Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. However, some deficiencies were cited over time, mainly related to medication management, timely incident reporting, resident rights, and maintaining a clean and safe environment, particularly in laundry areas and during a few isolated incidents. The most recent report from August 6, 2025, substantiated a complaint about unsanitary conditions in two laundry rooms but found no other immediate health or safety hazards. Earlier reports noted issues such as missed medications in early 2024 and failure to report incidents promptly, but more recent investigations often found no substantiated problems, suggesting some improvement in these areas. No fines, license suspensions, or severe enforcement actions were listed in the available reports.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
90% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 104
Capacity: 115
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint alleging that staff did not ensure the facility was kept clean, safe, and sanitary.
Complaint Details
The complaint was substantiated. The allegation was that staff did not ensure the facility was kept clean, safe, and sanitary, specifically regarding the laundry rooms. The investigation included interviews with nine residents and two staff members, and a physical plant tour. The findings confirmed the allegation.
Findings
The investigation substantiated the allegation that two out of four laundry rooms were not maintained in a clean, safe, and sanitary condition, with issues including unsecured waste bin lids, PPE gloves left on the floor, uncovered waste containers, and canned alcoholic beverages left on the floor. No other immediate health and safety hazards were observed.
Deficiencies (1)
87303 Maintenance and Operation (a): The facility shall be clean, safe, sanitary at all times. Laundry areas shall be maintained in a clean, sanitary condition. This requirement was not met as two out of four laundry rooms were not kept clean or sanitary.
Report Facts
Residents interviewed: 9
Staff interviewed: 2
Laundry rooms inspected: 4
Laundry rooms not clean: 2
Capacity: 115
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Aleman | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Angelica Segovia | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 115
Deficiencies: 0
Date: Jul 29, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted due to allegations that staff were leaving residents in soiled clothing for extended periods and not meeting residents' toileting needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents being left in soiled clothing for extended periods and staff not meeting toileting needs. Interviews with residents and staff, as well as observations and record reviews, did not support these claims.
Findings
Based on interviews with residents and staff, record reviews, and physical observations, there was insufficient evidence to verify the allegations. Residents were observed to be clean, well-groomed, and in good health, and staff were found to be conducting rounds and assisting residents appropriately. The allegations were determined to be unsubstantiated.
Report Facts
Residents interviewed: 11
Staff interviewed: 7
Residents asleep during interview: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Segovia | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Katherine Aleman | Executive Director | Facility representative met during the investigation |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 115
Deficiencies: 0
Date: May 20, 2025
Visit Reason
The visit was an unannounced subsequent Case Management visit to deliver findings regarding an incident reported on 2025-05-02 involving alleged inappropriate physical force by a staff member towards a resident.
Complaint Details
The complaint involved an allegation that staff member S1 used inappropriate physical force on resident R1 by pushing their head down twice. The resident could not name the staff member definitively. Interviews with staff and resident did not provide enough evidence to substantiate the claim. The facility conducted an internal investigation which was inconclusive.
Findings
Interviews and investigation revealed that a resident reported a staff member used inappropriate physical force causing pain, but there were no witnesses and insufficient evidence to prove the allegation. No deficiencies were cited and no immediate health or safety hazards were observed.
Report Facts
Facility capacity: 115
Resident census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Aleman | Executive Director | Facility representative who assisted with the visit and internal investigation |
| Angelica Segovia | Licensing Program Analyst | Conducted the inspection and interviews |
| Troy Agard | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 115
Deficiencies: 0
Date: May 5, 2025
Visit Reason
An unannounced Case Management visit was conducted regarding an incident reported on 2025-05-02 involving a staff member allegedly using inappropriate physical force towards a resident.
Complaint Details
The complaint involved Resident one (R1) reporting that Staff member (S1) used inappropriate physical force causing pain. The investigation is ongoing with no immediate hazards found.
Findings
The Licensing Program Analyst conducted interviews, record reviews, and a physical plant tour. No health or safety hazards were observed during the visit. Further review of the incident is pending and the analyst may return to the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Segovia | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Shannon Bailey | Business Director | Met with Licensing Program Analyst during the visit. |
| Katherine Aleman | Administrator/Director | Named as facility administrator/director. |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager overseeing the visit. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 115
Deficiencies: 1
Date: Apr 1, 2025
Visit Reason
An unannounced Case Management visit was conducted in conjunction with a complaint control #31-AS-20250324153245 to investigate the facility's failure to report an incident involving a resident's fall and hospitalization.
