts
Water temperature: 110.1
Room temperature: 76
Fire extinguisher check date: Apr 20, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Expectacio Vierra | Administrator | Met with Licensing Program Analyst during inspection and received report |
| Michael Bilger | Licensing Program Analyst | Conducted the annual inspection visit |
| Liza King | Licensing Program Manager | Named in report header |
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