Inspection Reports for The Courte at Citrus Heights
6825 Sunrise Blvd, Citrus Heights, CA 95610, CA, 95610
Back to Facility ProfileInspection Report Summary
The facility’s most recent inspection on October 29, 2025, found no deficiencies, continuing a trend of mostly clean reports in recent years. Past deficiencies have included medication administration errors, delayed refunds, and staffing shortages, some of which posed health and safety risks, with one civil penalty issued in 2020 related to inadequate supervision that contributed to a resident’s death. Several complaint investigations were unsubstantiated, and the facility has addressed issues such as staff training and safety protocols following incidents. The facility showed improvement over time, with no deficiencies noted in the last several inspections and appropriate responses to incidents like resident falls and abuse allegations. Overall, the record reflects isolated issues amid a generally compliant operation without recent enforcement actions or fines listed in the latest reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 38
Capacity: 48
Deficiencies: 0
Oct 29, 2025
Visit Reason
The inspection was an unannounced case management visit related to two incident reports submitted by the facility involving resident falls.
Findings
The facility responded appropriately to each fall incident, implementing safety protocols such as frequent checks and relocating a resident closer to staff. No deficiencies were issued in this report.
Report Facts
Incident reports: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Cobos | Administrator | Met with Licensing Program Analyst during the inspection and discussed incident reports. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced case management inspection. |
| Kashanna Nelson | Nurse | Discussed incident reports related to resident falls. |
| Diane Duey | Resident Care Coordinator | Discussed incident reports related to resident falls. |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 48
Deficiencies: 0
Aug 28, 2025
Visit Reason
The inspection was an unannounced case management visit related to two incident reports submitted by the facility, focusing on allegations of physical and verbal abuse.
Findings
The facility was observed to be clean and safe with no deficiencies noted. An internal investigation was underway regarding the alleged abuse, and staff involved was placed on administrative leave.
Complaint Details
The visit was triggered by two incident reports alleging physical and verbal abuse. The Administrator agreed to amend the report to reflect only physical abuse. The facility is conducting an internal investigation and placed the staff member on administrative leave. The Licensing Program Analyst attempted to interview the resident but obtained no significant information.
Report Facts
Incident reports: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Cobos | Administrator | Met with Licensing Program Analyst and Ombudsman during inspection; involved in discussion of incident reports and facility investigation |
| Sabrina Calzada | Licensing Program Analyst | Conducted the case management inspection |
| Byron Toliver | Ombudsman | Participated in the inspection and facility tour |
Inspection Report
Census: 38
Capacity: 48
Deficiencies: 0
Aug 19, 2025
Visit Reason
The inspection was a quarterly on-site case management inspection conducted pursuant to a Stipulation and Waiver and Order in effect from 8/19/2022 through 8/19/2025.
Findings
The facility was found to be in compliance with all required criteria including staffing ratios, medication audits, resident safety checks, and training documentation. No deficiencies were issued during this inspection.
Report Facts
Staffing ratio: 8
Caregivers on shift: 6
Capacity: 48
Census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Bollier | Administrator/Director | Facility Administrator named in the inspection |
| Brenda Cobos | Administrator | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in the report |
Inspection Report
Census: 38
Capacity: 48
Deficiencies: 1
May 15, 2025
Visit Reason
The inspection was an unannounced case management visit to address an outstanding balance due to the Department for unpaid annual fees, late fees, and probationary fees.
Findings
The facility had not paid all applicable and accrued licensing fees by the required date, posing a potential health and safety risk to residents. A citation was issued for failure to pay licensing fees, but the plan of correction was cleared on the day of the inspection.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to pay all applicable and accrued licensing fees by November 23, 2024, constituting grounds for denial or forfeiture of a license. | Type B |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: May 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met during inspection and discussed outstanding fees |
| Julia Wihl | Business Office Manager | Met during inspection and discussed outstanding fees |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection and issued citation |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 38
Capacity: 48
Deficiencies: 0
May 15, 2025
Visit Reason
The inspection was a quarterly on-site case management inspection conducted unannounced pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Licensing Program Analyst reviewed documentation including staffing schedules, medication audits, training records, and safety checks, and conducted a health and safety tour without observing any health or safety risks or personal rights violations. No citations were issued.
