Deficiencies (last 6 years)
Deficiencies (over 6 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
118% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
54% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 113
Capacity: 210
Deficiencies: 2
Date: Feb 19, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that residents were not being provided adequate food service and were being left in soiled diapers for an extended amount of time.
Complaint Details
The complaint investigation was substantiated. Allegations included inadequate food service and residents being left in soiled diapers for extended periods. Interviews with residents and staff, observations, and record reviews supported these findings.
Findings
The investigation substantiated the allegations that residents experienced delays in food service and diaper changes due to staff turnover. Observations and interviews confirmed meal service delays of 5-10 minutes on the visit date but historical delays of 1-2 hours in 2022, and diaper change delays ranging from 30-45 minutes with one resident waiting 3 hours.
Deficiencies (2)
Sufficient food service personnel were not employed, trained, or scheduled to meet the needs of residents, causing delays in food service.
Delays in diaper changes were confirmed, posing potential Health, Safety, and/or Personal Rights risks to residents.
Report Facts
Census: 113
Total Capacity: 210
Deficiencies cited: 2
Plan of Correction Due Date: Mar 6, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Evaluator | Conducted the complaint investigation and authored the report |
| Monica Aguirre | Assistant Executive Director | Met with Licensing Evaluator during investigation and exit interview |
| Rebecca Ramos | Medication Technician | Greeted Licensing Evaluator and explained reason for visit |
| Sarah Cleesen | Administrator | Facility administrator named in report header |
| Melanie Washington | Executive Director | Confirmed historical meal service delays during interviews |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 210
Deficiencies: 2
Date: Feb 19, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that residents were not being provided adequate food service and were being left in soiled diapers for extended periods.
Complaint Details
The complaint investigation was substantiated. Allegations included inadequate food service with residents experiencing long wait times for meals and residents being left in soiled diapers for extended periods. Interviews with residents and staff confirmed these issues, with some residents reporting wait times of 1-2 hours for meals in 2022 and diaper change delays of 30-45 minutes or up to 3 hours.
Findings
The investigation substantiated the allegations, finding delays in meal service due to staff turnover and residents waiting 30-45 minutes or longer for diaper changes. Observations, interviews with residents and staff, and document reviews confirmed these deficiencies.
Deficiencies (2)
Insufficient food service personnel employed, trained, and scheduled to meet the needs of residents, causing delays in food service.
Failure to provide safe and healthful living accommodations and services, evidenced by delays in diaper changes posing health and safety risks.
Report Facts
Census: 113
Total Capacity: 210
Plan of Correction Due Date: Mar 6, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Evaluator | Conducted the complaint investigation |
| Monica Aguirre | Assistant Executive Director | Interviewed during investigation and participated in exit interview |
| Rebecca Ramos | Medication Technician | Greeted Licensing Program Analyst at visit |
| Sarah Cleesen | Administrator | Named as facility administrator |
| Lourdes Montoya | Supervisor | Supervisor overseeing the investigation |
| Melanie Washington | Executive Director | Confirmed staff shortages causing meal delays |
Inspection Report
Follow-Up
Census: 116
Capacity: 210
Deficiencies: 1
Date: Feb 9, 2026
Visit Reason
Unannounced case management visit to follow up on complaint control no 22-AS-20251222102645 regarding medication administration.
Complaint Details
Complaint investigation visit on December 29, 2025 substantiated the allegation that staff gave medication to the wrong resident.
Findings
The Licensing Program Analyst amended a second deficiency related to staff giving medication to the wrong resident, which was substantiated during a prior complaint investigation on December 29, 2025. An exit interview was conducted with the Executive Director.
Deficiencies (1)
Staff gave medication to the wrong resident.
Report Facts
Facility capacity: 210
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with during the inspection and named in relation to the medication error finding. |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection visit and amended the deficiency. |
| Lourdes Montoya | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 210
Deficiencies: 0
Date: Feb 9, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-09-17 regarding timely laundry service and respect among residents.
Complaint Details
Two complaints were investigated: 1) Staff do not ensure residents' laundry service is provided in a timely manner, which was found unfounded. 2) Staff do not ensure residents are accorded respect from other residents, which was unsubstantiated.
Findings
The investigation found the allegation that staff do not ensure timely laundry service to be unfounded based on observations and resident interviews. The allegation that staff do not ensure residents are accorded respect from other residents was deemed unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 210
Census: 113
Residents interviewed: 10
Residents interviewed: 10
Staff interviewed: 4
Laundry bags observed empty: 9
Residents reporting timely laundry: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eboni Bentley | Licensing Program Analyst | Conducted the complaint investigation |
| Melanie Washington | Executive Director | Met with during the investigation and exit interview |
| Monica Aguirre | Administrator | Facility administrator mentioned in the report |
| Lourdes Montoya | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Follow-Up
Census: 116
Capacity: 210
Deficiencies: 1
Date: Feb 9, 2026
Visit Reason
Unannounced case management visit to follow up on complaint control no 22-AS-20251222102645 regarding medication administration.
Complaint Details
Complaint control no 22-AS-20251222102645 was substantiated regarding medication error during the complaint investigation visit on December 29, 2025.
Findings
During the visit, the Licensing Program Analyst amended a second deficiency related to staff giving medication to the wrong resident, which was substantiated during a prior complaint investigation on December 29, 2025. An exit interview was conducted with the Executive Director.
Deficiencies (1)
Staff gave medication to the wrong resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with during inspection and exit interview. |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection visit and amended deficiency. |
| Lourdes Montoya | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 210
Deficiencies: 0
Date: Feb 9, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-09-17 regarding timely laundry service and respect among residents.
Complaint Details
The complaint investigation addressed two main allegations: 1) Staff do not ensure residents' laundry service is provided in a timely manner, which was found to be unfounded. 2) Staff do not ensure residents are accorded respect from other residents, which was deemed unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found the allegation that staff do not ensure timely laundry service to be unfounded based on observations and resident interviews. The allegation that staff do not ensure residents are accorded respect from other residents was deemed unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 210
Census: 113
Residents interviewed: 10
Residents interviewed: 10
Staff interviewed: 4
Laundry bags observed empty: 9
Residents reporting timely laundry service: 8
Residents denying respect allegation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eboni Bentley | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melanie Washington | Executive Director | Met with during the investigation and exit interview |
| Monica Aguirre | Administrator | Facility administrator named in the report |
| Lourdes Montoya | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Follow-Up
Census: 115
Capacity: 210
Deficiencies: 1
Date: Jan 26, 2026
Visit Reason
Unannounced case management visit to follow up on complaint control no 22-AS-20251222102645 regarding a medication error.
Complaint Details
Complaint investigation visit on December 29, 2025 substantiated the allegation of medication error by staff.
Findings
During the visit, a second deficiency was issued for the substantiated allegation that staff gave medication to the wrong resident, originally found during a complaint investigation on December 29, 2025.
Deficiencies (1)
Staff gave medication to the wrong resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Aguirre | Assistant Executive Director | Met with during inspection and named in relation to the medication error finding. |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection visit and issued the deficiency. |
| Lourdes Montoya | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Follow-Up
Census: 115
Capacity: 210
Deficiencies: 1
Date: Jan 26, 2026
Visit Reason
Unannounced case management visit to follow up on complaint control no 22-AS-20251222102645 regarding medication administration.
Complaint Details
The visit followed up on a substantiated complaint regarding medication error from December 29, 2025.
Findings
During the visit, a second deficiency was issued for the substantiated allegation that staff gave medication to the wrong resident during a prior complaint investigation on December 29, 2025.
Deficiencies (1)
Staff gave medication to the wrong resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Aguirre | Assistant Executive Director | Met with during inspection and named in medication error finding. |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection visit. |
| Lourdes Montoya | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 0
Date: Jan 13, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2022-06-07 regarding staff adherence to COVID-19 protocols, resident supervision, dietary needs, hot water availability, personal alarm system functionality, and medication distribution.
