Most inspections found no deficiencies, including the most recent annual inspection on May 21, 2025, which was clean with no citations. Earlier reports showed some issues, notably a substantiated complaint in November 2023 where neglect led to a resident developing a severe pressure injury, and a March 2023 visit that cited the facility for retaining a resident with a prohibited health condition and administrative lapses. Other deficiencies involved plumbing disrepair causing lack of hot water in late 2021, but the majority of complaint investigations, including those about staffing and refund delays, were unsubstantiated. The facility appears to have improved over time, with recent inspections showing no deficiencies after earlier problems. Minor or isolated issues were otherwise noted, with no fines or enforcement actions listed in the available reports.
An unannounced annual required visit was conducted focusing primarily on infection control measures and using the new CARE Inspection Tool to review 12 domains including infection control, staffing, resident rights, food service, and emergency preparedness.
Findings
The facility was found to be in compliance with all audited Title 22 regulated areas including bedrooms, bathrooms, kitchen and food service, medication storage, common areas, safety equipment, emergency preparedness, environmental safety, staff training, and administrative compliance. No deficiencies were cited during the inspection.
Report Facts
Hot water temperature: 113.3Fire drill date: May 8, 2025
Employees Mentioned
Name
Title
Context
Anita Csukardi
Executive Director
Met with Licensing Program Analyst during inspection and received the Facility Evaluation Report
The inspection was an unannounced Required-1-year annual visit conducted to assess compliance with regulatory standards and facility conditions.
Findings
The facility was found to be in good repair with clean, clear, and hazard-free walkways and bathrooms. All required documentation, medications, and safety equipment were in order. No deficiencies or citations were observed during the inspection.
The inspection visit was conducted as a complaint investigation regarding an allegation that a resident sustained a pressure injury while in care.
Findings
The investigation found that due to neglect and lack of supervision, Resident #1 developed an unstageable pressure injury on the coccyx while in care. The allegation was substantiated based on records review, staff interviews, and evidence gathered.
Complaint Details
The complaint investigation was substantiated. The allegation was that a resident sustained a pressure injury while in care. The investigation confirmed neglect/lack of supervision leading to the injury. An enhanced civil penalty determination is pending related to serious bodily injury.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to provide wound care and repositioning for Resident #1's coccyx pressure injury between 5/23/2020 and 5/30/2020, resulting in progression to a Stage 4 pressure injury.
Type A
Report Facts
Capacity: 142Census: 78Deficiency count: 1Plan of Correction Due Date: Nov 3, 2023
Employees Mentioned
Name
Title
Context
Eric Mensah
Administrator
Named in relation to the complaint investigation and exit interview
An unannounced required annual visit was conducted using the full CARE tools to evaluate compliance with regulations and facility conditions.
Findings
The facility was found to be in good repair with clean and sanitary conditions throughout. No deficiencies or citations were observed during the inspection. Residents and staff interviews were positive.
Report Facts
Fire extinguishers: 12Resident files reviewed: 5Staff files reviewed: 5Medications reviewed: 5Beds: 94Bathrooms: 99Fire alarm last inspected: Mar 11, 2023Emergency drill last conducted: Mar 24, 2023PPE supply duration: 90Perishable food supply duration: 3Nonperishable food supply duration: 7
Employees Mentioned
Name
Title
Context
Eric K Mensah
Executive Director
Met with Licensing Program Analyst and participated in exit interview
An unannounced case management visit was conducted to investigate deficiencies related to retaining a resident with a prohibited health condition and to discuss exception requests.
Findings
Deficiencies were cited for retaining a resident with an unstageable pressure injury, which is a prohibited health condition, and for the administrator's failure to timely request an exception as required by Title 22 regulations.
Severity Breakdown
Type B: 2
Deficiencies (2)
Description
Severity
Retaining resident R1 with an unstageable pressure injury, a prohibited health condition.
Type B
Administrator failed to adhere to Title 22 regulations and failed to timely request an exception for a prohibited health condition.
