Inspection Report Summary
Most inspections found no deficiencies, with the most recent report on October 11, 2025, showing no deficiencies though the inspection was not completed due to time constraints. Earlier complaint investigations were mostly unsubstantiated, except for one in June 2022, when staff were found to have restrained a resident in a way that posed a health and safety risk, resulting in a deficiency. Other issues noted in past inspections included minor food safety concerns, such as expired perishable items, which were addressed during visits. The facility showed improvement over time, with recent annual inspections consistently clean and no enforcement actions or fines listed in the available reports. Overall, the facility has maintained compliance with regulations and addressed isolated concerns as they arose.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 87
Capacity: 124
Deficiencies: 0
Oct 11, 2025
Visit Reason
An unannounced site visit was made for an annual inspection of the facility to evaluate compliance with licensing requirements.
Findings
The facility was inspected for fire safety, personal accommodations and services, food service, and medication procedures. No deficiencies were observed during the visit, but the inspection was not completed due to time constraints and will be continued at a later date.
Report Facts
Water temperature range: 111
Water temperature range: 118
Units inspected: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the unannounced site visit and inspection |
| Edith Kennedy | Administrator/Director | Met with Licensing Program Analyst during inspection |
| Zinnia Martinez | Staff | Assisted with physical plant tour during inspection |
| Desaree Perera | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 92
Capacity: 124
Deficiencies: 0
Sep 12, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure there are no health and safety hazards.
Findings
The facility was found to be in compliance with no deficiencies cited at the time of the visit. The kitchen was inaccessible to residents, appliances were operable, and food storage was proper. Safety equipment such as smoke detectors, fire extinguishers, and emergency evacuation chairs were operational and up to date. Resident rooms and restrooms were clean and properly furnished. The annual inspection was not fully completed due to time constraints and will continue on a follow-up visit.
Report Facts
Fire extinguisher last serviced date: Oct 3, 2023
Fire alarm and sprinkler inspection date: Jan 8, 2024
Number of resident bedrooms inspected: 8
Number of interviews conducted: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edith Kennedy | Executive Director | Met with Licensing Program Analyst during inspection |
| Brian Balisi | Licensing Program Analyst | Conducted the inspection visit |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 85
Capacity: 124
Deficiencies: 0
Oct 13, 2023
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure health and safety standards.
Findings
The facility was found to be generally compliant with regulations, with clean and functional kitchen and common areas, properly furnished bedrooms and bathrooms, adequate infection control measures, and no medication errors observed. However, some perishable food items were found past their expiration dates and were discarded during the visit. No deficiencies were issued.
Report Facts
Expired food items: 4
Bedrooms inspected: 10
Resident records reviewed: 5
Personnel records reviewed: 5
Fire extinguisher last serviced: Oct 3, 2023
Fire and earthquake drills last conducted: Oct 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zachary Howell | Executive Director | Met with Licensing Program Analysts during inspection and involved in facility tour |
| Teresa Camara | Licensing Program Analyst | Conducted inspection and authored report |
| Martha Arroyo | Licensing Program Analyst | Conducted inspection |
| Desaree Perera | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 79
Capacity: 124
Deficiencies: 0
Aug 25, 2022
Visit Reason
The visit was an unannounced required annual inspection with an emphasis on infection control practices and procedures, conducted in conjunction with local and state health departments.
Findings
The facility was found to be in compliance with Title 22 regulations, with clean and safe common areas, adequate infection control measures, and no deficiencies cited. Due to current COVID-19 positive cases, dining was suspended and meals were delivered to residents' rooms. Staff were reminded to observe proper disinfecting contact times and additional training was recommended.
Report Facts
Facility capacity: 124
Resident census: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Zak Howell | Executive Director | Met with inspection team during the visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 124
Deficiencies: 1
Jun 28, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were restraining a resident in care.
Findings
The investigation substantiated that staff restrained Resident #1 by leaving their pants around their ankles and placing a pillow between their legs, which restricted movement and constituted unintentional restraint. Staff confirmed repositioning every two hours and use of heel protectors, but the incident on 06/05/2022 violated safe and comfortable accommodations.
Complaint Details
The complaint alleged that staff were restraining a resident by placing them in bed facing the wall, pulling their pants to their ankles, and placing a pillow between their knees. The allegation was substantiated based on interviews, observations, and record review.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to afford Resident #1 safe and comfortable accommodations as they were restrained on at least one occasion, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 124
Census: 74
Deficiency Type: 1
Plan of Correction Due Date: Jun 30, 2022
Training Completion Date: Jul 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Zak Howell | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 124
Deficiencies: 0
Aug 23, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not providing a comfortable environment for residents, specifically concerning residents smoking on balconies and outside patios causing secondhand smoke to enter the facility.
Findings
The investigation found that the facility had designated smoking areas appropriately and had reminded staff, residents, and responsible parties of the smoking policy. Interviews with residents and staff did not corroborate the claim that smoke was entering the facility. The allegation was deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that residents were smoking on balconies and outside patios causing secondhand smoke to enter the facility, creating an uncomfortable environment. The allegation was investigated and found unsubstantiated based on interviews and observations.
Report Facts
Capacity: 124
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Zak Howell | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 124
Deficiencies: 0
Jul 13, 2021
Visit Reason
Unannounced Case Management visit conducted in response to an incident communicated to the Department on July 8, 2021 involving Resident #1.
Findings
No deficiencies were cited at the time of the visit. Further investigation is required.
Complaint Details
Visit was triggered by a complaint/incident involving Resident #1. Investigation is ongoing and no substantiation status is provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and interviews during the visit. |
| Zachary Howell | Executive Director | Reported the incident that triggered the visit and met with the Licensing Program Analyst. |
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