Complaint Details
The complaint investigation was unsubstantiated for five allegations including staff not adhering to COVID-19 protocols, failure to observe resident change in condition, unmet dietary needs, inoperable personal alarm system, and hot water issues. One medication distribution allegation was unfounded as the resident self-administered medications.
Findings
The investigation found the allegations to be unsubstantiated or unfounded. Most residents and staff denied the allegations, and testing showed compliance with regulatory requirements. One allegation was found to be opened in error as the resident self-administered medication.
Report Facts
Capacity: 210
Census: 123
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Lopez | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Melanie Washington | Executive Director | Facility representative present during the investigation and exit interview |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 0
Date: Jan 13, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2022-07-21 regarding multiple allegations including inadequate record keeping, unmet resident hygiene needs, residents left out of bed for extended periods, inadequate staffing, and lack of PPE.
Complaint Details
The complaint involved five allegations: inadequate record keeping, unmet resident hygiene needs, residents left out of bed for extended periods, inadequate staffing, and lack of PPE. The investigation found the allegations unsubstantiated due to lack of preponderance of evidence. Some staff and residents corroborated past issues with record keeping and staffing, but most denied the allegations. The medication room allegation was unfounded.
Findings
The investigation included staff and resident interviews and a physical tour. The Department found insufficient evidence to substantiate the allegations. Some staff and residents corroborated previous issues with record keeping and staffing, but most denied the allegations. The medication room was found to be in good condition. Overall, the complaint was deemed unsubstantiated or unfounded.
Report Facts
Capacity: 210
Census: 123
Staff interviews: 7
Resident interviews: 7
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Melanie Washington | Executive Director | Facility representative present during the investigation and exit interview |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 0
Date: Jan 13, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-08-15 alleging understaffing, inadequate response to residents' concerns, and facility equipment disrepair.
Complaint Details
The complaint involved allegations that residents were not provided care in a timely manner due to understaffing, the facility was not promptly responding to residents' concerns, and facility equipment was in disrepair. The investigation found mixed resident and staff statements with no preponderance of evidence to prove the allegations; thus, the complaint was unsubstantiated.
Findings
The investigation included resident and staff interviews and review of facility records. The Department found insufficient evidence to substantiate the allegations; some residents and staff corroborated staffing and care delays, but most denied the allegations. The equipment and response to concerns allegations were also mostly denied. Therefore, all allegations were deemed unsubstantiated.
Report Facts
Complaint Control Number: 22-AS-20220815094602
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Melanie Washington | Executive Director | Facility representative present during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 1
Date: Jan 13, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including staff losing a resident's diapers and other care-related complaints.
Complaint Details
The complaint investigation was substantiated for the allegation that staff lost resident's diapers. The other four allegations were unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated the allegation that staff lost a resident's diapers, citing a deficiency related to safeguarding resident property. Four other allegations regarding soiled diapers, oxygen orders, food accessibility, and timely sheet changes were unsubstantiated based on resident and staff interviews.
Deficiencies (1)
Failure to safeguard Resident #1's diapers, posing a potential health, safety, and personal rights risk.
Report Facts
Capacity: 210
Census: 123
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative present during the investigation and exit interview |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
| Staff #1 | Admitted to losing Resident #1's diaper order |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 1
Date: Jan 13, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including staff losing a resident's diapers, resident left in soiled diapers, staff not following physician's orders for oxygen, staff not making food accessible to residents, and residents' sheets not being changed timely.
Complaint Details
The complaint investigation was triggered by allegations received on 09/07/2022. The allegation that staff lost Resident #1's diapers was substantiated. The other allegations regarding resident left in soiled diapers, staff not following physician's orders for oxygen, staff not making food accessible, and residents' sheets not being changed timely were unsubstantiated.
Findings
The investigation substantiated the allegation that staff lost a resident's diapers, citing a deficiency related to safeguarding residents' personal property. The other four allegations were unsubstantiated based on resident and staff interviews and lack of sufficient evidence.
Deficiencies (1)
Failure to safeguard Resident #1's diapers, posing a potential health, safety, and personal rights risk.
Report Facts
Capacity: 210
Census: 123
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative present during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 0
Date: Jan 13, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-08-15 regarding allegations of understaffing, inadequate response to residents' concerns, and facility equipment disrepair.
Complaint Details
The complaint was unsubstantiated. Allegations included residents not receiving timely care due to understaffing, inadequate response to residents' concerns, and facility equipment disrepair. Resident and staff interviews yielded conflicting accounts, and the Department was unable to obtain staffing records for the complaint period.
Findings
The investigation found mixed responses from residents and staff regarding the allegations. Some residents and staff corroborated issues with staffing and timely care, concerns response, and equipment disrepair, while others denied these allegations. Due to insufficient evidence, all three allegations were deemed unsubstantiated.
Report Facts
Capacity: 210
Census: 123
Resident interviews: 6
Staff interviews: 4
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Melanie Washington | Executive Director | Facility representative present during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 0
Date: Jan 13, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2022-06-07 regarding staff adherence to COVID-19 protocols, resident supervision, dietary needs, hot water availability, personal alarm system functionality, and medication distribution.
Complaint Details
The complaint investigation was unsubstantiated for five allegations including COVID-19 protocol adherence, resident supervision, dietary needs, hot water delivery, and personal alarm system operability. One additional allegation regarding medication distribution was found to be unfounded. The investigation included resident and staff interviews, record reviews, and facility testing.
Findings
The investigation found insufficient evidence to substantiate the allegations. Most residents and staff denied the allegations, with some residents and staff partially corroborating issues with hot water, but testing showed compliance with regulatory requirements. The medication distribution allegation was found to be unfounded as the resident was independent in medication administration.
Report Facts
Capacity: 210
Census: 123
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Lopez | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Melanie Washington | Executive Director | Facility representative present during the investigation and exit interview |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 0
Date: Jan 13, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-07-21 regarding multiple allegations including inadequate record keeping, unmet resident hygiene needs, residents left out of bed for extended periods, inadequate staffing, lack of PPE, and medication room disrepair.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate record keeping, unmet hygiene needs, residents left out of bed, inadequate staffing, lack of PPE, and medication room disrepair. Interviews with seven residents and seven staff members were conducted. Most denied the allegations, with a few staff and residents partially corroborating some claims. The Department was unable to obtain staffing records. The medication room was found in good condition. The complaint was deemed unsubstantiated or unfounded.
Findings
The investigation found the allegations to be unsubstantiated or unfounded. Staff and resident interviews, as well as facility observations, did not provide sufficient evidence to prove the allegations. The medication room was observed to be in good condition, and PPE supply was adequate. Staffing records were unavailable, but most residents and staff denied staffing issues. Overall, there was no preponderance of evidence to confirm the allegations.
Report Facts
Capacity: 210
Census: 123
Estimated Days of Completion: 90
Number of staff interviewed: 7
Number of residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandon Lopez | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Melanie Washington | Executive Director | Facility representative present during the investigation and exit interview |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 210
Deficiencies: 0
Date: Jan 9, 2026
Visit Reason
The visit occurred to deliver amended complaint investigation findings related to Complaint Control No 22-AS-20251222102645 for a prior visit on December 29, 2025.
Complaint Details
The visit was related to amended complaint investigation findings for Complaint Control No 22-AS-20251222102645. No substantiation status or specific findings are detailed in the report.
Findings
The Licensing Program Analyst arrived unannounced to present amended complaint investigation findings and conducted an exit interview with the Executive Director. A copy of the report including the amended complaint investigation was provided at the end of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with during the visit and exit interview. |
| Eboni Bentley | Licensing Program Analyst | Conducted the visit and delivered amended complaint investigation findings. |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 2
Date: Dec 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff gave medication to the wrong resident and did not follow reporting requirements.
Complaint Details
The complaint investigation was substantiated. Allegations included staff giving medication to the wrong resident and failure to follow reporting requirements. Interviews and record reviews confirmed the medication error and lack of reporting.
