Most inspections found no deficiencies, including the most recent report on October 28, 2025, which cited a deficiency for insufficient supervision that led to a resident eloping, posing an immediate health and safety risk. Earlier reports show a pattern of medication management issues, including repeated medication errors that resulted in civil penalties totaling $500 and required staff retraining. Several complaint investigations were unsubstantiated, though one in February 2023 found residents experienced fear and intimidation from another resident, which was cited as a personal rights violation. The facility showed improvement in some areas, with clean annual inspections in mid-2025 and no deficiencies noted in the latest annual inspection. Minor or isolated issues also involved staff certification and resident care practices, but no license suspensions or warnings were listed in the available reports.
The inspection was conducted as a case management - incident visit to obtain more information regarding an incident report received about a resident who eloped from the facility after attending a community event.
Findings
The facility was cited for not providing necessary services to meet resident needs, specifically due to lack of supervision outside the memory care unit which led to the resident's elopement, posing an immediate health, safety, and personal rights risk.
Complaint Details
The visit was complaint-related, triggered by an incident report received on 08/28/2025 regarding an incident on 08/27/2025 involving a memory care resident who eloped from the facility.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by the resident eloping from the community without staff knowledge and staff not preventing wandering.
Type A
Report Facts
Capacity: 86Census: 77Deficiency count: 1Plan of Correction Due Date: Oct 29, 2025
Employees Mentioned
Name
Title
Context
Dorla Licausi
Administrator
Met with during inspection and named in findings
Julie Florio
Licensing Program Analyst
Conducted the inspection and signed the report
Bethany Moellers
Licensing Program Manager
Named as Licensing Program Manager overseeing the inspection
The visit was an unannounced case management - incident inspection to obtain more information regarding two incident reports involving staff and residents, which were part of a complaint investigation received by the Department.
Findings
The inspection followed up on two incidents involving staff and residents, resulting in a citation issued under the complaint investigation. An exit interview was conducted with the Administrator.
Complaint Details
The visit was triggered by complaint investigation #21-AS-20250821122246 related to two incidents involving Staff 1 and Residents 1 and 2, with a citation issued.
Report Facts
Facility capacity: 86Census: 78
Employees Mentioned
Name
Title
Context
Dorla Licausi
Administrator
Met with Licensing Program Analyst during inspection and exit interview
The inspection was a required unannounced 1-year annual inspection of the Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be in compliance with regulations including safety measures, emergency preparedness, staff and resident file documentation, medication management, and environmental conditions. No deficiencies were explicitly listed in the report.
The inspection was a case management-incident visit conducted to obtain more information regarding an incident that occurred on 2025-05-31 involving multiple residents and a staff member, as reported by the Executive Director via email and incident reports.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst obtained records, made observations, and conducted an interview with the Executive Director.
Employees Mentioned
Name
Title
Context
Dorla Licausi
Executive Director
Met with during the case management-incident inspection and involved in the incident report.
Julie Florio
Licensing Program Analyst
Conducted the case management-incident inspection.
An unannounced complaint investigation was conducted in response to allegations received on 2024-12-11 regarding staff failing to call emergency services, prevent residents from smoking indoors, sleeping on the floor, entering other resident rooms, and interfering with care needs.
Findings
The investigation found no evidence to substantiate the allegations. Records and interviews showed emergency services were called when needed, a strict no-smoking policy was enforced though residents sometimes chose to smoke indoors, residents were occasionally found sleeping in public areas or other resident rooms but were assisted back to their rooms, and no evidence was found of residents interfering with others' care needs.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.
Report Facts
Capacity: 86Census: 72
Employees Mentioned
Name
Title
Context
Christopher Arnhold
Licensing Program Analyst
Conducted the complaint investigation
Dorla Licausi
Executive Director
Met with Licensing Program Analyst during investigation
The visit was an unannounced case management inspection conducted in response to an incident report submitted on 2024-08-26 regarding a medication error involving a resident.
Findings
The facility failed to ensure a resident received the correct amount of medication, posing an immediate health risk. This was a repeat violation within 12 months, resulting in a $250 civil penalty and staff retraining on medication practices.