Complaint Details
Complaint control #31-AS-20250324153245 triggered the visit. The complaint was substantiated by the finding that the facility did not report the resident's incident as required.
Findings
The facility failed to submit a required incident report to the Community Care Licensing Department regarding a resident's multiple falls and hospitalization, which poses a potential health and safety risk. The Executive Director admitted unawareness of the reporting requirement.
Deficiencies (1)
Failure to notify CCLD regarding R2's multiple falls and hospitalization on or before 03/24/24, violating reporting requirements.
Report Facts
Census: 97
Total Capacity: 115
Plan of Correction Due Date: Apr 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Aleman | Executive Director | Admitted no incident report was submitted and was met during the inspection |
| Angelica Segovia | Licensing Program Analyst | Conducted the inspection and signed the report |
| Huma Rahimi | Licensing Program Analyst | Conducted the inspection |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 115
Deficiencies: 0
Date: Jan 21, 2025
Visit Reason
The visit was conducted as a Case Management follow-up on a self-reported incident alleging a physical and verbal altercation between a resident and a staff member on 2025-01-10.
Complaint Details
The complaint involved an alleged physical and verbal altercation between Resident 1 and Staff 1 on 2025-01-10. The resident reported delayed medication administration and scratches on their hands. The staff member denied physical contact. The resident has a history of false reporting and self-inflicted wounds. The complaint was not substantiated.
Findings
Based on record review and interviews, there was insufficient evidence to prove that the staff member physically harmed the resident. No immediate health and safety issues were observed during the visit.
Report Facts
Medication timing: 6
Medication administration time: 1530
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Aleman | Executive Director | Met with Licensing Program Analysts and involved in incident follow-up |
| Angelica Segovia | Licensing Program Analyst | Conducted the inspection and investigation |
| Gary Tan | Licensing Program Analyst | Conducted the inspection and investigation |
Inspection Report
Annual Inspection
Census: 91
Capacity: 115
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
An unannounced annual visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in good repair with no immediate health or safety hazards observed. Common areas, kitchen, medication storage, resident and staff records were all compliant and well maintained.
Report Facts
Licensed capacity: 115
Current census: 91
Hospice waiver capacity: 6
Memory Care rooms: 13
Memory Care capacity: 18
Perishable food stock: 2
Non-perishable food stock: 7
Laundry rooms: 3
Hot water temperature range: 113.5
Hot water temperature range: 120
Smoke alarm last inspection date: Oct 31, 2024
Fire extinguisher last inspection date: May 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Segovia | Licensing Program Analyst | Conducted the inspection and authored the report |
| Marhlyn Sapugay | Director of Engagement | Met with Licensing Program Analyst during inspection and assisted with facility tour |
| Katherine Aleman | Administrator | Facility Administrator notified of the inspection visit |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 115
Deficiencies: 0
Date: Nov 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff do not provide residents with activities, specifically that arts and crafts and rides to outings are not provided.
Complaint Details
The complaint alleged that staff do not provide residents with activities, including arts and crafts and rides to outings. The allegation was investigated through interviews, observations, and record review and was found to be unsubstantiated.
Findings
The investigation found that the facility provides residents with activities and accommodates sufficient space for activities. Observations included residents engaged in various activities, sufficient supplies, posted activity schedules, and interviews confirmed adequate activity provision. The allegation was deemed unsubstantiated.
Report Facts
Residents playing cards: 5
Residents playing board game: 2
Residents engaged in arts and crafts: 2
Residents interviewed: 8
Years resident #1 played cards: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation visit |
| Katherine Aleman | Administrator | Facility administrator interviewed during investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 115
Deficiencies: 0
Date: Jul 11, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the licensee was not following proper infection control protocols.
Complaint Details
The complaint alleged that the facility was exposed to Scabies and did not disclose this to family members. The investigation revealed that the facility informed the family promptly, quarantined the resident for five days, changed all bedding, and reported to the Community Care Licensing Department. Interviews with nine out of eleven residents confirmed no concerns with infection control. The allegation was unsubstantiated.