Findings
The investigation substantiated that on November 3, 2025, staff administered Resident #2's medication to Resident #1 instead of the prescribed medication, and the medication error was not reported to the resident's family, physician, or the Department as required.
Deficiencies (2)
Failure to report Resident #1's medication error to the licensing agency and responsible persons within seven days.
Failure to administer medication to Resident #1 as prescribed, resulting in administration of Resident #2's medication.
Report Facts
Facility Capacity: 210
Census: 123
Deficiencies cited: 2
Plan of Correction Due Dates: 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eboni Bentley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative interviewed during the investigation and exit interview |
| Monica Aguirre | Administrator | Named in relation to plan of correction for reporting deficiency |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 210
Deficiencies: 2
Date: Dec 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff gave medication to the wrong resident and did not follow reporting requirements.
Complaint Details
The complaint investigation was substantiated. Allegations included staff giving medication to the wrong resident and failure to follow reporting requirements. Interviews and record reviews confirmed the medication error and lack of reporting.
Findings
The investigation substantiated that on November 3, 2025, staff administered Resident #2's medication to Resident #1 instead of the prescribed medication, and the medication error was not reported to the resident's family, physician, or the Department as required.
Deficiencies (2)
Failure to submit a written report to the licensing agency and responsible persons within seven days of the medication error occurrence.
Failure to administer medication to Resident #1 as prescribed, resulting in a medication error.
Report Facts
Facility capacity: 210
Census: 123
Deficiencies cited: 2
Plan of Correction due dates: 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eboni Bentley | Licensing Program Analyst | Conducted the complaint investigation |
| Melanie Washington | Executive Director | Facility representative interviewed during the investigation |
| Monica Aguirre | Administrator | Named in relation to plan of correction and reporting deficiencies |
Inspection Report
Follow-Up
Census: 116
Capacity: 210
Deficiencies: 0
Date: Dec 5, 2025
Visit Reason
The visit was an unannounced case management follow-up to an incident report received on November 6, 2025, concerning Resident 1 (R1).
Complaint Details
The visit was triggered by an incident report related to Resident 1. No deficiencies were found during the investigation.
Findings
During the visit, full access to Resident 1's records was provided and no deficiencies were cited. The facility was requested to provide copies of the Coroner's Report and Death Certificate at a later date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Aguirre | Assistant Executive Director | Met with during the visit and involved in the exit interview. |
| Lourdes Montoya | Licensing Program Manager | Conducted the visit and named in the report. |
| Eboni Bentley | Licensing Program Analyst | Conducted the visit and named in the report. |
Inspection Report
Follow-Up
Census: 118
Capacity: 210
Deficiencies: 1
Date: Nov 12, 2025
Visit Reason
This was a follow-up visit for an incident report received on November 6, 2025, and a case management visit to inspect and audit resident records that were not available during the previous visit.
Findings
The licensing agency was not granted full access to inspect, audit, and copy/print all electronic resident records upon demand, which poses a potential risk to residents' health and safety. Some records were provided but full electronic access was denied.
Deficiencies (1)
The Licensee did not grant licensing agency full access to inspect, audit, and copy/print all electronic resident records upon demand, which poses potential risk to resident’s health and safety.
Report Facts
Capacity: 210
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during inspection and involved in discussion about access to records |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 118
Capacity: 210
Deficiencies: 0
Date: Nov 7, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report received by the Orange County Regional Office on November 6, 2025.
Findings
During the visit, no imminent health and safety issues were observed and no deficiencies were cited. Relevant resident and staff records were reviewed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 210
Deficiencies: 0
Date: Sep 26, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff do not ensure floors in residents' rooms are kept clean.
Complaint Details
The complaint alleged that staff do not clean the floors in any of the residents' rooms. The investigation found this allegation to be unfounded.
Findings
Based on observation of ten apartment units, the Licensing Program Analysts found the floors to be clean and sanitary. The complaint was determined to be unfounded and dismissed.
Report Facts
Capacity: 210
Census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with during the investigation and exit interview |
| Eboni Bentley | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation |
| Lourdes Montoya | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 210
Deficiencies: 0
Date: Sep 26, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff do not ensure floors in residents' rooms are kept clean.
Complaint Details
The complaint alleged that staff do not clean the floors in any of the residents' rooms. The investigation found this allegation to be unfounded.
Findings
Based on observation of ten apartment units, Licensing Program Analysts found the floors to be clean and sanitary. The complaint was deemed unfounded, meaning the allegation was false and without reasonable basis.
Report Facts
Capacity: 210
Census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with during the investigation and exit interview |
| Eboni Bentley | Licensing Evaluator | Conducted the complaint investigation |
| Jessica Cho | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Census: 118
Capacity: 210
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The inspection visit was an unannounced compliance check conducted following a Noncompliance Conference held on May 14, 2025.
Findings
During the inspection, a deficiency was cited related to water temperatures in resident bathrooms being below the required minimum, posing an immediate health and safety risk. The facility has implemented some corrective measures including hiring and training new staff and conducting quality assurance audits.
Deficiencies (1)
Water supplies and plumbing fixtures were not maintained to automatically regulate water temperature to between 105 and 120 degrees F in 4 out of 5 resident bathrooms, with observed temperatures ranging from 98.2 to 104.5 degrees F.
Report Facts
Residents on census: 118
Total licensed capacity: 210
Deficiencies cited: 1
Plan of Correction due date: Aug 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Accompanied Licensing Program Analyst on facility tour and was present during exit interview |
| Monica Aguirre | Assistant Executive Director | Provided information regarding medication training and facility staffing |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Census: 118
Capacity: 210
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The unannounced visit on August 6, 2025, was conducted to perform compliance checks following a Noncompliance Conference held on May 14, 2025.
Findings
A deficiency was cited due to hot water temperatures in four out of five resident bathrooms being below the required minimum of 105 degrees F, posing an immediate health and safety risk. The facility has hired new staff and is performing quality assurance checks, but has not yet begun the required annual refresher training for staff.
Deficiencies (1)
Water supplies and plumbing fixtures did not maintain hot water temperatures between 105 and 120 degrees F in 4 out of 5 resident bathrooms, with observed temperatures ranging from 98.2 to 104.5 degrees F.
Report Facts
Residents on census: 118
Total licensed capacity: 210
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Accompanied Licensing Program Analyst on facility tour and exit interview |
| Monica Aguirre | Assistant Executive Director | Provided information about medication training and facility oversight |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 210
Deficiencies: 0
Date: Jun 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-06-04 regarding quality of meals, foul odors, personal privacy, and cleanliness of facility floors at Sunnycrest Senior Living Facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included poor meal quality, foul odors, lack of personal privacy, and unclean floors. The Licensing Program Analyst conducted tours, interviews, and record reviews and found no violations.
Findings
The investigation found no evidence to substantiate the allegations. Observations, interviews, and record reviews indicated that meals were of good quality, no foul odors were detected, staff respected residents' privacy, and facility floors were clean and well maintained.
Report Facts
Resident interviews: 11
Staff interviews: 7
Facility capacity: 210
Facility census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Aguirre | Assistant Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager on report |
| Melanie Washington | Executive Director | Participated in exit interview |
Inspection Report
Annual Inspection
Census: 115
Capacity: 210
Deficiencies: 2
Date: May 27, 2025
Visit Reason
An unannounced required 1-Year annual visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.
Findings
Two Type A deficiencies were cited related to hot water temperatures exceeding safe limits in three rooms and unsecured medications in resident rooms, posing immediate health and safety risks. The facility otherwise met requirements for emergency preparedness, physical plant conditions, and food stock.
Deficiencies (2)
Hot water temperatures in three out of ten rooms measured between 125.4 F and 130.2 F, posing an immediate health and safety risk to residents.
Centrally stored medications were not kept in a safe and locked place; one or more medications were unlocked in a resident's room and one medication ointment was missing.
