Inspection Report Summary
Most inspections found no deficiencies, reflecting a generally compliant facility with appropriate infection control, safety measures, and resident care practices. Several complaint investigations were unsubstantiated, including allegations of inadequate supervision, improper staff conduct, and facility disrepair. The one substantiated deficiency occurred in August 2025 when a medication error was reported involving a substitute technician giving medication to the wrong resident; this was addressed with staff training and improved procedures, and no harm resulted. The most recent report from September 4, 2025, was a complaint investigation that found no deficiencies and unsubstantiated allegations. Overall, the facility’s record shows mostly consistent compliance with isolated issues related to medication management that have been addressed.
Deficiencies per Year
4
3
2
1
0
High
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 56
Capacity: 80
Deficiencies: 0
Sep 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not provide adequate supervision to a resident in care and did not seek medical attention in a timely manner.
Findings
The investigation found that the facility staff checked on the resident at least every two hours and contacted hospice regularly regarding the resident's condition. The written plan of care required frequent checks but did not specify exact frequency. There was insufficient evidence to prove the allegations; therefore, both allegations were found to be unsubstantiated or unfounded.
Complaint Details
The complaint investigation was unsubstantiated regarding inadequate supervision and unfounded regarding failure to seek medical attention in a timely manner. The findings concluded there was no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 80
Census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brandy Strahl | Administrator | Facility administrator met during the investigation |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 80
Deficiencies: 1
Aug 19, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff mismanaged residents' medication.
Findings
The investigation found that a substitute medication technician accidentally gave medication intended for one resident to another resident with the same first name. The incident was immediately reported and investigated, with no ill effects to the resident. Refresher training for staff and methods to flag residents with the same names were planned.
Complaint Details
The complaint alleging staff mismanagement of residents' medication was substantiated based on the preponderance of evidence.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement a plan for incidental medical and dental care, resulting in a medication pass error posing an immediate health and safety risk to a resident. | Type A |
Report Facts
Capacity: 80
Census: 54
Deficiency count: 1
Plan of Correction Due Date: Aug 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brandy Strahl | Administrator | Facility administrator interviewed during investigation and responsible for corrective actions |
| Troy Ordonez | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 54
Capacity: 80
Deficiencies: 0
Jan 22, 2025
Visit Reason
Licensing Program Analysts arrived unannounced to conduct an annual inspection to ensure compliance with Title 22 regulations.
Findings
The inspection found the facility compliant with no deficiencies cited. The facility had adequate food supplies, operational safety detectors, secured medication storage, and reviewed resident and staff files.
Report Facts
Resident rooms: 54
Perishable food supply: 2
Non-perishable food supply: 7
Resident files reviewed: 5
Staff files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Strahl | Administrator | Met with Licensing Program Analysts during inspection |
| Cassandra Mikkelson | Licensing Program Analyst | Conducted the annual inspection |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Monitoring
Census: 56
Capacity: 80
Deficiencies: 0
Nov 14, 2024
Visit Reason
This unannounced case management visit was conducted in response to the facility submitting a death report.
Findings
The licensing program analyst obtained a copy of some documents from the resident's file. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Strahl | Administrator/Director | Met with during the inspection visit |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced case management visit |
| Troy Ordonez | Licensing Program Manager | Named in the report |
Inspection Report
Annual Inspection
Census: 56
Capacity: 80
Deficiencies: 0
Jan 17, 2024
Visit Reason
This was an unannounced annual visit conducted as a required one-year inspection of the facility.
Findings
The inspection found no deficiencies. Several staff and resident files were reviewed, and multiple topics were discussed during the visit.
Report Facts
Resident rooms: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Strahl | Administrator | Met with during the inspection and toured the facility |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 80
Deficiencies: 0
Sep 27, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff forced a resident to take medication.
Findings
The Licensing Program Analyst conducted interviews and reviewed medication records but could not prove or disprove the allegation due to conflicting accounts. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff forced a resident to take medication. The investigation found conflicting statements between staff and resident regarding medication administration, resulting in an unsubstantiated finding.
Report Facts
Capacity: 80
Census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 80
Deficiencies: 0
Sep 27, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to a complaint received on 2023-08-25 alleging that staff spoke inappropriately to a resident.
Findings
The investigation found that the staff denied any ill intent and the resident felt humiliated by the staff's loud and boisterous voice. No witnesses could be contacted, and the Licensing Program Analyst was unable to prove or disprove the allegation. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff spoke inappropriately to a resident. The allegation was investigated and found to be unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Brandy Strahl | Administrator | Named as facility administrator. |
| Jamie Scott | Met with during the investigation. | |
| Troy Ordonez | Licensing Program Manager | Named in report signature section. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 80
Deficiencies: 0
Mar 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff caused a resident to fall while in care and that the facility does not have backup emergency services for residents.