Findings
The investigation found that the facility followed proper infection control protocols regarding a resident diagnosed with Scabies, including timely family notification, isolation, and reporting to the licensing department. Interviews with staff and residents confirmed adherence to infection control plans, and the allegation was deemed unsubstantiated.
Report Facts
Resident diagnosed quarantine duration: 5
Number of residents interviewed: 9
Facility capacity: 115
Facility census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Huma Rahimi | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Nichelle Gillyard | Licensing Program Manager | Named in the report as Licensing Program Manager. |
| Karen Marin | Administrator | Facility administrator mentioned in the report. |
| Amber Fraser | Wellness Specialist | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Annual Inspection
Census: 89
Capacity: 115
Deficiencies: 0
Date: May 11, 2024
Visit Reason
An annual required unannounced inspection visit was conducted to evaluate compliance with licensing regulations.
Findings
The facility was found to be in compliance with no deficiencies observed. The physical plant, safety systems, resident rooms, common areas, and medication management were all inspected and found functional and properly maintained.
Report Facts
Memory care beds: 18
Fire extinguisher charge date: May 2, 2024
Smoke alarm inspection date: Apr 3, 2024
Fire drill date: Apr 2, 2024
Hot water temperature range: 113.4-118
Number of elevators: 2
Number of laundry rooms: 3
Medication carts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Marin | Administrator/Director | Facility administrator/director named in report header. |
| Christine Ellis | Community Sales Director | Met with LPAs during inspection and assisted with facility tour. |
| Gary Tan | Licensing Program Analyst | Conducted the annual inspection. |
| Michael Cava | Licensing Program Analyst | Conducted the annual inspection and signed the report. |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 115
Deficiencies: 0
Date: May 2, 2024
Visit Reason
The visit was conducted as an unannounced complaint investigation regarding allegations that staff did not accurately assess a resident's needs and inappropriately placed the resident in the Assisted Living Unit instead of the Memory Care Unit.
Complaint Details
The complaint alleged that staff did not accurately assess resident R1's needs and placed R1 in the Assisted Living Unit instead of the Memory Care Unit. After investigation, including interviews with facility staff and the resident's Hospice agency Director of Nurses, the allegation was found to be unsubstantiated.
Findings
The investigation included interviews and record reviews which determined that the resident's Physician’s Report was complete prior to admission and placement in the Assisted Living Unit was appropriate. The resident was alert, oriented, and did not require Memory Care placement. The allegation was deemed unsubstantiated.
Report Facts
Complaint Control Number: 31-AS-20240412163855
Facility Capacity: 115
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager |
| Karen Marin | Administrator | Facility Administrator |
| Blaine Lyons | Regional Operations Specialist | Met with during inspection |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 115
Deficiencies: 1
Date: Apr 16, 2024
Visit Reason
Unannounced visit conducted in conjunction with a complaint regarding failure to timely report incidents where a resident left the facility unassisted.
Complaint Details
Complaint control #31-AS-20240412163855 triggered the visit. The complaint was substantiated based on interviews and record reviews confirming failure to report incidents timely.
Findings
The licensee failed to submit required Unusual Incident / Injury Reports to the Community Care Licensing Department within seven days for at least two incidents involving a resident leaving the facility unassisted between 03/24/2024 and 04/13/2024.
Deficiencies (1)
Failure to submit timely Unusual Incident / Injury Reports to the licensing agency regarding incidents where a resident left the facility unassisted.
Report Facts
Number of incidents not reported: 2
Capacity: 115
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Marin | Administrator | Named as facility administrator during inspection. |
| Kristine Ellis | Community Sales Director | Met with Licensing Program Analysts and admitted no incident reports were submitted. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 115
Deficiencies: 1
Date: Mar 15, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff did not administer resident's medications as prescribed.
Complaint Details
The complaint was substantiated. The allegation was that staff did not administer resident's medications as prescribed. Record reviews and interviews confirmed missed medications for resident R1 on 03/08/24 and 03/09/24.
Findings
The investigation found that resident R1 missed medications on 03/08/24 and 03/09/24 due to a miscommunication and delay in updating the medication system after hospital discharge. The allegation was substantiated and citations were issued.