Report Facts
Rooms with hot water temperature issues: 3
Resident medications reviewed: 10
Resident medications with issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monica Aguirre | Administrator | Met with Licensing Program Analysts during inspection. |
| Melanie Washington | Administrator/Executive Director | Notified and assisted with the visit; received exit interview. |
| Sergio Mendoza | Dining Services Manager | Greeted and granted entry to Licensing Program Analysts. |
| Eboni Bentley | Licensing Program Analyst | Conducted inspection and signed report. |
| Jenifer Tirre | Licensing Program Analyst | Conducted inspection. |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 210
Deficiencies: 1
Date: Mar 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that facility staff were not abiding by the terms and conditions of the Admission Agreement.
Complaint Details
The complaint was substantiated. The investigation revealed ongoing issues with cable TV service quality since January 2025, verified by residents and staff, with the cable provider having visited multiple times without resolving the problem.
Findings
The investigation found that the facility did not provide all cable television channels as stated in the admission agreement, with issues including missing channels, poor picture quality with static interference on several channels, and no sound on one channel in a resident's room. The allegation was substantiated based on evidence gathered.
Deficiencies (1)
The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not being met as evidenced by the admission agreement stating basic cable television hook-up will be provided but channel 39 is not being provided, 5 out of the 51 channels have poor picture quality with static and channel 15 does not have sound for Resident 1, posing a potential personal rights risk to residents in care.
Report Facts
Channels with poor picture quality: 5
Facility capacity: 210
Census: 106
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and made observations regarding the cable TV issues. |
| Monica Aguirre | Assistant Executive Director | Met with the Licensing Program Analyst during the investigation and provided information about the cable TV service. |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 210
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not ensure that a resident was provided a comfortable environment while in care.
Complaint Details
The complaint was unsubstantiated based on the investigation findings, which included interviews with 6 residents and staff, observations of the facility environment, and temperature measurements within regulatory standards.
Findings
The investigation included interviews with residents and staff, a tour of the facility, and review of pertinent documents. The department found no evidence to substantiate the allegation, noting that residents were informed about remodeling activities which did not affect their comfort or care, and the facility maintained appropriate room temperatures.
Report Facts
Capacity: 210
Census: 90
Temperature range: 78.2
Temperature range: 79.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Melanie Washinton | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 91
Capacity: 210
Deficiencies: 0
Date: Jun 19, 2024
Visit Reason
The visit was an unannounced required annual inspection conducted to evaluate compliance with regulatory standards.
Findings
The facility was found to be in compliance with no deficiencies cited under Title 22 Division 6 of the California Code of Regulations. Two Technical Violation Advisory Notes were provided. The facility was observed to have adequate staffing, clean and well-maintained rooms, operational safety systems, and proper medication and food storage.
Report Facts
Staff members on roster: 39
Staff records reviewed: 10
Resident records reviewed: 10
Medication carts: 2
Perishable food stock requirement: 2
Non-perishable food stock requirement: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the inspection visit |
| Melanie Washington | Executive Director | Facility representative who assisted with the visit |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 210
Deficiencies: 0
Date: May 6, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations of neglect resulting in multiple falls and injuries to a resident.
Complaint Details
The complaint alleged neglect causing a resident to sustain multiple falls resulting in injuries. The investigation included interviews, record reviews, and observations. The resident sustained falls including one on January 1, 2024, resulting in serious injury and subsequent death, but the evidence did not prove neglect by staff.
Findings
The investigation found insufficient evidence to substantiate neglect or lack of supervision by facility staff related to the resident's falls. The resident had an established fall risk and the facility followed the fall prevention plan. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 210
Resident census: 89
Resident age: 95
Fall incident date: Jan 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melanie Washington | Administrator | Facility administrator present and assisted with the visit |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Enforcement
Census: 92
Capacity: 210
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
An unannounced case management visit was conducted for the purpose of issuing a civil penalty concluded during investigation of complaint control #22-AS-20230817163330.
Complaint Details
Visit was complaint-related, conducted following investigation of complaint control #22-AS-20230817163330. Civil penalty was assessed.
Findings
A civil penalty was assessed on the date of the visit. An exit interview was conducted with the Executive Director, who was provided with a copy of the report, appeal rights, and civil penalty assessment documentation.
Report Facts
Census: 92
Total Capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met during visit and exit interview; provided with report and civil penalty assessment |
| Rosie Quiroz | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 210
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate an allegation that staff did not make medication inaccessible to a resident, resulting in hospitalization.
Complaint Details
The complaint alleged that staff did not make medication inaccessible to the resident, resulting in hospitalization. The allegation was substantiated based on interviews and record reviews.
Findings
The investigation found that staff failed to follow medication administration protocols, resulting in Resident 1 ingesting the wrong medication, leading to two hospitalizations and a stroke caused by a missed Eliquis medication dose. Both staff involved were terminated and the allegation was substantiated.
Deficiencies (1)
Licensee failed to ensure Resident 1 received prescribed Eliquis medication twice daily resulting in at least one missed dosage on 8/13/23 and 8/15/23, causing a stroke and cerebral blood clot requiring surgery.
Report Facts
Capacity: 210
Census: 89
Deficiencies cited: 1
Plan of Correction Due Date: Feb 16, 2024
Medication training proof due date: Feb 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Facility Administrator who confirmed missed medication doses and conducted internal investigation |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 210
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
An unannounced visit was conducted to deliver findings on an investigation related to medication administration errors involving Resident 1 ingesting another resident's medication.
Complaint Details
The investigation was complaint-related, involving medication errors where staff failed to properly supervise medication distribution, leading to Resident 1 ingesting the wrong medication. The complaint was substantiated as evidenced by the cited deficiency.
Findings
The facility failed to ensure medications were securely locked and properly administered, resulting in Resident 1 ingesting another resident's medication, becoming lethargic and unresponsive, and requiring hospital transport. The facility was cited for this deficiency under Title 22, Division 6 of the California Code of Regulations.
Deficiencies (1)
Licensee failed to ensure medications were locked and inaccessible to Resident 1, resulting in Resident 1 ingesting another resident’s medication, posing an immediate health and safety risk.
Report Facts
Census: 89
Total Capacity: 210
Deficiency Count: 1
Plan of Correction Due Date: Feb 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosie Quiroz | Licensing Program Analyst | Conducted the investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative met during the inspection |
| Alisa Ortiz | Licensing Program Manager | Supervisor overseeing the licensing program and cited in the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 210
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
An unannounced visit was conducted to deliver findings on an investigation related to medication administration errors at the facility.
Complaint Details
The investigation was complaint-related, involving medication errors where staff passed off medication duties and did not physically observe residents taking medications. The complaint was substantiated by the findings.
Findings
The facility was cited for failing to ensure medications were securely stored and properly administered, resulting in a resident ingesting another resident's medication and becoming lethargic and unresponsive, requiring hospitalization.
Deficiencies (1)
Licensee failed to ensure medications were locked and inaccessible to Resident 1, resulting in Resident 1 ingesting another resident’s medication, posing an immediate health and safety risk.
Report Facts
Deficiencies cited: 1
Plan of Correction due date: Feb 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosie Quiroz | Licensing Program Analyst | Conducted the unannounced visit and authored the report |
| Melanie Washington | Executive Director | Facility representative met during the visit |
| Alisa Ortiz | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 210
Deficiencies: 0
Date: Jan 29, 2024
Visit Reason
An unannounced visit was conducted to investigate complaints alleging that a resident's room was in disrepair and that the facility was not adhering to the admission agreement.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included the resident's room being in disrepair and the facility not adhering to the admission agreement. Evidence did not support these claims.
Findings
The investigation found the allegations to be unsubstantiated after verifying the operation of the resident's room fixtures and reviewing the admission agreement and billing statements. No preponderance of evidence was found to prove or refute the alleged violations.
Report Facts
Facility capacity: 210
Resident census: 84
Shower water temperature: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation |
| Melanie Washington | Executive Director | Facility representative interviewed during investigation |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 210
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to follow up on allegations received on 2024-01-16 regarding the facility's admission agreement, description of services, additional fees, and medical evaluations prior to admission.