Findings
The investigation found the allegation that staff caused a resident to fall while in care to be unsubstantiated due to conflicting accounts and lack of evidence. The complaint regarding lack of backup emergency services was found to be unfounded as the facility has a written emergency plan and complies with regulations.
Complaint Details
The complaint investigation was unannounced and conducted by Evaluator Kerry Hiratsuka. The allegation that staff caused a resident to fall was unsubstantiated due to insufficient evidence. The allegation that the facility lacks backup emergency services was found to be unfounded as the facility has appropriate emergency plans and procedures.
Report Facts
Capacity: 80
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Carol Pickard | Administrator | Facility administrator mentioned in the report |
| Brandy Strahl | Person met with during the investigation | |
| Lauren Crocker | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 54
Capacity: 80
Deficiencies: 0
Dec 20, 2022
Visit Reason
This was an unannounced annual inspection visit conducted as a required one-year evaluation of the facility.
Findings
The inspection found no deficiencies. The facility was observed to have appropriate infection control measures with staff wearing surgical masks, and the physical environment was described in detail.
Report Facts
Resident rooms: 54
Restrooms: 2
Inspection Report
Complaint Investigation
Census: 54
Capacity: 80
Deficiencies: 0
Dec 16, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-09-22 alleging multiple issues including improper staff training, unattended residents, untimely response to alerts, retention of residents needing higher care, uncomfortable accommodations, and forced early sleeping.
Findings
The investigation found all allegations to be unfounded or unsubstantiated. Staff training met requirements, residents and staff interviews indicated no issues with supervision or care, and no evidence supported the complaint allegations.
Complaint Details
The complaint investigation was unannounced and addressed allegations of improper staff training, unattended residents, untimely response to alerts, retention of residents requiring higher care, uncomfortable accommodations, forced early sleeping, denial of restroom use, lack of privacy, residents left soiled, falls, and delayed medical attention. The findings determined the allegations were unfounded or unsubstantiated due to lack of evidence and interviews.
Report Facts
Capacity: 80
Census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Administrator | Facility administrator met during the investigation |
| Kerry Hiratsuka | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Manager overseeing the complaint investigation |
Inspection Report
Census: 54
Capacity: 80
Deficiencies: 0
Nov 2, 2022
Visit Reason
This unannounced case management visit was conducted in response to an incident reported to the Licensing Program Analyst (LPA) while conducting an annual inspection at the sister facility. The visit addressed the evacuation of the facility due to smoke in the building earlier that morning.
Findings
The facility was evacuated at approximately 6:30 AM due to smoke, with residents outside for about fifteen minutes. The fire department cleared the building for re-occupation, and all residents returned inside. The licensee's engineering staff checked and cleared the building, and emergency evacuation procedures were properly conducted. No residents or staff were injured during the evacuation. No deficiencies were cited.
Report Facts
Evacuation duration (minutes): 15
Time of evacuation: 630
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Administrator | Met with during the visit and mentioned in the incident report |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced case management visit |
| Troy Ordonez | Licensing Program Manager | Named in the report header |
Inspection Report
Census: 51
Capacity: 80
Deficiencies: 0
Jul 13, 2022
Visit Reason
The visit was an unannounced Case Management - Incident visit conducted in response to an incident reported by the Director of Assisted Living Services regarding a resident who died unexpectedly on 2022-07-06.
Findings
The Licensing Program Analyst discussed the incident with the facility representative and determined that no extra documentation was required at this time, but further investigation is needed. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Director of Assisted Living Services | Reported the incident of a resident's unexpected death. |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Troy Ordonez | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 22
Capacity: 80
Deficiencies: 0
Jan 4, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain as part of the annual case management continuation.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Administrator | Met with Licensing Program Analyst during inspection and involved in infection control domain review. |
| Dawn Keane | Licensing Program Analyst | Conducted the inspection and infection control domain review. |
Inspection Report
Annual Inspection
Census: 48
Capacity: 80
Deficiencies: 0
Dec 22, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Administrator | Met with Licensing Program Analyst during inspection and involved in infection control domain completion. |
| Dawn Keane | Licensing Program Analyst | Conducted the Required-1 Year Inspection and infection control domain evaluation. |
| Rayna L Bryson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 80
Deficiencies: 0
Feb 23, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 12/18/2020 regarding the facility being in disrepair.
Findings
The Licensing Program Analyst concluded that the complaint was unsubstantiated after interviews and investigation, finding no evidence of violations. No deficiencies were cited.
Complaint Details
The complaint alleged that the facility was in disrepair. After investigation, the complaint was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 80
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Misty Valencia | Licensing Program Analyst | Conducted the complaint investigation and concluded findings |
| Carol Pickard | Administrator | Facility administrator interviewed during investigation |
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