Report Facts
Staffing ratio: 8
Caregivers: 6
Capacity: 48
Census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection |
| Julia Wihl | Business Officer Manager | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in report |
Inspection Report
Census: 41
Capacity: 48
Deficiencies: 0
Apr 4, 2025
Visit Reason
The inspection was an unannounced case management visit conducted to review three recent incident reports involving residents at the facility.
Findings
The inspection found no deficiencies. Three residents were observed with various minor health issues related to falls, bruising, and skin redness, with appropriate care plans and monitoring in place.
Report Facts
Incident reports reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Named in relation to the inspection and phone exit interview |
| Julia Wihl | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Jasmine Juchniewicz | Health and Services Director | Met with Licensing Program Analyst during inspection and provided information on resident conditions |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Census: 40
Capacity: 48
Deficiencies: 0
Feb 5, 2025
Visit Reason
The inspection was a quarterly on-site case management inspection conducted pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Licensing Program Analyst conducted a health and safety tour and did not observe any health and safety risks or personal rights violations. Staffing ratios, medication audits, training, and safety drills were reviewed and found compliant. No citations were issued.
Report Facts
Staffing ratio: 8
Caregivers: 5
Capacity: 48
Census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection and discussed findings |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection and authored the report |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 48
Deficiencies: 1
Jan 24, 2025
Visit Reason
The inspection was conducted as a case management visit for two recent incident reports involving resident safety and staff compliance with protocols.
Findings
The inspection found that one resident was treated for seizures and another was found sitting in a wheelchair with a sling attached to a hoyer lift, which was not properly followed by staff. The staff member involved was placed on administrative leave and later left employment. A deficiency was cited for failure to ensure staff followed approved training protocols for using the hoyer lift, resulting in potential risk to residents.
Complaint Details
The visit was triggered by two incident reports: one involving a resident (R1) who had seizures and was treated with medication, and another involving a resident (R2) found sitting in a wheelchair with a sling attached to a hoyer lift improperly. The staff member (S1) involved was placed on administrative leave and left employment before the investigation was completed.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that staff (S1) followed approved training protocols in using the hoyer lift with resident (R2) on 1/8/25, resulting in potential risk to residents in care. | Type B |
Report Facts
Capacity: 48
Census: 40
Plan of Correction Due Date: Feb 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Contacted by phone for additional details regarding incidents |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection and signed the report |
| Maribeth Senty | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 40
Capacity: 48
Deficiencies: 0
Jan 17, 2025
Visit Reason
The visit was a virtual office meeting to discuss a pending change in the facility's ownership, the reasons for the change, and the next steps required by the Department to initiate a change in ownership for a new facility license.
Findings
No deficiencies were issued in this report. The meeting emphasized the requirement for the facility to issue a 60-day notice to residents about the ownership change and ongoing communication with the Department during the transition.
Report Facts
Notice period: 60
Notice submission timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Madeline Noble | Director of Finance | Met during the virtual office meeting and recipient of the report |
| Maribeth Senty | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Sabrina Calzada | Licensing Program Analyst | Named in the report as Licensing Program Analyst |
Inspection Report
Annual Inspection
Census: 42
Capacity: 48
Deficiencies: 0
Nov 19, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements.
Findings
The facility was found to be clean, in good repair, odor free, and well supplied. Resident files, medication management, and staff training were all in order. No deficiencies were observed during the inspection.
Report Facts
Residents on hospice: 14
Resident files reviewed: 6
Medications reviewed: 2
Staff files reviewed: 6
Fire extinguisher last serviced: Feb 2, 2024
Hot water temperature readings: 109
Hot water temperature readings: 112
Hot water temperature readings: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the annual inspection |
| Julia Wihl | Business Office Manager | Present during inspection and toured facility |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 42
Capacity: 48
Deficiencies: 0
Nov 14, 2024
Visit Reason
The inspection was a quarterly on-site case management inspection conducted pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Licensing Program Analyst conducted a health and safety tour and found no health or safety risks or personal rights violations. Documentation related to stipulation requirements, staffing, medication audits, training, and drills were reviewed and found in compliance. No citations were issued.
Report Facts
Water stations on site: 2
Training hours: 4
Inspection duration: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection |
| Julia Wihl | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Census: 42
Capacity: 48
Deficiencies: 0
Nov 14, 2024
Visit Reason
The inspection was an unannounced case management inspection conducted pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022, to follow up on a notice received regarding the property and discuss related compliance requirements.