Complaint Details
The complaint investigation was unsubstantiated, meaning the allegations were found to be false, without reasonable basis, or not supported by evidence after review of resident records, interviews with residents and staff, and examination of admission agreements and fee schedules.
Findings
The investigation found all allegations to be unsubstantiated. Resident records reviewed included required medical assessments, and admission agreements on file were valid and unchanged despite a recent change in ownership. Some residents expressed confusion about prospective admission packets and fee statements, but no violations were substantiated.
Report Facts
Capacity: 210
Census: 84
Resident records reviewed: 6
Resident interviews: 6
Staff interviews: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation visit and follow-up |
| Melanie Washington | Executive Director | Facility representative who assisted during the investigation |
| Monica Aguirre | Administrator | Facility administrator named in the report |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 210
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to follow up on allegations received on 2023-12-13 regarding staff not assisting residents with bathing needs, residents being billed for services not rendered, and failure to provide residents with a copy of admissions agreements.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Kevin Saborit-Guasch. Allegations included failure to assist residents with bathing, improper billing, and failure to provide admission agreements. The allegation regarding bathing assistance was unsubstantiated, the billing allegation was unsubstantiated, and the failure to provide admission agreement was found to be unfounded.
Findings
The investigation found all allegations to be either unsubstantiated or unfounded. Staff were determined to have provided appropriate assistance and documentation, and billing practices were consistent with the admission agreement terms. No violations were substantiated based on interviews, record reviews, and billing analysis.
Report Facts
Capacity: 210
Census: 84
Additional monthly charge: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Melanie Washington | Executive Director | Facility administrator present during the investigation |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 210
Deficiencies: 2
Date: Dec 22, 2023
Visit Reason
The visit was an unannounced Case Management inspection conducted due to an investigation related to a complaint concerning a resident's injury and related documentation issues.
Complaint Details
Investigation connected to Complaint Control Number: 22-AS-20230911142552. The complaint involved a resident's fall and injury and related documentation deficiencies. Technical Violation Advisory notes were issued.
Findings
The facility failed to submit a written report within seven days regarding a resident's skin tear injury from a fall and lacked an updated Physician’s Report or doctor’s order for a wheelchair. Technical Violation Advisory notes were issued as a result.
Deficiencies (2)
Failure to submit a written report within seven days of the occurrence pertaining to a resident's skin tear injury.
Lack of an updated Physician’s Report or doctor’s order prescribing the wheelchair.
Report Facts
Complaint Control Number: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with during the inspection and involved in the exit interview. |
| Jessica Cho | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Sheila Santos | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 210
Deficiencies: 1
Date: Dec 20, 2023
Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations received on 09/11/2023 regarding staff not seeking timely medical attention for a resident, mismanagement of resident's medication, and failure to provide a safe and comfortable environment.
Complaint Details
The complaint investigation was initiated based on allegations received on 09/11/2023. The allegations included failure to seek timely medical attention, medication mismanagement, unsafe environment, and facility disrepair. The first three allegations were unsubstantiated, while the facility disrepair allegation was substantiated.
Findings
The investigation found insufficient evidence to substantiate allegations related to medical attention, medication management, and environment safety, deeming these allegations unsubstantiated. However, the allegation that the facility is in disrepair was substantiated due to an uneven and unstable backyard patio ground posing a safety risk to a resident with mobility impairment.
Deficiencies (1)
Backyard patio ground is uneven/unstable and may potentially be a safety risk to a resident with motor impairment.
Report Facts
Capacity: 210
Census: 91
Deficiency due date: Dec 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Melanie Washington | Executive Director | Facility representative met during investigation and exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Capacity: 210
Deficiencies: 0
Date: Jul 26, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on a previously referenced complaint regarding the exit gate latch on the left side of the community.
Findings
The Licensing Program Analyst observed that the exit gate latch had been vandalized and was bent, preventing proper operation. Maintenance was actively repairing the gate latch during the visit. No health concerns were observed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and observed the gate latch issue. |
| Melanie Washington | Administrator | Facility administrator met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 210
Deficiencies: 0
Date: Jun 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility gates were left unsecured and staff failed to provide a safe and comfortable environment for residents.
Complaint Details
The complaint investigation was unannounced and based on allegations regarding unsecured facility gates and unsafe environment. The allegations were found to be unfounded, meaning they were false or without reasonable basis.
Findings
The investigation found that the facility gates were unlocked and operational as required for designated exits, with a one-way lock installed to prevent unauthorized entry. The facility was observed to be safe, clean, and comfortable with residents participating in activities and dining. Therefore, the allegations were deemed unfounded.
Report Facts
Capacity: 210
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melanie Washington | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Capacity: 210
Deficiencies: 0
Date: Jun 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not meet residents' toileting needs, handled residents in a rough manner, and spoke inappropriately to residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not meeting residents' toileting needs, rough handling of residents, and inappropriate speech. Interviews with 14 individuals provided conflicting statements and could not corroborate the allegations.
Findings
After interviews with staff and residents and review of facility records, conflicting statements were found and there was no preponderance of evidence to substantiate the allegations. Therefore, all allegations were deemed unsubstantiated.
Report Facts
Capacity: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Brenda Bravo | Resident Care Director, L.V.N. | Met with Licensing Program Analyst during the visit |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 210
Deficiencies: 0
Date: Jun 9, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-09-14 regarding insufficient staff, inadequate incontinent care to a resident, and lack of administrator responsiveness to responsible party concerns.
Complaint Details
The complaint allegations were: insufficient staff, inadequate incontinent care to a resident, and the Administrator not responding to responsible party concerns. Interviews with 13 individuals showed conflicting statements and no corroboration. Observations during a prior visit showed adequate incontinent care. The Administrator was reported as responsive. The allegations were unsubstantiated.
Findings
The investigation included interviews with residents and staff, and review of facility and resident records. Conflicting statements were provided by all interviewed individuals, and no corroboration of the allegations was found. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Individuals interviewed: 13
Facility capacity: 210
Facility census: 86
Caregivers observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the investigation |
| Sarah Cleesen | Administrator | Named in allegations regarding responsiveness to responsible party concerns |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 210
Deficiencies: 1
Date: May 12, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility gate was left unsecured.
Complaint Details
The complaint was substantiated based on observations, interviews with five individuals who confirmed the gate was left ajar, and review of records including photographs. The facility failed to ensure the gate was secured at all times.
Findings
The investigation found that the side gate was left ajar on multiple occasions, confirmed by interviews and photographic evidence, posing a potential risk to resident safety. The allegation was substantiated.
Deficiencies (1)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services for the safety and well-being of residents, employees and visitors. This requirement is not met as the licensee did not ensure the side gate was properly secured at all times, posing a potential risk to residents.
Report Facts
Capacity: 210
Census: 82
Deficiency Type: 1
Plan of Correction Due Date: May 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility administrator met during investigation |
| Brenda Bravo | Resident Care Director, L.V.N. | Participated in exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 210
Deficiencies: 1
Date: Apr 27, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 09/13/2022 regarding the facility director being impaired while at the facility, failure to treat residents with respect and politeness, and excessive wait times for meals.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility director was impaired while at the facility. The other allegations regarding disrespectful treatment of residents and excessive meal wait times were unsubstantiated.
Findings
The allegation that the facility director was impaired while at the facility was substantiated based on interviews, observations, and record reviews. The allegations that the director did not treat residents with respect and politeness and that residents had to wait excessive amounts of time for meals were unsubstantiated due to lack of corroborating evidence.
Deficiencies (1)
Administrator Qualifications and Duties. The administrator did not meet the requirement of good character and integrity as they were under the influence of alcohol while working, posing a potential risk to the health and safety of residents.
Report Facts
Capacity: 210
Census: 82
Deficiency Type B: 1
Plan of Correction Due Date: May 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the investigation and was the subject of the impairment allegation |
| Sarah Cleesen | Administrator | Facility administrator implicated in the impairment allegation |
| Sheila Santos | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 210
Deficiencies: 0
Date: Apr 22, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff do not respond to residents' call buttons in a timely manner.