Deficiencies (1)
87465(a)(4) Incidental Medical and Dental Care: The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by missed medications for resident R1 on 03/08/24 and 03/09/24, posing an immediate risk to residents.
Report Facts
Deficiency due date: Mar 16, 2024
Capacity: 115
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Karen Marin | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 115
Deficiencies: 0
Date: Jan 12, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations including staff pushing residents, failure to ensure residents are bathed, failure to clean resident rooms, and failure to provide laundry service to residents.
Complaint Details
The complaint investigation was triggered by multiple allegations: staff pushed residents, staff do not ensure residents are bathed, staff do not clean resident rooms, and staff do not provide laundry service. After interviewing 12 residents, 12 staff members, 2 managers, and 3 family members, all allegations were found unsubstantiated.
Findings
The investigation found all allegations to be unsubstantiated after interviews with residents, staff, managers, and family members. Residents and staff uniformly denied the allegations, and no evidence was found to support the claims.
Report Facts
Residents interviewed: 12
Staff interviewed: 12
Managers interviewed: 2
Family members interviewed: 3
Residents receiving shower assistance: 12
Residents assisted with showering twice a week: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Agard | Licensing Program Manager | Oversaw the complaint investigation |
| Mindy Mendoza-Perry | Administrator | Facility administrator present during investigation |
Inspection Report
Census: 73
Capacity: 115
Deficiencies: 0
Date: Mar 16, 2023
Visit Reason
The visit was an unannounced case management inspection to tour the memory care renovation section of the assisted living facility.
Findings
The Licensing Program Analyst toured the memory care wing, observed keypad locations for delayed egress, and inspected resident suites and common areas. No health or safety issues were observed during the tour.
Report Facts
Private rooms: 8
Companion suites: 5
Potential residents: 18
Keypads: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mindy Mendoza-Perry | Administrator | Met during the visit and provided information about the memory care section |
| Melissa Spaeth | Licensing Program Analyst | Conducted the unannounced visit and inspection |
| Cassandra Harris | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Capacity: 115
Deficiencies: 0
Date: Feb 13, 2023
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that staff were not following COVID-19 protocols.
Complaint Details
The complaint alleged staff were not following COVID-19 protocols. The allegation was found unsubstantiated based on interviews with the reporting party and residents confirming compliance.
Findings
The investigation found the allegation to be unsubstantiated after interviews with the reporting party and twelve residents who confirmed staff were properly following COVID-19 guidelines.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Evaluator | Conducted the complaint investigation visit and interviews. |
| Mindy Mendoza-Perry | Administrator | Met with the evaluator during the investigation. |
Inspection Report
Annual Inspection
Census: 78
Capacity: 115
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
The visit was an unannounced annual inspection to evaluate the facility's compliance with licensing requirements.
Findings
The inspection found no health or safety issues and no deficiencies. The facility was observed to be clean, well-maintained, and adequately supplied, including PPE and food supplies. The new memory care wing was under construction with completion imminent.
Report Facts
Residents in memory care wing: 18
Single rooms in memory care wing: 8
Shared rooms in memory care wing: 5
PPE supply duration: 6
Facility capacity: 115
Current census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mindy Mendoza-Perry | Administrator | Facility Administrator present during inspection and mentioned in report |
| Melissa Spaeth | Licensing Program Analyst | Conducted the inspection and authored the report |
| Cassandra Harris | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 115
Deficiencies: 0
Date: Jan 9, 2023
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that staff were not providing residents with adequate food service, not meeting residents' needs, not following COVID-19 protocols, not ensuring residents' rooms were locked, and not keeping the facility free of dust.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate food service, unmet resident needs, failure to follow COVID-19 protocols, unlocked resident rooms, and facility dust issues. Interviews with thirteen residents and facility inspections did not support these allegations.
Findings
The investigation found no health or safety issues during the visit. Resident interviews and facility checks showed that meals were delivered timely during the COVID-19 outbreak, residents' needs were met, COVID-19 protocols were followed, rooms could be locked, and the facility was kept clean and free of dust. All allegations were unsubstantiated.
Report Facts
Capacity: 115
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cassandra Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 115
Deficiencies: 0
Date: Nov 18, 2022
Visit Reason
The visit was an unannounced case management incident investigation triggered by a call reporting that a call was not answered by staff after 8:00 pm and that a caller was allowed entry into the facility without proper verification.