Findings
No deficiencies were issued during this inspection. The Licensing Program Analyst discussed the notice with facility management and plans to follow up with the Director of Finance and Department management.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection and discussed inspection matters. |
| Julia Wihl | Business Office Manager | Discussed notice and inspection matters with Licensing Program Analyst. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced case management inspection. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 48
Deficiencies: 1
Sep 24, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the licensee did not provide the responsible party with a refund.
Findings
The investigation substantiated the allegation that the facility failed to issue a refund within 15 days after the resident's belongings were removed. A refund check was eventually issued on 09/24/2024 and sent by overnight mail to the responsible person.
Complaint Details
The complaint was substantiated. The allegation was that the licensee did not provide the responsible party with a refund. The resident passed on 07/20/2024, belongings were removed on 07/25/2024, and the refund was due by 08/09/2024. The refund was not issued timely but was sent on 09/24/2024.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to issue a refund within 15 days after the resident's belongings were removed from the facility, as required by California Code of Regulations, Title 22, Division 6, Chapter 8, Section 1569.652(c). | Type B |
Report Facts
Days refund overdue: 46
Refund period days: 6
Facility capacity: 48
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during investigation and provided information regarding refund. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Jasmine Juchniewicz | Health and Services Director | Met with Licensing Program Analyst during investigation. |
| Julia Wihl | Business Office Manager | Met with Licensing Program Analyst during investigation. |
Inspection Report
Census: 40
Capacity: 48
Deficiencies: 0
Sep 13, 2024
Visit Reason
The visit was an unannounced case management visit to confirm orders for immediate exclusion of an individual from all facilities.
Findings
The facility was informed of an immediate exclusion effective 09/13/2024, requiring removal of the individual S1 from any contact with clients and prohibiting physical presence in the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the unannounced case management visit and confirmed immediate exclusion orders. |
| Kylie Whitaker | Administrator/Director | Facility administrator named in the report header. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager in the report. |
| Hannah Pryor | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 48
Deficiencies: 1
Jul 9, 2024
Visit Reason
The inspection was an unannounced case management inspection related to missed medications for eight residents during June 2024, triggered by errors discovered in a medication audit.
Findings
The inspection found that medications were not administered as ordered for eight residents between 6/11/24 and 6/24/24, posing an immediate health and safety risk. No adverse reactions or harm were noted, and corrective actions including incident reporting, resident alerts, and physician notifications were completed.
Complaint Details
The visit was complaint-related due to missed medications for eight residents. The complaint was substantiated as evidenced by the deficiency issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medications were not administered as ordered for eight residents during the time frame 6/11/24 to 6/24/24, posing an immediate health and safety risk. | Type A |
Report Facts
Residents affected: 8
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the case management inspection |
| Kylie Whitaker | Administrator | Facility administrator involved in the inspection and findings |
| Julia Wihl | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Maribeth Senty | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 35
Capacity: 48
Deficiencies: 0
Jul 9, 2024
Visit Reason
The inspection was a quarterly on-site case management inspection conducted pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Licensing Program Analyst conducted a health and safety tour and observed no health and safety risks or personal rights violations. Documentation related to staffing, medication audits, high risk residents, door checks, elopement drills, and training was reviewed and found compliant. No citations were issued.
Report Facts
Capacity: 48
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection |
| Julia Wihl | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 48
Deficiencies: 0
Jul 9, 2024
Visit Reason
The inspection was conducted as a case management visit related to an incident report submitted regarding a resident exiting through a side exit door without proper alarm notification on 07/01/2024.
Findings
The investigation found that the first 30-second egress alarm did not alert staff pagers as expected, though the second alarm was heard and staff responded promptly. The resident was safely redirected without injury, and the alarm system was functioning correctly during the inspection. Follow-up training and care plan updates were conducted.
Complaint Details
The visit was triggered by a complaint/incident report about a resident exiting through a side door where the first alarm failed to alert staff pagers. The incident was isolated, and no deficiencies were issued.