Complaint Details
The complaint alleged that staff do not respond to residents' call buttons in a timely manner. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation included interviews with residents and staff, and review of facility records. Staff response times to call pendants ranged from 1 to 10 minutes with an average just under 5 minutes, though some residents reported longer response times. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Response time range (minutes): 1
Response time range (minutes): 10
Average response time (minutes): 5
Capacity: 210
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
| Gail Blessum | Business Office Director | Met with Licensing Program Analyst during investigation |
| Brenda Bravo | Resident Care Director, L.V.N. | Met with Licensing Program Analyst during investigation and exit interview |
| Juli Sanchez | Vibrant Life Director | Met with Licensing Program Analyst during investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 210
Deficiencies: 0
Date: Apr 22, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility has inadequate staffing to meet residents' needs.
Complaint Details
The allegation was that the facility had inadequate staffing to meet residents' needs. Twelve individuals interviewed provided conflicting statements; ten felt staffing was sufficient, while four felt more staff were needed. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Findings
Interviews with residents and staff, along with a review of facility records, revealed conflicting statements regarding staffing adequacy. The investigation found insufficient evidence to substantiate the allegation, and the complaint was deemed unsubstantiated.
Report Facts
Capacity: 210
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sarah Cleesen | Administrator | Facility administrator named in report header |
| Gail Blessum | Business Office Director | Met with Licensing Program Analyst during visit |
| Brenda Bravo | Resident Care Director, L.V.N. | Met with Licensing Program Analyst during visit and participated in exit interview |
| Juli Sanchez | Vibrant Life Director | Met with Licensing Program Analyst at start of visit |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 210
Deficiencies: 1
Date: Mar 23, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 12/29/2022 regarding facility kitchen equipment disrepair and other allegations related to food quality, cleanliness, resident safety, communication, and snack availability.
Complaint Details
The complaint investigation was substantiated for the allegation of kitchen equipment disrepair. Other allegations including food quality, facility cleanliness, resident safety, communication, and snack quantity were unsubstantiated. The investigation included interviews with residents and staff, review of facility and resident records, and facility tours.
Findings
The investigation substantiated the allegation that the facility kitchen equipment is in disrepair, citing a violation of California Code of Regulations. All other allegations regarding food quality, cleanliness, resident safety, communication, and snack quantity were deemed unsubstantiated based on interviews, observations, and record reviews.
Deficiencies (1)
Facility kitchen equipment is in disrepair, posing a potential risk to the health and safety of residents.
Report Facts
Capacity: 210
Census: 80
Deficiency POC Due Date: Apr 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative who assisted during the investigation and exit interview |
| Gail Blessum | Business Office Director/Manager | Met with Licensing Program Analyst during the investigation |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 210
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 07/28/2022 regarding staff mismanagement of resident's medication, unsafe environment, dehydration, and unkempt resident room.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff mismanagement of medication, unsafe environment, dehydration, and unkempt resident room. No evidence was found to prove these allegations.
Findings
The investigation included interviews with residents and staff, and review of records. Conflicting statements were found and no corroboration of allegations was established. Observations showed the facility and resident rooms were clean and well-maintained. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 210
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 210
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility did not properly notify a resident of a rate increase.
Complaint Details
The complaint alleged the facility failed to properly notify a resident of a rate increase. The investigation reviewed level of care assessments, invoices, and email communications. The facility waived additional charges for the resident due to notification concerns. The allegation could not be corroborated and was unsubstantiated.
Findings
The investigation included interviews, record reviews, and communication analysis. Conflicting statements were found and there was insufficient evidence to substantiate the allegation. The complaint was deemed unsubstantiated.
Report Facts
Capacity: 210
Census: 79
Invoice amount: 7803.25
Invoice amount: 6003.25
Level of care assessment dates: February 19, 2022 and October 21, 2022 for Resident #1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation visit and report |
| Melanie Washington | Executive Director | Facility representative interviewed during the investigation |
| Judi Williams | Resident Care Director | Notified Resident #1 of level of care increase via email |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 210
Deficiencies: 4
Date: Dec 1, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations including ants in a resident's room, exposure to hazardous chemicals, medication mismanagement, and failure to change resident's bedding.
Complaint Details
The complaint investigation was substantiated based on interviews and record reviews. The allegations included ants in the resident's room, hazardous chemical exposure, medication errors, and failure to change bedding. The findings confirmed these issues and posed immediate health and safety risks.
Findings
The investigation substantiated the allegations, finding that ants were present in a resident's bed, staff sprayed ant poison without removing the resident, medication was mismanaged resulting in a double dose given to the resident, and bedding was not changed promptly after contamination. These conditions posed immediate health, safety, and personal rights risks.
Deficiencies (4)
Personal Accommodations and Services - The premises were not maintained in a safe and healthful environment due to ants in resident's bed and room.
Personal Rights of Residents - Staff sprayed ant poison in resident's room without removing the resident, exposing them to hazardous chemicals.
Incidental Medical and Dental Care - Medication mismanagement occurred with a double dose given and incorrect documentation on the MAR.
Personal Rights - Resident's bedding was not changed immediately after being soiled and sprayed with ant poison.
Report Facts
Capacity: 210
Census: 81
Deficiencies cited: 4
Plan of Correction Due Date: Dec 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Administrator | Facility administrator involved in the investigation and exit interview |
Inspection Report
Census: 84
Capacity: 210
Deficiencies: 0
Date: Nov 9, 2022
Visit Reason
This unannounced site visit was made for the purpose of a case management visit to amend a prior report dated September 24, 2022 regarding complaint control number 22-AS-20220823113818 and to address the plan of corrections for two deficiencies cited on that date.
Complaint Details
The visit was related to complaint control number 22-AS-20220823113818. The purpose was to amend the prior report and verify correction of two deficiencies cited on September 24, 2022. The deficiencies were reported as corrected.
Findings
The Executive Director indicated that the two deficiencies cited in the prior complaint report have been corrected. An exit interview was conducted and a copy of the report was provided to the Executive Director.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met during visit and indicated correction of deficiencies |
| Kathrina Chin | Licensing Program Analyst | Conducted the site visit |
| Sheila Santos | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 210
Deficiencies: 3
Date: Oct 13, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations received on 02/28/2022 regarding resident care issues including injuries, rough handling, insufficient staff, and inadequate cleaning.
Complaint Details
The complaint was substantiated based on a preponderance of evidence. Allegations included resident sustaining multiple injuries, rough handling by staff, insufficient staffing, inadequate incontinent care, and unclean living conditions. One allegation about staff not feeding the resident was found to be unfounded.
Findings
The investigation substantiated several allegations including that a resident sustained multiple skin tears due to improper care and rough handling by staff, insufficient staffing to provide required two-person lifts, inadequate incontinent care, and failure to clean the resident's room and bathroom. One allegation regarding failure to feed the resident was found to be unfounded.
Deficiencies (3)
Facility personnel were not sufficient in numbers and competent to provide necessary services, resulting in resident sustaining three skin tears due to improper care and transfers.
Licensee did not ensure adequate care and supervision; resident did not receive regular incontinent care and proper showers, and was forgotten for a breakfast meal.
Facility was not clean, safe, sanitary, and in good repair; resident's apartment unit was not cleaned on February 22, 2022.
Report Facts
Capacity: 210
Census: 78
Plan of Correction Due Date: Oct 14, 2022
Plan of Correction Due Date: Oct 20, 2022
Number of stitches: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the investigation |
| Heather Yost | Administrator | Facility administrator named in the report and responsible for submitting plans of correction |
Inspection Report
Census: 75
Capacity: 210
Deficiencies: 2
Date: Sep 29, 2022
Visit Reason
This unannounced site visit was made for the purpose of a case management visit following a substantiated complaint dated 09/01/2022.
Complaint Details
Complaint control number 22-AS-20220826102143 was substantiated on 09/01/2022, leading to the citation of two deficiencies.
