Most inspections found no deficiencies, with the facility generally maintaining a clean, safe, and well-managed environment. Several complaint investigations were unsubstantiated, including allegations of inappropriate staff conduct, medication errors, and communication issues. One complaint investigation in May 2023 found a substantiated issue where staff failed to replace a toilet riser, leading to a resident fall, but no fines or enforcement actions were listed in the available reports. The most recent inspection on July 30, 2025, issued only one minor technical advisory related to emergency food storage, indicating continued compliance with licensing requirements. Overall, the facility’s record shows mostly isolated and minor issues with no clear pattern of worsening or severe deficiencies.
The inspection was an unannounced annual inspection conducted by Licensing Program Analyst Yolanda Delgado to assess compliance with licensing requirements.
Findings
The facility met documentation requirements for resident and employee records, maintained a safe and clean environment, and complied with physical plant and safety regulations. One Technical Advisory was issued related to emergency food storage.
Deficiencies (1)
Description
One (1) Technical Advisory issued per Title 22, Division 6 of The California Code of Regulations.
Report Facts
Capacity: 88Census: 71Fire extinguisher last tested: Dec 19, 2024Last disaster drill: Jun 12, 2025
Employees Mentioned
Name
Title
Context
Heather Segura
Administrator
Met with Licensing Program Analyst during inspection and reviewed report findings
The visit was an unannounced complaint investigation triggered by an allegation received on 2024-10-07 that staff inappropriately touched a resident during care.
Findings
The investigation included interviews, record reviews, and observations. The allegation that staff inappropriately touched a resident was found to be unsubstantiated due to insufficient evidence, with the resident and staff denying inappropriate contact, though the resident felt uncomfortable due to the staff member's gender.
Complaint Details
The complaint alleged that Staff Number 1 inappropriately touched Resident Number 1 during a diaper change, making the resident uncomfortable. Interviews with the resident, staff, and other residents, as well as a police report, did not substantiate the allegation. The facility made policy changes to ensure resident comfort and safety.
Report Facts
Capacity: 88Census: 63
Employees Mentioned
Name
Title
Context
Heather Segura
Administrator
Met during investigation and involved in interviews regarding the complaint
The inspection was an unannounced Required One Year Annual inspection conducted to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean, orderly, and well-maintained with no Title 22, Division 6 Regulation violations observed or cited. Medication storage, food service, care and supervision, and records were all in compliance.
Report Facts
Hospice waiver residents: 19Staff count: 10
Employees Mentioned
Name
Title
Context
Heather Segura
Administrator
Met with Licensing Program Analyst during inspection and named in report
An unannounced complaint investigation was conducted to investigate allegations that facility staff were not responding promptly to communications from resident representatives.
Findings
The investigation found conflicting information from resident representatives and staff interviews. The Licensing Program Analyst was able to contact the facility phone and found that staff assist the resident with phone calls. The allegation that staff were not responding promptly was unsubstantiated.
Complaint Details
The complaint alleged that staff were not responding to communications from Resident #1's representatives, resulting in no communication for several weeks. The investigation found conflicting statements but ultimately determined the allegation was unsubstantiated.
Report Facts
Capacity: 88Census: 70
Employees Mentioned
Name
Title
Context
Heather Segura
Administrator
Met with Licensing Program Analyst during the investigation and named in the report
Licensing Program Analyst Janette Romero conducted an unannounced visit to the facility for a required annual inspection.
Findings
The facility was toured and inspected, including interior and exterior areas, fire safety systems, food storage, medication security, and resident accommodations. No deficiencies were observed during this visit.
Report Facts
Hospice residents: 13Hospice waiver capacity: 20Number of cottages: 3Number of cottages for assisted living: 2Number of cottages for memory care: 1Number of bedridden residents allowed: 3
Employees Mentioned
Name
Title
Context
Heather Segura
Administrator
Met with Licensing Program Analyst during inspection and discussed report
Unannounced complaint investigation visit conducted due to multiple allegations received regarding resident care issues including falls, medication mishandling, and failure to assist residents properly.
Findings
The investigation found one allegation substantiated regarding a resident fall caused by staff forgetting to replace a toilet riser, while all other allegations including multiple fractures, staff causing falls, delayed response to alerts, medication mishandling, toileting assistance failure, and feeding issues were unsubstantiated due to lack of evidence or witnesses.
Complaint Details
The complaint investigation was triggered by multiple allegations including resident sustaining multiple fractures, staff causing falls, failure to respond timely to alerts, medication mishandling, failure to assist with toileting, and failure to ensure proper feeding. The complaint was partially substantiated with one finding related to a fall caused by staff negligence; all other allegations were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Facility personnel did not ensure the riser was placed on the toilet to prevent resident from falling, which is a potential health, safety, personal rights violation.
Type B
Report Facts
Capacity: 88Census: 66Call button activations: 9Response times: 18Response times: 16Plan of Correction Due Date: May 19, 2023
Employees Mentioned
Name
Title
Context
Heather Segura
Executive Director
Met with Licensing Program Analyst during investigation
Rayshaun Nickolas
Licensing Program Analyst
Conducted complaint investigation and authored report
Karen Clemons
Licensing Program Manager
Oversaw complaint investigation
Shaunte Henry
Licensing Program Analyst
Initiated ten-day telephone complaint investigation due to COVID-19 protocols
S1
Staff who admitted forgetting to replace toilet riser leading to resident fall
S2
Staff who failed to notice toilet riser was missing leading to resident fall
S3
Staff escorting resident during alleged fall incident
An unannounced complaint investigation was conducted due to allegations that the licensee was not following infection control requirements and not providing residents with healthful accommodations.
Findings
The Licensing Program Analyst found no infection control concerns upon inspection, no feces or blood was found, and the resident's room was in immaculate order. Conflicting accounts of the incident were reported with no other witnesses present, resulting in the allegations being unsubstantiated.
Complaint Details
The complaint was unsubstantiated. Although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur.
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility was administering medication without a prescription.
Findings
The investigation found that the facility had a valid prescription for the THC/CBD oil administered to Resident One, and the allegation was determined to be unfounded.
Complaint Details
The complaint alleging the facility was administering medication without a prescription was investigated and found to be unfounded, meaning the allegation was false and without reasonable basis.
Report Facts
Facility capacity: 88Census: 66
Employees Mentioned
Name
Title
Context
Jesse Gardner
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Heather Segura
Executive Director
Facility representative who received the report
Eden Rivera
Business Office Coordinator
Met with Licensing Program Analyst during the investigation
The visit was an unannounced required annual inspection with emphasis on infection control.
Findings
The Licensing Program Analyst observed sufficient hand hygiene supplies, cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead responsible for tracking COVID-19 cases and maintaining PPE and cleaning supplies.
An unannounced annual inspection was conducted with an emphasis on infection control to assess compliance with Community Care Licensing guidelines.
Findings
The facility was found to have adequate infection control measures including proper PPE use, cleaning protocols, and staff training. No deficiencies were cited during the inspection.