Report Facts
Incident date: Jul 1, 2024
Alarm response time: 30
Inspection start time: 1530
Inspection end time: 1700
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kylie Whitaker | Administrator | Facility administrator involved in incident notification and inspection |
| Julia Wihl | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 36
Capacity: 48
Deficiencies: 0
May 22, 2024
Visit Reason
The inspection was an unannounced follow-up case management visit related to an incident report involving a resident who went to the hospital on 2024-05-11.
Findings
The facility was observed to be clean and odor free with residents participating in activities. Staffing was sufficient with a 1:8 ratio. No deficiencies were observed during the inspection.
Report Facts
Staffing ratio: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met during inspection and discussed incidents |
| Sabrina Calzada | Licensing Program Analyst | Conducted the follow-up case management inspection |
| Julia Wihl | Business Office Manager | Met during inspection and discussed incidents |
| Jasmine Juchniewicz | Health and Services Director | Met during inspection and discussed incidents |
Inspection Report
Census: 39
Capacity: 48
Deficiencies: 0
Apr 16, 2024
Visit Reason
The inspection was an unannounced quarterly on-site case management inspection conducted pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Licensing Program Analyst reviewed documentation including medication audits, high risk resident notes, door checks, elopement drills, and training records. No health or safety risks or personal rights violations were observed, and no citations were issued.
Report Facts
Capacity: 48
Census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection |
| Jasmine Juchniewicz | Health and Services Director | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Census: 39
Capacity: 48
Deficiencies: 0
Apr 16, 2024
Visit Reason
The inspection was an unannounced quarterly on-site case management inspection focused on several recent incident reports received or to be submitted to the Department.
Findings
The inspection discussed residents with pressure wounds and recent hospitalizations, staffing ratios due to rapid admissions growth, and found no deficiencies cited during the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection and discussed resident care and staffing. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced quarterly case management inspection. |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 39
Capacity: 48
Deficiencies: 0
Mar 26, 2024
Visit Reason
The inspection was an unannounced case management visit to discuss staffing level increases due to recent additional resident move-ins since around 02/28/2024.
Findings
The Licensing Program Analyst reviewed staffing schedules and confirmed new staff hires for all shifts, including caregivers, Med-Techs, and a nurse. There were no deficiencies cited in this report.
Report Facts
Additional residents moving in: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julia Wihl | Business Office Manager | Met with Licensing Program Analyst during inspection. |
| Jasmine Juchniewicz | Health and Services Director | Met with Licensing Program Analyst during inspection. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the case management inspection. |
| Maribeth Senty | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 48
Deficiencies: 0
Mar 1, 2024
Visit Reason
The inspection was an unannounced case management visit related to an incident reported on 2024-02-01 involving two residents, including a reported altercation and subsequent interventions.
Findings
The facility timely reported the incident to the Department, law enforcement, family members, and physicians. No injuries were sustained by the residents involved, and no deficiencies were issued. The facility took several interventions to prevent future altercations, and no subsequent incidents occurred.
Complaint Details
The visit was triggered by a complaint regarding an altercation between two residents on 2024-02-01 and a prior incident in January 2024. The complaint was not substantiated as the facility's report and third-party report contained differing information, and no injuries were found.
Report Facts
Incident report dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kylie Whitaker | Administrator | Facility administrator involved in the inspection and discussions |
Inspection Report
Census: 25
Capacity: 48
Deficiencies: 0
Jan 18, 2024
Visit Reason
The inspection was an unannounced quarterly on-site case management inspection conducted pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Licensing Program Analyst reviewed compliance documentation including medication audits, high risk resident notes, door checks, elopement drills, and training records. No health or safety risks or personal rights violations were observed, and no citations were issued.
Report Facts
Capacity: 48
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 48
Deficiencies: 0
Jan 18, 2024
Visit Reason
The inspection was an unannounced case management visit related to an incident reported on 2024-01-17 involving a resident's unwitnessed fall resulting in a hip fracture and surgery.
Findings
The report found no deficiencies. The resident who fell was a new resident considered a fall risk, with a faulty bed alarm. Another resident was placed on hospice after contracting Covid and Post Covid Syndrome.
Complaint Details
The visit was triggered by a complaint/incident report regarding a resident's fall on 2024-01-17, which resulted in hospitalization and surgery. The incident was documented and a report will be submitted by 2024-01-24.