Findings
Two deficiencies were cited on Section 87311 and Section 87468.1(a), initially classified as Type A violations but later lowered to Type B violations after an amended report was provided.
Deficiencies (2)
Deficiency cited on Section 87311
Deficiency cited on Section 87468.1(a)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the visit and received the amended report. |
| Kathrina Chin | Licensing Program Analyst | Conducted the visit and substantiated the complaint. |
| Sheila Santos | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 210
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not respond to a resident call button and did not adequately assist the resident with showering.
Complaint Details
The complaint involved allegations that staff did not respond to a resident call button and did not adequately assist the resident with showering. The allegations were found unsubstantiated after investigation, including interviews and record reviews.
Findings
The investigation found that the resident fell and was assisted appropriately by staff, and that the resident was independent in bathing and showering. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 210
Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the investigation |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 210
Deficiencies: 2
Date: Sep 23, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including roaches in a resident's room, facility cleanliness issues, disrepair of resident's closet and blinds, and unsecured front doors.
Complaint Details
The complaint investigation was substantiated for allegations of roaches in a resident's room, facility dirtiness, disrepair of resident's closet and blinds, and unsecured front doors. The allegation that staff did not ensure the resident had a key to lock her room was unfounded.
Findings
The investigation substantiated the allegations that the resident's room had roaches, the facility was dirty, the resident's closet and blinds were in disrepair, and staff did not ensure the front doors were locked for resident safety. One allegation regarding a resident not having a key to lock her room was found to be unfounded.
Deficiencies (2)
Personal Right of Residents in all Facilities - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Witness observed the front door to be unlocked at 10:17 PM on August 18, 2022.
Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Resident's room was observed to be dirty and had two roaches. Resident's closet door was off track and difficult to open. Two blinds were missing on the sliding door blinds.
Report Facts
Capacity: 210
Census: 75
Deficiency Type A: 1
Deficiency Type B: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative met during investigation and exit interview |
| Sheila Santos | Licensing Program Manager | Oversaw the licensing program and signed the report |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
| Building Services Director | Interviewed regarding key issuance to resident |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 210
Deficiencies: 1
Date: Sep 23, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not assisting residents in a timely manner.
Complaint Details
The complaint investigation was substantiated. Residents reported long wait times for staff assistance, with some waiting up to one hour. The malfunctioning auditory call system was identified as the cause of delayed staff response.
Findings
The investigation substantiated that staff were not assisting residents promptly due to a malfunctioning auditory call system installed on November 8, 2021, which caused delays in staff response to resident calls for assistance.
Deficiencies (1)
Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floor or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement is not being met as evidenced by interviews, file review, and observation. The new auditory call system installed on November 8, 2021 was not working properly causing delays for staff to respond to residents requesting assistance, posing an immediate health and safety risk.
Report Facts
Capacity: 210
Census: 75
Deficiency Type: 1
Plan of Correction Due Date: Sep 26, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Yost | Executive Director | Named in relation to the auditory call system malfunction and efforts to fix it |
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 210
Deficiencies: 1
Date: Sep 22, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 08/30/2022 regarding medication technicians not being properly trained and staff not administering residents' medication as prescribed.
Complaint Details
The complaint investigation was substantiated for the allegation that medication technicians are not properly trained. The allegation that staff are not administering resident's medication as prescribed was unsubstantiated.
Findings
The allegation that medication technicians are not properly trained was substantiated based on observations and interviews, including a new medication technician failing to keep the medication cart with her and not knowing resident details. The allegation that staff are not administering medication as prescribed was found unsubstantiated after review and interviews.
Deficiencies (1)
Facility personnel failed to demonstrate competency in dispensing medications as Staff 1 did not know the name of the resident or room number and left the medication cart unattended, posing an immediate health and safety risk.
Report Facts
Capacity: 210
Census: 85
Civil penalty: 421
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Sarah Cleesen | Administrator | Facility administrator named in report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 210
Deficiencies: 2
Date: Sep 22, 2022
Visit Reason
An unannounced complaint investigation was conducted following allegations that the facility mismanaged a resident's medication and failed to provide competent staff to meet resident needs.
Complaint Details
The complaint investigation was substantiated based on evidence that a medication technician gave the wrong medications to a resident and failed to use the medication cart with laptop to verify medications. The facility failed to provide competent staff to meet resident needs.
Findings
The investigation substantiated that a medication technician gave a resident another resident's medications due to medication carts being labeled by room number only, posing an immediate health and safety risk. The facility staff failed to demonstrate competency in medication dispensing.
Deficiencies (2)
Facility gave resident another resident's medication not authorized by physician, posing immediate health and safety risk.
Facility personnel were insufficient and incompetent to meet resident needs, as evidenced by medication dispensing errors.
Report Facts
Facility capacity: 210
Resident census: 85
Plan of Correction due date: Sep 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst and provided statements regarding medication technician training and corrective actions |
| Sarah Cleesen | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 210
Deficiencies: 0
Date: Sep 22, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of lack of care and supervision resulting in a resident falling.
Complaint Details
The complaint was investigated and determined to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis. Resident 1 was interviewed and staff actions were verified.
Findings
The investigation found that Resident 1 fell multiple times due to weakness and balance issues, staff promptly called 911 emergency personnel, and the complaint was determined to be unfounded as the allegation was false or without reasonable basis.
Report Facts
Facility capacity: 210
Resident census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Melanie Washington | Executive Director | Met with Licensing Program Analyst during investigation and received report |
| Stephanie Guerrero | Resident Care Coordinator | Interviewed during investigation |
| Jessica Thielmann | Resident Care Director | Interviewed during investigation |
| Julie Sanchez | Activities Director | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 210
Deficiencies: 1
Date: Sep 6, 2022
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not provide resident records to the resident's authorized person.
Complaint Details
The complaint alleging that staff did not provide resident records to the resident's authorized person was substantiated after investigation. The preponderance of evidence standard was met.
Findings
The allegation that staff did not provide resident records to the resident's authorized person was substantiated based on observations, document review, and interviews. The facility failed to provide the August invoice to the resident's responsible party despite multiple requests, posing a potential health and safety risk.
Deficiencies (1)
Resident Records- The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not being met as evidenced by failure to provide the August invoice to the resident's responsible party after multiple requests.
Report Facts
Capacity: 210
Census: 87
Plan of Correction Due Date: Sep 12, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Facility representative interviewed during investigation and named in findings |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 210
Deficiencies: 1
Date: Sep 1, 2022
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not ensure the facility was free from pests.
Complaint Details
The complaint was substantiated based on observations and interviews. Staff and a witness reported roach sightings in the kitchen, bathroom, Bistro area, and resident apartments. The Building Services Director acknowledged the issue and scheduled extermination services.
Findings
The investigation substantiated the allegation that the facility was not free from pests, with multiple staff and a witness reporting roach sightings in various areas of the facility. A deficiency was cited for failure to maintain a clean, safe, and sanitary environment.
Deficiencies (1)
Maintenance & Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met as evidenced by observed roaches in the kitchen area, several apartment units, and the Bistro area, posing an immediate health & safety risk to residents.
Report Facts
Capacity: 210
Census: 87
Deficiencies cited: 1
Plan of Correction Due Date: Sep 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melanie Washington | Executive Director | Interviewed during investigation; acknowledged pest issue and plan of correction |
| Sarah Cleesen | Administrator | Facility administrator named in the report |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
| Staff 3 | Building Services Director | Reported seeing roaches in several resident apartments and scheduled extermination services |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 210
Deficiencies: 2
Date: Sep 1, 2022
Visit Reason
The inspection was an unannounced visit to investigate a complaint received on 2022-08-26 regarding the facility not having a working telephone on the premises and the back entrance being unlocked at night.
Complaint Details
The complaint was substantiated based on interviews and observations. The facility did not have working telephones on August 25, 2022, and the back entrance was unlocked and propped open at night, posing immediate health and safety risks.