Complaint Details
The complaint involved an incident where a call was not answered after 8:00 pm and a caller was allowed entry by a security guard. The complaint was investigated and found to be unsubstantiated as caregivers promptly answered calls and the door was opened for a resident, not an unauthorized person.
Findings
The investigation found that caregivers carry cell phones connected to the facility phone number and promptly answer calls. A resident left and returned during evening hours, and a caregiver opened the front door for the resident. There were no deficiencies identified during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mindy Mendoza-Perry | Administrator | Interviewed during the investigation and named in the report narrative. |
| Melissa Spaeth | Licensing Program Analyst | Conducted the investigation and authored the report. |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 60
Capacity: 115
Deficiencies: 0
Date: Nov 9, 2022
Visit Reason
The visit was conducted as a Case Management - Incident type to request resident documentation regarding an incident report received by the Community Care Licensing (CCL).
Findings
No health or safety issues were observed during the tour, and there are no deficiencies to report at this time.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mindy Mendoza-Perry | Administrator | Met with during the visit and greeted the Licensing Program Analyst. |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 115
Deficiencies: 1
Date: Aug 5, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that a resident sustained a stage 4 pressure injury while in care and other related allegations including denial of access to home healthcare services and failure to meet resident care needs.
Complaint Details
The complaint investigation was initiated due to allegations that a resident sustained a stage 4 pressure injury while in care, was denied access to home healthcare services, and had unmet care needs. The stage 4 pressure injury allegation was found unfounded. The denial of access to home healthcare services was substantiated, violating PIN 24-04-ASC and resulting in delayed wound care. Other care-related allegations were unsubstantiated.
Findings
The investigation found the allegation that the resident developed a stage 4 pressure injury while in care to be unfounded. However, the allegation that the resident was denied access to home healthcare services was substantiated, citing a violation of PIN 24-04-ASC, resulting in delayed wound care and progression of the pressure injury from stage 1 to stage 2. Other allegations regarding special diet, communication, laundry, and room cleanliness were unsubstantiated.
Deficiencies (1)
8768.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement was not met as evidenced by denial of access to home healthcare services posing an immediate health and safety risk.
Report Facts
Capacity: 115
Census: 79
Deficiency count: 1
Plan of Correction Due Date: Aug 12, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jose Santana | Investigator | Conducted the complaint investigation |
| Mindy Mendoza | Facility staff member met during investigation | |
| Autumn Roberts Rodriguez | Administrator | Facility administrator named in the report |
| Cassandra Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 115
Deficiencies: 0
Date: Jul 22, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that the facility was in disrepair due to cloudy water.
Complaint Details
The complaint alleged cloudy water in the facility. The investigation included interviews with staff and a resident, and water testing. The allegation was found to be unsubstantiated.
Findings
The investigation found that the water in the resident's apartment and other apartments was clear and not cloudy. The allegation of cloudy water was unsubstantiated after interviews and water testing.
Report Facts
Capacity: 115
Census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 115
Deficiencies: 1
Date: May 12, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that the facility did not notify an authorized representative about a hospital visit and was not providing access to medical records to the authorized representative.
Complaint Details
The complaint was substantiated regarding failure to notify the authorized representative about the hospital visit. The allegation regarding denial of access to medical records was unsubstantiated. The investigation included interviews with staff and review of resident records and incident reports.
Findings
The allegation that the facility did not notify the authorized representative about the hospital visit was substantiated due to failure to report the hospitalization and notify the family. The allegation that the facility did not provide access to medical records was unsubstantiated as the requested documentation was sent to the complainant's attorney.
Deficiencies (1)
Failure to submit a written report to the licensing agency and responsible person within seven days of an incident threatening the welfare, safety, or health of a resident, specifically failure to report the hospitalization of the resident.
Report Facts
Capacity: 115
Census: 84
Deficiency count: 1
Plan of Correction Due Date: May 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cassandra Harris | Licensing Program Manager | Oversaw the complaint investigation |
| Mindy Mendoza-Perry | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 115
Deficiencies: 0
Date: Apr 28, 2022
Visit Reason
The visit was an unannounced complaint investigation to address allegations that staff were not answering call bells timely, residents were not receiving medications timely, dining room tables were not cleaned properly, and staff did not attend to residents' medical needs in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included delayed call bell responses, untimely medication administration, improper cleaning of dining tables, and delayed medical assistance. Interviews and observations showed these allegations were not supported.