Report Facts
Incident report submission deadline: 6
Hospice notification timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection and provided information about the incident and residents |
Inspection Report
Annual Inspection
Census: 21
Capacity: 48
Deficiencies: 0
Nov 15, 2023
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations for the facility.
Findings
The facility was observed to be clean, in good repair, and compliant with safety and infection control standards. No deficiencies were found during the inspection.
Report Facts
Residents on hospice: 8
Resident files reviewed: 10
Staff files reviewed: 10
Physician reports and care plans timeframe: 12
Fire extinguisher last serviced: Mar 30, 2023
Kitchen extinguisher service due: Feb 1, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection |
| Julia Wihl | Business Office Manager | Present during inspection tour |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Census: 23
Capacity: 48
Deficiencies: 0
Oct 18, 2023
Visit Reason
The inspection was an unannounced quarterly on-site case management inspection conducted pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Licensing Program Analyst reviewed the facility's compliance binder and documentation, observed no health or safety risks or personal rights violations, and found the facility to be in compliance with no citations issued.
Report Facts
Capacity: 48
Census: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kylie Whitaker | Administrator | Met with Licensing Program Analyst during inspection |
| Jasmine Juchniewicz | Health and Services Director | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Census: 21
Capacity: 48
Deficiencies: 0
Jul 26, 2023
Visit Reason
The inspection was an unannounced case management visit related to several recent incident reports submitted to the Department.
Findings
The inspection reviewed incidents involving two residents, including an unwitnessed fall resulting in a skin tear and subsequent death of one resident, and episodes of agitation and aggression in another resident managed with medication changes. No deficiencies were issued in this report.
Report Facts
Incident dates: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Met with Licensing Program Analyst during inspection and involved in incident discussions |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced case management inspection |
Inspection Report
Census: 21
Capacity: 48
Deficiencies: 0
Jul 26, 2023
Visit Reason
The inspection was an unannounced quarterly on-site case management inspection conducted pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Licensing Program Analyst reviewed the Compliance Binder and current documentation, observed no health and safety risks or personal rights violations, and noted ongoing training and drills. No citations were issued during this inspection.
Report Facts
Capacity: 48
Census: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Met with Licensing Program Analyst during inspection |
| Kylie Whitaker | Health Services Director | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Routine
Census: 21
Capacity: 48
Deficiencies: 0
May 10, 2023
Visit Reason
The inspection was an unannounced quarterly on-site case management inspection pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Licensing Program Analyst reviewed compliance documentation including medication audits, high risk resident notes, door checks, elopement and fire drills, and training records. No health and safety risks or personal rights violations were observed, and no citations were issued.
Report Facts
Facility capacity: 48
Resident census: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Met with Licensing Program Analyst during inspection |
| Kylie Whitaker | Health Services Director | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Census: 21
Capacity: 48
Deficiencies: 0
May 10, 2023
Visit Reason
The inspection was an unannounced case management visit to follow up on a recent email report regarding a fire in the facility van parked outside.
Findings
The inspection found that a fire occurred in the facility van on 2023-05-09, with no residents or staff involved or near the vehicle. The fire department investigated and ruled out arson, but the cause remains unknown. The van had not been used since February 2023 and will be removed after follow-up inspections. No deficiencies were issued.
Report Facts
Days to submit incident report: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Met with LPA during inspection and provided information about the fire incident. |
| Kylie Whitaker | Health Services Director | Met with LPA during inspection and discussed the fire incident. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced case management inspection. |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 48
Deficiencies: 0
Apr 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-03-14 alleging illegal eviction of a resident after hospitalization for suicidal ideations.
Findings
The investigation found that the allegation was unfounded. The resident was hospitalized after refusing medications and exhibiting suicidal ideations, but the facility did not issue an eviction notice and allowed the resident to return with 1:1 supervision. The resident's family removed belongings and sought new placement. The hospital could not pay for required 1:1 care.
Complaint Details
The complaint alleged illegal eviction after the resident was sent to the ER for suicidal ideations and the facility refused to take the resident back or issue a 30-day eviction notice. The allegation was found to be unfounded based on interviews, documentation review, and hospital evaluation.