Type B
Report Facts
Capacity: 142Census: 71
Employees Mentioned
Name
Title
Context
Eric K Mensah
Administrator
Named in relation to deficiencies and during the visit
Jeremiah Randle
Licensing Program Analyst
Conducted the inspection visit and authored the report
An unannounced annual required and infection control visit was conducted to evaluate compliance with regulations and infection control practices at the facility.
Findings
The facility was found to be in good repair with no deficiencies observed. Infection control practices were adequate, including sanitizing stations, PPE availability, and staff mask usage. No citations or technical advisories were issued.
A Case Management visit was initiated to investigate an incident report and Death Report regarding a resident's passing on 3/12/22.
Findings
The Licensing Program Analyst conducted interviews, reviewed relevant documents, and toured the facility. No deficiencies were observed during the health and safety check, but additional time is needed to complete the investigation.
Employees Mentioned
Name
Title
Context
Martessa Brown
Licensing Program Analyst
Conducted the case management visit and investigation.
Janelle Odishoo
Administrator
Met with Licensing Program Analyst and participated in the investigation.
Lennora Folkes
Resident Care Director
Assisted with the health and safety check during the visit.
The visit was an unannounced complaint investigation triggered by a complaint received on 12/09/2020 regarding facility plumbing being in disrepair and staff mishandling residents' personal belongings.
Findings
The investigation substantiated the allegation that the facility plumbing was in disrepair, resulting in residents lacking hot water for a substantial time without proper notification to the licensing agency. The allegation regarding mishandling of residents' personal belongings was found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that facility plumbing was in disrepair causing lack of hot water affecting residents. The allegation that staff mishandled residents' personal belongings was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Maintenance & Operation 8703(a): The facility was not clean, safe, sanitary, and in good repair as residents did not have hot water for a substantial amount of time and CCLD was not notified of the incident.
Type B
Report Facts
Capacity: 142Census: 80Deficiency count: 1Plan of Correction Due Date: Nov 9, 2021
Employees Mentioned
Name
Title
Context
Travis Morris
Administrator
Interviewed regarding plumbing issues and incident reporting
Janelle Odishoo
Facility Administrator
Met with Licensing Program Analyst during investigation
Ami Mehta
Resident Care Director
Met with Licensing Program Analyst during investigation
The inspection was conducted as an unannounced complaint investigation following a complaint received on 03/26/2021 alleging insufficient staff numbers to meet residents' needs.
Findings
The investigation included interviews and record reviews and found that the facility had sufficient staff for all shifts, including a newly hired coordinator for the memory care unit. Residents interviewed reported their needs were being met, and staff schedules confirmed adequate staffing. The allegation was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff were not sufficient in numbers to provide necessary services to meet residents' needs. The investigation found no evidence to substantiate this allegation, and it was determined unsubstantiated.
Report Facts
Capacity: 142Census: 76Staff shifts: 3
Employees Mentioned
Name
Title
Context
Travis Morris
Executive Director
Interviewed during investigation and exit interview
An unannounced complaint investigation was conducted regarding the allegation that staff failed to issue a refund to a resident who vacated the unit.
Findings
The investigation found that the refund process was delayed due to errors on the move-out form, but the refund was eventually processed and sent to the resident's family. There was no preponderance of evidence to prove the alleged violation, so the allegation was unsubstantiated.
Complaint Details
The complaint alleged that staff failed to issue a refund to a resident who vacated the facility. The allegation was found to be unsubstantiated after investigation revealed the refund was delayed due to paperwork errors but was ultimately issued and received.
Report Facts
Capacity: 142Census: 79
Employees Mentioned
Name
Title
Context
Travis Morris
Administrator
Interviewed regarding refund process and investigation findings
Ami Mehta
Resident Care Director
Participated in telephonic complaint investigation and exit interview
Jey Cardenas
Licensing Program Analyst
Conducted complaint investigation and authored report
Angela J Kendrick
Licensing Program Manager
Oversaw complaint investigation
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