Findings
All allegations were found to be unsubstantiated after interviews with residents and staff, observations of dining room sanitation, and review of residents' records. Staff response times, medication administration, dining room cleanliness, and medical assistance were all found to be adequate.
Report Facts
Capacity: 115
Census: 84
Number of residents interviewed: 15
Number of dining staff interviewed: 3
Number of residents interviewed per allegation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Mindy Mendoza-Perry | Administrator | Facility Administrator who greeted the investigator and participated in the exit interview |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 115
Deficiencies: 1
Date: Apr 22, 2022
Visit Reason
The inspection visit was conducted to investigate a complaint received on 08/09/2021 regarding illegal eviction, staff failing to provide a safe environment, failure to meet residents' needs, and failure to issue a refund.
Complaint Details
The complaint was substantiated regarding staff failing to provide a safe environment when a resident left the facility through an open fire exit door left open by construction workers. The resident should not leave without assistance. Other allegations of illegal eviction, failure to meet residents' needs, and failure to issue a refund were unsubstantiated.
Findings
The investigation substantiated the allegation that staff failed to provide a safe environment when a resident left the facility through an open fire exit door. The allegations of illegal eviction, failure to meet residents' needs, and failure to issue a refund were unsubstantiated. A deficiency was cited related to the failure to maintain a safe environment.
Deficiencies (1)
Failure to provide care, supervision, and services that meet individual needs and are delivered by sufficient staff, evidenced by caregivers not being aware that a resident left the building without an escort, posing an immediate health and safety risk.
Report Facts
Capacity: 115
Census: 83
Refund amount: 6325
Invoice amount: 10690
Refund total: 7666.88
Plan of Correction Due Date: Apr 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mindy Mendoza-Perry | Administrator | Met with Licensing Program Analyst during the investigation |
| Freda Brock | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 115
Deficiencies: 0
Date: Apr 21, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by multiple allegations received on 2021-02-18 regarding resident care issues at Havens at Antelope Valley Assisted Living.
Complaint Details
The complaint investigation addressed nine allegations related to resident hygiene, fluid provision, incontinence care, medication handling, wound treatment, and billing accuracy. Each allegation was found unsubstantiated after interviews with residents and staff, review of records, and observation.
Findings
All allegations including failure to meet resident hygiene, fluid intake, incontinence needs, medication mishandling, wound treatment, and billing errors were investigated and found to be unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Capacity: 115
Census: 83
Number of residents interviewed: 9
Number of residents interviewed: 8
Number of resident files reviewed: 7
Wait time for incontinence assistance: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cassandra Harris | Licensing Program Manager | Oversaw the complaint investigation |
| Mindy Mendoza-Perry | Administrator | Facility administrator who met with the investigator and was involved in the investigation |
| S1 | Med Tech | Spoke to investigator about shower documentation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 115
Deficiencies: 0
Date: Apr 15, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff were not responding to residents' call lights in a timely manner and that the food quality was poor.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not responding promptly to call lights and poor food quality. Interviews with residents and staff, along with review of staff schedules, confirmed adequate staffing and improved food quality. No complaints or issues were observed during the investigation.
Findings
The investigation found no substantiation for the allegations. Interviews with residents and staff, as well as a physical tour, revealed no health or safety issues. Residents reported timely response to call lights and improved food quality with adequate staff coverage confirmed by schedules.
Report Facts
Residents interviewed about call light response: 14
Residents interviewed about food quality: 10
Facility capacity: 115
Facility census: 84
Caregivers on day shift: 4
Med technicians on day shift: 2
Caregivers on evening shift: 3
Med technicians on evening shift: 2
Caregivers on night shift: 1
Med technicians on night shift: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Freda Brock | Administrator | Provided information regarding staffing and facility operations during investigation |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 115
Deficiencies: 0
Date: Apr 14, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including staff threatening a resident with eviction, unexplained weight loss of a resident, staff not allowing a resident to leave his room, and staff searching through a resident's personal belongings.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with staff, residents, and review of records. The facility followed COVID quarantine guidelines, and the eviction notice was a 30-day termination letter not implemented. Staff assisted the resident with banking and billing issues and searched belongings only with resident consent.