Report Facts
Facility capacity: 48
Resident census: 20
Dates of medication refusal reports: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Andrea Armstrong | Administrator | Facility administrator interviewed during investigation |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 48
Deficiencies: 0
Apr 19, 2023
Visit Reason
The inspection was conducted to conclude and deliver findings related to a complaint received on 2023-03-14 alleging the facility did not notify all individuals involved in a resident's probationary status with the Department.
Findings
The Licensing Program Analyst reviewed resident files and confirmed signed acknowledgements were obtained and maintained properly. The facility communicated its probationary status to the National Placement and Referral Alliance. No deficiencies were issued.
Complaint Details
Complaint alleged failure to notify all individuals involved in a resident's probationary status. The complaint was investigated and found to be unsubstantiated as proper notifications and acknowledgements were documented.
Report Facts
Residents reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Sabrina Calzada | Licensing Program Analyst | Conducted complaint investigation and inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 48
Deficiencies: 0
Mar 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 02/17/2023 regarding staff leaving residents in soiled diapers for extended periods and failure to reposition a resident.
Findings
The investigation included interviews with staff, residents, and a family member, review of medical and care documentation, and direct observation. The allegations were found to be unfounded, with evidence showing residents were checked regularly and care plans were followed.
Complaint Details
The complaint alleged that staff left residents in soiled diapers causing diaper rashes and failed to reposition a bedridden resident, causing pressure sores. The investigation found no evidence to support these allegations, determining them to be unfounded.
Report Facts
Capacity: 48
Census: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Met with Licensing Program Analyst during investigation |
| Kylie Whitaker | Health Services Director | Met with Licensing Program Analyst during investigation and provided information |
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Census: 19
Capacity: 48
Deficiencies: 0
Feb 21, 2023
Visit Reason
The inspection was a quarterly on-site case management inspection conducted pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Licensing Program Analyst reviewed the facility's Compliance Binder, training records, medication audits, and documentation related to high risk residents and door alarm checks. The binder was organized and all required trainings and audits were current. No citations were issued during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Named as facility administrator contacted by phone at the start of the inspection. |
| Kylie Whitaker | Health Services Director | Met with Licensing Program Analyst during the inspection. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the inspection. |
| Maribeth Senty | Licensing Program Manager | Named in report header. |
Inspection Report
Annual Inspection
Census: 17
Capacity: 48
Deficiencies: 0
Nov 22, 2022
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements and infection control protocols.
Findings
The facility was observed to be clean, in good repair, odor free, and compliant with infection control measures. No deficiencies were found during the inspection.
Report Facts
Residents on hospice: 4
Fire extinguisher service date: Feb 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Spoke with Licensing Program Analyst by phone during inspection |
| Kylie Whitaker | Health Services Director | Met with Licensing Program Analyst during inspection and participated in facility tour and Infection Control Domain tool completion |
| Sabrina Calzada | Licensing Program Analyst | Conducted the annual inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Monitoring
Census: 17
Capacity: 48
Deficiencies: 0
Nov 22, 2022
Visit Reason
The inspection was an unannounced quarterly on-site case management inspection conducted pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022.
Findings
The Compliance Binder was organized and contained required documentation including monthly RN training, medication room training, weekly staff training, weekly high risk resident documentation, and daily door alarm checks. A copy of the Stipulation was posted at the front entrance. No citations were issued during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Named as facility administrator contacted by phone at the start of the inspection. |
| Kylie Whitaker | Health Services Director | Met with Licensing Program Analyst during inspection and advised on placement of Stipulation copy. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced quarterly case management inspection. |
| Maribeth Senty | Licensing Program Manager | Named in report header. |
Inspection Report
Annual Inspection
Census: 19
Capacity: 48
Deficiencies: 0
Aug 31, 2021
Visit Reason
The visit was an unannounced annual required inspection focusing on the infection control domain to ensure compliance with health and safety regulations.
Findings
The facility was found to be in substantial compliance with infection control policies. No immediate health, safety, or personal rights violations were observed, and the facility maintained adequate supplies and proper PPE usage.
Report Facts
Capacity: 48
Census: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rouzbeh Moradhasel | Executive Director | Met with Licensing Program Analyst during inspection |
| Praveen Singh | Licensing Program Analyst | Conducted the inspection |
| Laura Munoz | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 48
Deficiencies: 1
Aug 31, 2021
Visit Reason
The inspection was conducted as a follow-up on a serious incident report submitted to Community Care Licensing regarding a medication error that occurred on 08/04/2021.