Complaint Details
The visit was triggered by a complaint/incident report regarding a medication error where resident R1 received a wrong dose of medication. The violation was substantiated as a repeat offense within 12 months.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Licensee did not ensure resident R1 received the correct amount of medication, posing an immediate health risk.
Type A
Report Facts
Civil penalty amount: 250Deficiency count: 1
Employees Mentioned
Name
Title
Context
Dorla Licausi
Executive Director
Met with Licensing Program Analyst during inspection and reviewed findings
The inspection was an unannounced required Annual Inspection conducted to evaluate compliance with licensing regulations for the facility.
Findings
The facility was found to be clean, in good repair, and compliant with regulations regarding resident rooms, water temperature, food storage, medication storage, and staff documentation. No deficiencies were found in medication management or resident and staff files. Fire safety equipment and drills were current.
Report Facts
Fire extinguisher inspection date: Aug 23, 2023Fire alarm inspection date: Apr 18, 2024Last fire drill date: Jun 11, 2024Resident files reviewed: 5Staff records reviewed: 6
Employees Mentioned
Name
Title
Context
Dorla Licausi
Administrator
Met with Licensing Program Analyst during inspection and participated in facility tour
Unannounced visit/investigation of a complaint alleging that facility staff arranged for a resident to have another resident assist them while in care.
Findings
The investigation found that the arrangement for one resident to assist another was voluntary and informal, with no staff request or requirement for such assistance, and no physician order for additional supervision. The allegation was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff arranged for Resident 1 to assist Resident 2 by remaining in Resident 2's room at night to remind them to call for assistance. The allegation was found unsubstantiated.
Report Facts
Capacity: 86Census: 59
Employees Mentioned
Name
Title
Context
David Leibert
Evaluator / Licensing Program Analyst
Conducted the complaint investigation and delivered findings
An unannounced complaint investigation was conducted due to an allegation that staff were mismanaging residents' medication.
Findings
The investigation found that the facility did not mismanage residents' medication. The delay in medication refills was due to the physician not responding timely, and no residents missed any prescribed doses. The complaint was determined to be unfounded.
Complaint Details
The complaint alleging medication mismanagement was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Report Facts
Capacity: 86Census: 60
Employees Mentioned
Name
Title
Context
Christopher Arnhold
Licensing Program Analyst
Conducted the complaint investigation
Dorla Licausi
Executive Director
Met with the Licensing Program Analyst during the investigation
Unannounced complaint investigation conducted due to allegations that medications and special diets, including liquids, were not being provided as ordered to a resident.
Findings
The investigation substantiated that medications and special diets were not provided as ordered, including failure to provide liquids thickened as prescribed and feeding the resident in a non-upright position, which led to choking and aspiration incidents.
Complaint Details
The complaint investigation was substantiated. Allegations included medications not being provided as ordered and special diets, including liquids, not being provided as ordered. The resident experienced choking and aspiration incidents. Staff were aware of doctor's orders but failed to comply. Training was conducted post-investigation.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
The licensee failed to assist residents with self-administered medications as needed, evidenced by photos showing a resident being fed while in a halfway lying position.
Type A
Report Facts
Facility Capacity: 86Census: 59Citation Number: 87465Plan of Correction Due Date: Sep 12, 2023
Employees Mentioned
Name
Title
Context
Kim Alsup
Administrator
Met with Licensing Program Analyst during investigation and conducted in-service training
Dylan Nunn
Resident Service Director, LVN
Met with Licensing Program Analyst and conducted in-service training
The inspection was a Required - 1 Year unannounced visit conducted to evaluate compliance with licensing regulations and facility operation standards.
Findings
The facility was generally compliant with safety, emergency, and operational requirements, including fire safety and infection control plans. However, a deficiency was cited for three out of five staff lacking current first aid certification, posing a potential health and safety risk.
Deficiencies (1)
Description
Three out of five staff did not have current first aid certification as required, posing a potential health, safety, or personal rights risk to residents.
Report Facts
Hospice care waiver residents: 16Fire clearance capacity: 86Bedridden rooms: 10Staff files reviewed: 5Staff lacking first aid certification: 3Staff providing direct care: 3POC due date: Jul 3, 2023
Employees Mentioned
Name
Title
Context
Kim Humphrey
Administrator
Met with Licensing Program Analyst during inspection and named in findings
The visit was an unannounced case management inspection conducted in response to a medication error incident at the facility.