Findings
The investigation found all allegations to be unsubstantiated. Staff did not verbally threaten eviction but assisted with billing issues; no extreme weight loss was witnessed; residents were quarantined during confirmed COVID cases which explained room confinement; and staff searched resident belongings only at the resident's request and presence.
Report Facts
Facility capacity: 115
Resident census: 84
Complaint control number: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation |
| Cassandra Harris | Licensing Program Manager | Oversaw the complaint investigation |
| Freda Brock | Administrator | Facility administrator who greeted the investigator |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 115
Deficiencies: 0
Date: Mar 24, 2022
Visit Reason
The visit was an unannounced case management inspection regarding an incident report sent to the Community Care Licensing on March 22, 2022, involving allegations of unkind behavior by a staff member towards residents and a resident's personal rights violation.
Complaint Details
The complaint involved a staff member (S2) speaking unkindly to three residents and a resident reporting a violation of personal rights. The complaint was substantiated by the Health & Wellness Director's investigation, leading to the termination of the staff member.
Findings
The Health & Wellness Director conducted a full internal investigation, resulting in the termination of the staff member involved. Staff informed the affected residents, who were comfortable with the outcome. No deficiencies were reported at this time.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Autumn Roberts Rodriguez | Administrator | Facility administrator named in the report header |
| Melissa Spaeth | Licensing Program Analyst | Conducted the unannounced case management visit |
| Cassandra Harris | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 115
Deficiencies: 4
Date: Mar 8, 2022
Visit Reason
Unannounced complaint investigation visit to investigate allegations including staff stealing from a resident, lack of dignity in staff-resident relationships, non-working air conditioning unit, and unmet incontinence needs.
Complaint Details
The complaint investigation was substantiated. Allegations included staff stealing from a resident, lack of dignity in staff-resident interactions, non-working air conditioning unit, and delayed staff response to resident's incontinence needs. Evidence included interviews, video footage, and response time reports.
Findings
The investigation substantiated all allegations: staff stole food from a resident and caused distress, the resident was not accorded dignity, the air conditioning unit in the resident's room was not working requiring a room change, and staff response times to the resident's pendant calls were often delayed beyond policy standards.
Deficiencies (4)
Personal Rights of Residents in All Facilities-To be accorded dignity in their personal relationships with staff, residents, and other persons.
Personal Rights of Residents in All Facilities-To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
Personal Rights of Residents in All Facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times.
Report Facts
Facility Capacity: 115
Census: 75
Response Time: 7
Response Time: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Cassandra Harris | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 115
Deficiencies: 1
Date: Feb 28, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/13/2020 alleging that the facility is understaffed.
Complaint Details
The complaint was substantiated based on interviews and investigation findings. Ten of sixteen residents reported waiting over thirty minutes for assistance, and staff acknowledged being short-handed.
Findings
The investigation found that the facility was understaffed, resulting in residents waiting over thirty minutes for staff assistance. Ten out of sixteen residents interviewed confirmed delays, and the allegation was substantiated with a cited deficiency under LIC 9099 D.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs, resulting in residents waiting long times for care.
Report Facts
Capacity: 115
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Andrea Gutierrez | Facility staff member interviewed during investigation and confirmed staffing levels | |
| Freda Brock | Administrator | Facility administrator who received a copy of the report |
| Cassandra Harris | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 115
Deficiencies: 1
Date: Feb 14, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that staff did not provide proper medication assistance to a resident in care.
Complaint Details
The complaint was substantiated based on interviews and documentation review. The allegation involved improper medication assistance resulting in missed and late medications for residents.
Findings
Investigation found that on 2/4/22, 2/5/22, and 2/6/22, five residents completely missed all of their medications and twenty-six residents received their medication late, posing an immediate health and safety risk. The administrator admitted staffing shortages caused the issue and corrective actions were taken including hiring new staff.
Deficiencies (1)
Incidental Medical and Dental Care - Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by five residents not given medications at all and twenty-six residents given medications late, posing an immediate health and safety risk.