Findings
It was found that a nurse on duty became distracted and administered four medications prescribed to a different resident to R1. The error was immediately reported to the resident's doctor and family, and the resident was monitored with no adverse reactions reported. Deficiencies related to medication administration were cited.
Complaint Details
The visit was complaint-related, following a serious incident report about a medication error where a resident received another resident's medications. The error was substantiated and corrective actions were discussed.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| On 8/4/21, R1 received four medications from another resident's centrally stored medications, violating medication administration protocols. | Type B |
Report Facts
Medications administered in error: 4
Deficiency count: 1
Plan of Correction Due Date: Sep 14, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Praveen Singh | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Laura Munoz | Licensing Program Manager | Supervisor overseeing the inspection. |
| Rouzbeh Moradhasel | Executive Director | Facility representative met during the inspection. |
Inspection Report
Follow-Up
Census: 19
Capacity: 48
Deficiencies: 0
Aug 31, 2021
Visit Reason
The inspection was conducted as a follow-up on legal/non-compliance issues at the facility.
Findings
No deficiencies were observed during this inspection. Personnel restructuring and reporting requirements were discussed and found to have improved the operation of the community.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rouzbeh Moradhasel | Executive Director | Met with Licensing Program Analyst during the inspection and discussed the purpose of the inspection. |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 48
Deficiencies: 0
Jul 22, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations received on 2021-02-11 regarding resident care deficiencies and reporting issues at the facility.
Findings
The investigation found all allegations to be unsubstantiated or unfounded after interviews, record reviews, and observations. Staff acknowledged resident refusals of care due to aggressive behavior, and documentation supported care attempts and communication with physicians. No formal diagnosis of scabies was found for earlier rash cases, and reporting was timely once diagnosis was confirmed.
Complaint Details
The complaint investigation addressed allegations including failure to assist residents with basic services, incontinence care, failure to report a scabies outbreak, failure to seek medical care, and failure to document changes in resident condition. All allegations were found unsubstantiated or unfounded based on evidence gathered.
Report Facts
Capacity: 48
Census: 21
Number of staff interviewed: 7
Residents reviewed for scabies: 6
Residents diagnosed with scabies: 11
Duration of continence care refusal: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Oliver Aden | Administrator | Facility administrator met during investigation |
| Martin Nicols | Administrator who provided information about scabies outbreak and resident care incidents | |
| Kayla Davis | Administrator | Named as facility administrator in report header |
| Troy Ordonez | Licensing Program Manager | Oversaw licensing program, named in report |
Inspection Report
Complaint Investigation
Census: 21
Capacity: 48
Deficiencies: 1
Jul 22, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including unexplained injuries to a resident, lack of supervision, inappropriate staff communication, medication destruction record keeping, failure to update resident reappraisals, and medication administration issues.
Findings
The investigation found most allegations unsubstantiated, including unexplained injuries, supervision, staff communication, medication destruction records, and reappraisals. However, the allegation regarding medications not administered as prescribed was substantiated, with specific medication doses missed. Deficiencies were cited related to medication administration.
Complaint Details
The complaint investigation was triggered by allegations received on 02/11/2021 regarding unexplained injuries to a resident, lack of supervision, inappropriate staff communication, medication destruction record keeping, failure to update resident reappraisals, and medication administration issues. The investigation was unannounced and conducted by Licensing Program Analyst Bethany Mirlohi. The allegation of medications not administered as prescribed was substantiated; all others were unsubstantiated or unfounded.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not provide medication prescribed by physician, posing an immediate health and safety risk to residents. | Type A |
Report Facts
Capacity: 48
Census: 21
Deficiencies cited: 1
Plan of Correction Due Date: Jul 23, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Oliver Aden | Administrator | Facility administrator met with LPA during investigation |
| Kayla Davis | Administrator | Named as facility administrator in report header |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Follow-Up
Census: 29
Capacity: 48
Deficiencies: 0
Apr 6, 2021
Visit Reason
The visit was an unannounced telephone follow-up conducted to address information received about a scabies outbreak at the facility.
Findings
The facility had a scabies outbreak with two confirmed cases initially, later eleven residents were diagnosed. Preventative measures including topical medication for all residents, cleaning protocols, and notifications to public health and responsible parties were implemented. No deficiencies were cited at this time.