Findings
The facility was found to have given a resident the wrong dose of medication, administering another resident's medication without verifying the name. This was a repeat violation within 12 months. The facility conducted an investigation and staff retraining. A civil penalty of $250 was issued.
Complaint Details
The visit was triggered by a medication error complaint. It was a repeat violation within 12 months and a civil penalty was issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to assist residents with self-administered medications as needed, resulting in a resident being given the wrong medication dose.
Type A
Report Facts
Civil penalty amount: 250
Employees Mentioned
Name
Title
Context
Kim Humphrey
Executive Director
Met with Licensing Program Analyst during the visit and reviewed records
Dylan Nunn
Resident Services Coordinator
Met with Licensing Program Analyst during the visit and reviewed records
Christopher Arnhold
Licensing Program Analyst
Conducted the case management visit and authored the report
The visit was an unannounced case management inspection triggered by an SOC 341 form submitted on 03/22/2023, related to a resident's emotional outburst and assault on a staff member, as well as an investigation into alleged physical abuse due to bruises observed on a resident.
Findings
The investigation found no evidence of physical abuse but identified several medication errors involving five residents who did not receive medications per physician orders. The medication technician failed to update records or notify responsible parties, posing an immediate health risk. A deficiency was cited and a plan of correction was implemented.
Complaint Details
The complaint involved alleged physical abuse of a resident due to bruises observed on the resident's arms. The investigation did not substantiate physical abuse but found medication errors by staff.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Licensee did not ensure 5 of 19 residents received medications per physician orders, posing an immediate health risk.
Type A
Report Facts
Residents who refused medications: 5Total residents: 19Facility capacity: 86
Employees Mentioned
Name
Title
Context
Kim Humphrey
Executive Director
Met with Licensing Program Analyst during the visit and reviewed findings
Christopher Arnhold
Licensing Program Analyst
Conducted the case management visit and investigation
The inspection was conducted as an unannounced complaint investigation visit following a complaint received on 2023-01-18 regarding reporting requirements and items posing danger accessible to residents.
Findings
The investigation found two allegations unsubstantiated due to lack of preponderance of evidence: failure to report incidents and dangerous items accessible to residents. However, the allegation of residents' personal rights violations was substantiated based on interviews revealing fear and intimidation by another resident, posing a potential health and safety risk.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Erik Gonzalez Campos. The complaint control number is 21-AS-20230118110739. The allegations included failure to report incidents and items posing danger accessible to residents, both unsubstantiated, and violation of residents' personal rights, substantiated. Appeal rights were provided.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Residents of residential care facilities for the elderly shall have the right to be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by three out of six resident interviews revealing fear and intimidation by another resident.
Type B
Report Facts
Capacity: 86Census: 53Deficiencies cited: 1Plan of Correction Due Date: Feb 17, 2023
Employees Mentioned
Name
Title
Context
Erik Gonzalez Campos
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Kim Humphrey
Administrator
Met with Licensing Program Analyst during the investigation
The inspection was conducted due to a complaint alleging that staff spoke to a resident in an inappropriate manner.
Findings
The investigation found no preponderance of evidence to substantiate the allegation. Six residents interviewed, including the subject resident, denied the allegation. No deficiencies were cited during the inspection.
Complaint Details
The allegation that staff spoke to a resident in an inappropriate manner was unsubstantiated after investigation.
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 08/22/2022 regarding the facility's care practices.
Findings
All allegations including failure to follow resident's special diet, leaving a resident in his room during lunch, failure to provide nail care, and improper medication administration were investigated and found to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the inspection.
Complaint Details
The complaint investigation addressed multiple allegations: the facility not following a resident's special diet, leaving a resident in his room during lunch, not ensuring nail care, and not administering medication per physician's orders. Each allegation was found unsubstantiated after review of records, interviews, and observations.
Report Facts
Facility capacity: 86Census: 62Complaint control number: 21-AS-20220822154523
Employees Mentioned
Name
Title
Context
Erik Gonzalez Campos
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Kim Humphrey
Administrator
Facility administrator met during inspection and involved in discussions
The inspection was a case management follow-up visit conducted in response to several SOC 341 incident reports received by Community Care Licensing in late August 2022.