Report Facts
Residents who missed medications: 5
Residents who received medications late: 26
Facility capacity: 115
Facility census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Autumn Roberts Rodriguez | Administrator | Admitted staffing shortages caused medication issues |
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation |
| Wendell Smith | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Cassandra Harris | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 77
Capacity: 115
Deficiencies: 0
Date: Feb 9, 2022
Visit Reason
The inspection was an unannounced required one-year annual visit to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in compliance with no deficiencies reported. Observations included proper COVID-19 precautions, well-maintained resident apartments, adequate food storage and preparation, and clean common areas.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Autumn Roberts Rodriguez | Administrator | Met with Licensing Program Analyst during the inspection and provided vaccine information. |
| David Hernandez | Dining Hall Director | Introduced to Licensing Program Analyst and described the noon meal menu. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 115
Deficiencies: 0
Date: Dec 1, 2021
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff were not following State of California COVID-19 guidelines and were endangering the health of residents.
Complaint Details
The complaint alleged staff worked after a positive COVID test, congregated without masks in break areas, delayed COVID testing, and hosted a car and craft show. The complaint was unsubstantiated based on interviews and observations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff were observed wearing masks, social distancing was possible in break areas, and the alleged car and craft show was cancelled. COVID testing records showed timely receipt of tests.
Report Facts
Capacity: 115
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
| Freda Brock | Administrator | Facility Administrator mentioned in report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 115
Deficiencies: 0
Date: Nov 5, 2021
Visit Reason
The visit was an unannounced case management incident investigation regarding the personal rights of a resident.
Complaint Details
Investigation of an incident report regarding the personal rights of a resident; further investigation needed; no deficiencies reported at this time.
Findings
The facility was observed to be neat and clean with adequate food supplies and proper hygiene signage. Interviews and record reviews were conducted, and no deficiencies were found at this time. Further investigation is needed regarding the incident.
Report Facts
Capacity: 115
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Autumn Roberts-Rodriguez | Assistant Executive Director | Met with during the inspection and escorted the licensing analyst |
| Melissa Spaeth | Licensing Program Analyst | Conducted the inspection and interviews |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 115
Deficiencies: 1
Date: Aug 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including staff causing injury, rough handling of residents, unqualified hospice services, hiding call buttons, unmet therapy needs, and understaffing.
Complaint Details
The complaint investigation was unannounced and addressed allegations including staff causing injury, rough handling, unqualified hospice services, hiding call buttons, unmet therapy needs, understaffing, and failure to meet residents' hygiene needs. Most allegations were unsubstantiated except for the failure to timely assist residents with incontinent care, which was substantiated.
Findings
Most allegations were found to be unsubstantiated after interviews with residents, staff, and review of records. However, the allegation that staff failed to assist residents in a timely manner with incontinent care was substantiated, resulting in a cited deficiency.
Deficiencies (1)
Failure to assist in a timely manner with resident's incontinent needs, violating CCR 87468.1(a)(2) Personal Rights of All Residents.
Report Facts
Capacity: 115
Census: 77
Deficiencies cited: 1
Plan of Correction Due Date: Aug 31, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cassandra Harris | Licensing Program Manager | Oversaw the complaint investigation |
| Erica Reyes | Health and Wellness Director | Named in plan of correction addressing call light response times |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 115
Deficiencies: 0
Date: Apr 23, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of financial abuse by facility staff and staff mismanaging a resident's clothing.
Complaint Details
The complaint involved allegations of financial abuse by facility staff and mismanagement of a resident's clothing. The complaint was deemed unsubstantiated after interviews with the resident, staff, and administrator, and review of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. The $415.00 erroneous charge was removed from the resident's bill, and the missing jacket was later found by the administrator. Staff and administrator interviews did not support claims of theft or mismanagement.
Report Facts
Charge amount: 415
Capacity: 115
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Spaeth | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Freda Brock | Administrator | Facility administrator involved in investigation and communication |
| Cynthia Edwards | Administrator | Administrator who participated in FaceTime visit and interviews |
| Cassandra Harris | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 115
Deficiencies: 0
Date: Apr 9, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility had roaches.
Complaint Details
The complaint alleged the presence of roaches in the facility. The allegation was unsubstantiated based on observations, interviews, and record review.
Findings
The investigation found no evidence of roaches or droppings during a physical tour, interviews with residents and staff, and a review of pest control records. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 115
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Gutierrez | Business Office Manager | Met with during the investigation |
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