Report Facts
Confirmed scabies cases: 2
Residents diagnosed with scabies: 11
Facility capacity: 48
Resident census: 29
Clothing suffocation duration: 7
Final treatment day: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martin Nichols | Executive Director | Interviewed during the telephone follow-up regarding the scabies outbreak |
| Jasmine McCrory | Licensing Program Analyst | Conducted the unannounced telephone visit and follow-up |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 48
Deficiencies: 1
Dec 30, 2020
Visit Reason
The visit was conducted to follow up on a substantiated allegation of inadequate supervision that led to an injury of a resident, specifically regarding an incident where one resident was forcefully pushed to the ground by another resident, resulting in serious injury and subsequent death.
Findings
The licensee was found to have failed in properly observing and documenting behavioral changes of the aggressive resident, failed to notify the physician timely, did not update the care plan, and failed to provide appropriate staff training. These failures led to inadequate supervision and protection of residents, resulting in the injury and death of a resident. A civil penalty was issued for these violations.
Complaint Details
The complaint investigation was substantiated. The allegation involved inadequate supervision that led to Resident 1 being thrown to the ground by Resident 2, causing injury and eventual death. The Department reviewed the incident, including witness statements and the coroner's report listing the cause of death as homicide due to blunt force trauma.
Deficiencies (1)
| Description |
|---|
| Violation of CCR Title 22, § 87466 for not properly observing Resident 1, documenting behavioral changes, notifying physician timely, updating care plan, and providing staff training. |
Report Facts
Civil penalty amount: 14500
Staff interviewed: 14
Staff reporting aggression: 8
Staff reporting prior aggression: 5
Capacity: 48
Census: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Davis | Administrator | Facility administrator involved in the follow-up and acknowledged receipt of appeal rights. |
| Bethany Huusfeldt | Licensing Program Analyst | Conducted the follow-up visit and investigation. |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 48
Deficiencies: 1
Dec 21, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not keep emergency exits clear of obstruction.
Findings
The Licensing Program Analyst investigated the allegation by interviewing staff, inspecting the facility, and reviewing documentation. The allegation was substantiated based on staff interviews, photographic evidence of chairs and tables blocking emergency exits, and facility plan review.
Complaint Details
The complaint was substantiated. The allegation that facility staff did not keep emergency exits clear of obstruction was found valid based on the preponderance of evidence including staff interviews and photographic evidence.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not keep emergency exits clear which poses an immediate health & safety risk to residents in care. | Type A |
Report Facts
Capacity: 48
Census: 38
Deficiency POC Due Date: Dec 31, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Huusfeldt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Kayla Davis | Administrator | Facility Administrator met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 48
Deficiencies: 2
Dec 21, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to multiple allegations including residents sustaining multiple falls, staff neglect resulting in a resident's death, failure to keep the facility free from pests, failure to address an outbreak, and failure to take universal precautions for residents.
Findings
The investigation substantiated allegations that residents sustained multiple falls due to insufficient staffing and that staff neglect resulted in a resident's death, leading to a $500 civil penalty. Allegations regarding pest control, outbreak management, and universal precautions were found to be unsubstantiated or unfounded.
Complaint Details
The complaint investigation was substantiated for allegations that residents sustained multiple falls and that staff neglect resulted in a resident's death. The resident (R1) was found outside in the courtyard with high body temperature and sunburn, leading to cardiac arrest and death. Staffing shortages and inadequate supervision were noted. Allegations related to pest control, outbreak management, and universal precautions were unsubstantiated or unfounded.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Facility did not have sufficient staffing to meet the needs of the residents which poses an immediate health & safety risk. | Type A |
| Licensees who accept and retain residents with dementia shall ensure adequate number of direct care staff to support residents' needs. Facility did not have adequate number of direct care staff to support residents which poses an immediate health & safety risk. | Type A |
Report Facts
Resident falls: 17
Civil penalty amount: 500
Outdoor temperature: 90
Resident temperature: 104.1
Caregiver to resident ratio: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Huusfeldt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kayla Davis | Administrator | Met with Licensing Program Analyst during investigation |
| Donna Bautista-Colmenares | Executive Director | Notified about resident's condition and involved in investigation |
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