Findings
The investigation substantiated the allegations that the facility phones were not working on August 25, 2022, due to staff forgetting to charge cordless phones, and that the back entrance was unlocked and propped open by a rock at night, posing an immediate health and safety risk to residents.
Deficiencies (2)
Telephones- All facilities shall have telephone service on the premises. This requirement is not being met as evidenced by staff forgetting to charge cordless telephones on August 25, 2022.
Personal Right of Residents in all Facilities- To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The back entrance was unlocked and propped open on the evening of August 25, 2022.
Report Facts
Capacity: 210
Census: 87
Deficiencies cited: 2
Plan of Correction Due Date: Sep 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Interviewed regarding telephone service and back entrance security deficiencies |
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Census: 85
Capacity: 210
Deficiencies: 0
Date: Aug 3, 2022
Visit Reason
The visit was an unannounced Case Management visit conducted to inform the Executive Director of the facility's overdue annual fees and to provide payment instructions.
Findings
No deficiencies were issued during this Case Management visit. The Executive Director was provided with a copy of the Facility Transaction History and payment instructions for the overdue fees.
Report Facts
Facility fees payment deadline: 5
Complaint control numbers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Washington | Executive Director | Met during the Case Management visit and informed about overdue fees |
| Patricia Velazquez | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Sheila Santos | Licensing Program Manager | Named in the report header |
Inspection Report
Follow-Up
Census: 90
Capacity: 210
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
This informal conference was conducted virtually to discuss proof of corrections for a recent visit to the facility as well as concerns and deficiencies issued to the facility.
Findings
The facility was found to have staffing issues impacting assistance to residents with activities of daily living, including missed medications, absence of showers, missed laundry, dining, and housekeeping. The licensee agreed to provide a staffing plan and updated personnel reports, and the Department will conduct additional visits over the next six months.
Report Facts
Capacity: 210
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Marty | Vice President of Operations | Met during the informal conference and discussed staffing issues |
| Melanie Washington | Executive Director | Met during the informal conference and discussed staffing issues |
Inspection Report
Census: 90
Capacity: 210
Deficiencies: 0
Date: Jul 25, 2022
Visit Reason
The visit was a case management follow-up on an incident report received by the Regional Office dated July 13, 2022, regarding an incident that occurred on July 1, 2022.
Findings
No deficiencies were observed during the visit. The resident involved in the incident was present and interviewed. An exit interview was conducted and a copy of the report was provided to the Business Office Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Nino | Business Office Director | Met with Licensing Program Analyst and Ombudsman during the visit and received a copy of the report. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 210
Deficiencies: 2
Date: Jun 30, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2022-06-21 regarding insufficient staffing and failure to provide assistance with medications as prescribed.
Complaint Details
The complaint alleged insufficient staff and failure to provide medication assistance. The investigation found these allegations substantiated based on interviews, observations, and documentation. The preponderance of evidence standard was met.
Findings
The investigation substantiated that the facility did not have sufficient staff and failed to assist thirty-eight residents with their morning medications on June 19, 2022. The facility acknowledged the staffing shortage and the missed medications, which posed an immediate health and safety risk to residents.
Deficiencies (2)
Licensee did not assist residents with self-administered medications for thirty-eight residents on June 19, 2022 morning medications.
Facility personnel were not sufficient in numbers and competent to provide the services necessary to meet resident needs.
Report Facts
Residents who missed morning medications: 38
Facility capacity: 210
Census: 91
Plan of Correction due date: Jul 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit. |
| Joan Johnson | Interim Executive Director | Provided information about staffing and medication issues during investigation. |
| Chantelle Hudson | Nurse Consultant | Provided list of residents who missed medications and informed doctors. |
| Allison Marty | Vice President of Operations | Stated that a Plan of Correction will be submitted and additional staff will be hired. |
Inspection Report
Follow-Up
Census: 83
Capacity: 210
Deficiencies: 0
Date: May 9, 2022
Visit Reason
This unannounced case management visit was conducted to follow up on a death reported to Community Care Licensing on 05/02/22 for a resident who died on 05/01/22.
Findings
During the visit, documents related to the deceased resident were reviewed and staff were interviewed. No deficiencies were cited based on the information available at the time of the review.
Report Facts
Capacity: 210
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Cleesen | Executive Director | Met with Licensing Program Analyst during the visit and provided information about the resident and incident |
| Kathrina Chin | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 87
Capacity: 210
Deficiencies: 0
Date: May 9, 2022
Visit Reason
Licensing Program Analyst Kathrina Chin conducted an unannounced required annual inspection of the Sunnycrest Senior Living Facility to assess compliance with regulatory standards.
Findings
The facility was found to be in good repair with operational safety alarms, adequate food stock, and proper infection control measures. No deficiencies were cited during this review as per Title 22 of the California Code of Regulations.
Report Facts
Staff members on floor: 16
Hot water temperature: 118.4
PPE supply: 30
First aid kits: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathrina Chin | Licensing Program Analyst | Conducted the annual inspection and exit interview |
| Sarah Cleesen | Executive Director | Facility administrator met during inspection and exit interview |
Inspection Report
Follow-Up
Census: 85
Capacity: 210
Deficiencies: 0
Date: Apr 25, 2022
Visit Reason
This unannounced case management visit was conducted as a follow-up to an incident report regarding a resident's death on 12/5/2021.
Findings
No deficiencies were cited based on the information available at the time of the visit per Title 22 of the California Code of Regulations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Cleesen | Executive Director | Met with Licensing Program Analyst during the visit and discussed the incident report. |
| Kathrina Chin | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Sheila Santos | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 210
Deficiencies: 1
Date: Nov 18, 2021
Visit Reason
This unannounced case management visit was conducted to follow up on an incident reported on 11/9/2021 regarding multiple falls concerning resident 1.
Complaint Details
Visit was complaint-related following a report on 11/9/2021 about multiple falls concerning resident 1. The facility did not report the incident to the licensing agency within the required timeframe.
Findings
The facility failed to report the incident within seven days when resident 1 sustained an unwitnessed fall on 11/9/2021 and 911 emergency personnel was contacted. A deficiency was cited for this failure as per Title 22 of the California Code of Regulations.
Deficiencies (1)
Failure to report the incident within seven days of the fall when resident 1 sustained an unwitnessed fall on 11/9/2021 and 911 emergency personnel was contacted.
Report Facts
Census: 87
Total Capacity: 210
Deficiency Type Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Yost | Executive Director | Met with Licensing Program Analyst during the visit and involved in the incident discussion |
| Kathrina Chin | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the case |
Inspection Report
Follow-Up
Census: 87
Capacity: 210
Deficiencies: 1
Date: Nov 18, 2021
Visit Reason
This unannounced case management visit was conducted to follow up on an incident reported on 11/9/2021 regarding multiple falls concerning a resident.
Findings
The facility failed to report the incident to the licensing agency within seven days after a resident fell and hit the back of her head on the bed rails, and 911 emergency was not contacted within seven days of the occurrence. A deficiency was cited for this failure to report.
Deficiencies (1)
Failure to report the incident within seven days when resident sustained an unwitnessed fall and 911 emergency personnel was contacted.
Report Facts
Deficiency citation count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Yost | Executive Director | Spoke with Licensing Program Analyst regarding the incident and visit |
| Kathrina Chin | Licensing Program Analyst | Conducted the unannounced case management visit and cited the deficiency |
| Sheila Santos | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 79
Capacity: 210
Deficiencies: 0
Date: Jun 30, 2021
Visit Reason
Licensing Program Analyst Michelle Reed made an unannounced visit to the facility to conduct an Annual visit.
Findings
The facility was found to be clean and sanitary with Covid precautions in place, including signage, sanitization stations, PPE supply, and screening procedures. No deficiencies were noted during the visit.
Report Facts
PPE supply: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Yost | Administrator | Met with Licensing Program Analyst during the visit |
| Michelle Reed | Licensing Program Analyst | Conducted the annual inspection visit |
| Sheila Santos | Licensing Program Manager | Named in report header |
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