Findings
The inspection reviewed incidents involving resident-on-resident and resident-on-staff altercations in the memory care unit. The facility provided incident narratives and clarification, and has implemented measures to address resident behavior.
Employees Mentioned
Name
Title
Context
Kim Humphrey
Administrator
Met with Licensing Program Analyst during inspection and involved in incident clarifications.
Erik Gonzalez Campos
Licensing Program Analyst
Conducted the case management inspection.
Kimberley Mota
Licensing Program Manager
Named in report header.
Inspection Report Original LicensingCensus: 65Capacity: 86Deficiencies: 0Aug 2, 2022
Visit Reason
The inspection was an unannounced Post Licensing inspection conducted to evaluate the facility's compliance following licensing.
Findings
The facility was found to be in good repair, clean, and compliant with safety and care standards. No deficiencies were cited during the inspection.
Report Facts
Fire extinguisher last charged date: Aug 6, 2021Fire drill date: Jul 29, 2022Fire panel last inspection date: 202110Number of stairwells: 3
Employees Mentioned
Name
Title
Context
Kim Humphrey
Administrator
Administrator was involved in the inspection and exit interview.
Juan Mendoza
Maintenance Director
Maintenance Director accompanied the Licensing Program Analyst during the inspection.
The inspection was an unannounced case management visit conducted regarding an SOC341 received by Community Care Licensing on 06/30/2022.
Findings
During the inspection, the Licensing Program Analyst interviewed staff and reviewed resident records. Follow-up notes concerning SOC341 are pending the Wellness Coordinator's return. Yearly resident assessments for memory care unit residents were discussed with the administrator.
Employees Mentioned
Name
Title
Context
Kim Humphrey
Administrator
Met with Licensing Program Analyst during inspection and discussed yearly resident assessments.
Erik Gonzalez Campos
Licensing Program Analyst
Conducted the case management inspection.
Kimberley Mota
Licensing Program Manager
Named in the report header.
Inspection Report Original LicensingCensus: 65Capacity: 86Deficiencies: 0Jun 23, 2022
Visit Reason
The visit was conducted as a change of ownership evaluation and pre-licensing readiness assessment for the Residential Care Facility for the Elderly.
Findings
The applicant/administrator participated in a COMP II telephone interview verifying identity and understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and reporting.
Report Facts
Capacity: 86Census: 65
Employees Mentioned
Name
Title
Context
Kimberly Humphrey
Administrator
Applicant/administrator who participated in COMP II interview
Jude De La Concepcion
Licensing Program Manager
Named in report header
Bethany Hunter
Licensing Program Analyst
Conducted COMP II interview and signed report
Inspection Report Original LicensingCensus: 64Capacity: 86Deficiencies: 0Jun 21, 2022
Visit Reason
The inspection was a pre-licensing unannounced visit conducted due to a change in ownership from Brookdale Napa and included a hospice waiver request with the new application.
Findings
The facility was found to be in compliance with all applicable regulations, with no deficiencies cited. The environment was safe, clean, and well-maintained, with proper staffing, emergency systems, and infection control measures observed.
Report Facts
Assisted living residents: 42Residents on hospice: 6Memory care unit residents: 22Fire clearance capacity: 76Fire clearance capacity: 10Double occupant bedrooms: 17Water temperature range: 112.6Water temperature range: 119.6Perishable food supply: 2Non-perishable food supply: 7Last disaster drill date: Feb 24, 2022Last fire drill date: May 18, 2022Last elopement drill date: Apr 29, 2022
Employees Mentioned
Name
Title
Context
Kim Humphrey
Administrator
Met with Licensing Program Analyst during pre-licensing inspection
The visit was conducted as an office evaluation related to a Change of Ownership application for the Residential Care Facility for the Elderly.
Findings
The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.
Report Facts
Capacity: 86Census: 70
Employees Mentioned
Name
Title
Context
Kim Humphrey
Administrator
Facility administrator participating in the evaluation
Cluney Stagg
Participant in COMP II telephone interview
Michel Augsburger
Participant in COMP II telephone interview
Jude De La Concepcion
Licensing Program Manager
Named in the report as Licensing Program Manager
Bethany Hunter
Licensing Program Analyst
Named in the report as Licensing Program Analyst
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