Most inspections found no deficiencies, including the most recent annual inspection on August 1, 2025, which was perfect with no issues cited. One complaint investigation in September 2022 found the facility improperly restricted resident family visits based on a Power of Attorney’s unauthorized limitations, which was a violation of residents’ rights. Other complaint investigations, including several related to COVID-19 protocols and resident care concerns, were unsubstantiated. There were no fines, enforcement actions, or severe deficiencies reported in any inspections. The facility’s record shows consistent compliance with licensing requirements and improvement over time, with the latest reports all clean.
An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in compliance with all licensing requirements. Resident rooms and common areas were properly maintained, staff and resident records were complete, and no deficiencies were cited during the inspection.
Report Facts
Residents on hospice: 20Licensed capacity: 132Current census: 112Staff records reviewed: 10Resident records reviewed: 10Residents' medication reviewed: 4Hot water temperature: 119Hot water temperature: 120.1
Employees Mentioned
Name
Title
Context
Robert May
Executive Director
Met with Licensing Program Analysts during inspection
Rachael Martinez
Associate Executive Director
Received copy of the report and participated in exit interview
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements and facility operations.
Findings
The facility was found to be in compliance with no deficiencies cited. All reviewed staff and resident records met required standards, and the facility environment was clean, safe, and well-maintained.
Report Facts
Staff records reviewed: 7Resident records reviewed: 9Residents' medication reviewed: 3Hot water temperature: 116Hot water temperature: 116.7Facility capacity: 132Current census: 117
Employees Mentioned
Name
Title
Context
Robert May
Executive Director
Met with Licensing Program Analyst during inspection and participated in exit interview
An unannounced annual visit was conducted to evaluate the facility's compliance with licensing requirements and overall operations.
Findings
The facility was found to be in compliance with all applicable regulations. No deficiencies were cited during the visit. The physical plant, kitchen, common areas, safety measures, infection control, medication storage, and file reviews were all satisfactory.
The visit was an initial case management visit conducted by Licensing Program Analyst Ana Soto to address an incident involving resident R#1's aggressive behavior and subsequent hospitalization.
Findings
Resident R#1 exhibited aggressive behavior that staff could not control, leading to paramedics and police involvement. R#1 was hospitalized, placed on hospice, and passed away on 02/08/2023. Relevant medical and incident records were obtained and reviewed.
Report Facts
Facility capacity: 132Census: 117
Employees Mentioned
Name
Title
Context
Amy Adam
RN
Met with Licensing Program Analyst during the visit and involved in incident management
The inspection was an unannounced complaint investigation conducted in response to allegations that facility staff were withholding residents' mail and that the facility administrator did not spend sufficient time at the facility.
Findings
The investigation found no evidence to support the allegations. Interviews and record reviews showed that mail was properly distributed and the administrator was present and available at the facility as required. Therefore, the allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with staff and residents, review of mail distribution procedures, resident rosters, and the administrator's work schedule. There was no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Facility capacity: 132
Employees Mentioned
Name
Title
Context
Robert May
Executive Director
Named in relation to allegations and investigation findings
Unannounced complaint investigation conducted due to allegations that staff denied resident family visits and other communication with family.
Findings
The investigation substantiated the allegations that staff denied resident family visits and other communication with family based on a Power of Attorney's (POA) restrictions, which the POA is not authorized to impose. The facility was found to be non-compliant with regulations regarding visitor and communication rights.
Complaint Details
The complaint investigation was substantiated. Allegations included staff denying resident family visits and other communication with family. The investigation found that the facility was abiding by a POA's request to restrict visitors and communication, but the POA does not have the legal right to restrict visitors or communication. The facility's actions posed a potential health and safety risk for persons in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to allow visitors, including ombudspersons and advocacy representatives, to visit privately during reasonable hours and without prior notice, infringing on residents' rights.
Type B
Report Facts
Capacity: 132Census: 22Deficiencies cited: 1Plan of Correction Due Date: Oct 7, 2022
Employees Mentioned
Name
Title
Context
Robert May
Executive Director
Named in findings related to visitor and communication restrictions
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not following COVID-19 protocols.
Findings
The investigation found that the facility was following the latest COVID-19 protocols, including resident and staff testing, use of PPE, and separation of residents by COVID status. The allegation was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that the facility was not following COVID-19 protocols. The investigation included interviews with the Executive Director, Director of Nursing, Haven Supervisor, staff, and residents, as well as record reviews and a tour of the Haven Unit. The Department of Public Health had also conducted a site visit with no concerns. The allegation was found unsubstantiated.
Report Facts
Capacity: 132Census: 113
Employees Mentioned
Name
Title
Context
Robert May
Executive Director
Interviewed during complaint investigation and exit interview
The inspection was an unannounced complaint investigation conducted in response to allegations that staff denied resident family visits and other communication with family.
Findings
The investigation found that the facility was abiding by the Power of Attorney's (POA) requests regarding visitation and communication restrictions. Interviews and record reviews did not substantiate the allegations, and there was no preponderance of evidence to prove the alleged violations occurred.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff denying resident family visits and other communication with family. The facility followed POA instructions restricting certain family members' visits and communications. Interviews with staff and review of legal documents supported the facility's compliance.
Report Facts
Capacity: 132Census: 22
Employees Mentioned
Name
Title
Context
Robert May
Executive Director
Interviewed during complaint investigation and involved in findings
An unannounced complaint investigation was conducted in response to an allegation that the facility was not following COVID-19 protocols.
Findings
The investigation included interviews and record reviews, and found that the facility was following the latest COVID-19 protocols, including resident and staff testing, use of PPE, and separation of residents by COVID status. The allegation was unsubstantiated due to lack of evidence.
Complaint Details
The complaint alleged that the facility was not following COVID-19 protocols. The investigation found all interviewed staff and residents agreed the facility followed the latest COVID-19 protocols. The allegation was unsubstantiated.
Report Facts
Capacity: 132Census: 115
Employees Mentioned
Name
Title
Context
Robert May
Executive Director
Met with during investigation and participated in interviews
An unannounced complaint investigation was conducted based on a complaint received on 05/26/2021 alleging that staff do not ensure resident's toileting needs are met.
Findings
The investigation included interviews and record reviews and found that the resident in question was a temporary respite resident with a temporary physical disability receiving therapy. Interviews and documentation indicated that the resident's toileting needs were being met and the allegation was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff do not ensure resident's toileting needs are met. The allegation was found unsubstantiated after investigation including interviews with staff, residents, and review of records.
Report Facts
Capacity: 132Census: 95
Employees Mentioned
Name
Title
Context
Robert May
Executive Director
Interviewed during complaint investigation and named in findings
An unannounced annual required visit and infection control inspection were conducted to evaluate compliance with regulations and infection control practices at the facility.
Findings
No deficiencies were observed during the inspection. The facility was found to be in excellent repair with all safety and infection control measures in place, including sanitizing stations, PPE supplies, and proper medication storage.
Report Facts
Fire extinguishers: 10Hot water temperature: 111PPE supply duration: 30Resident ambulatory count: 38Resident non-ambulatory count: 60Bedrooms: 116Bathrooms: 133
Employees Mentioned
Name
Title
Context
Robert May
Executive Director
Met with Licensing Program Analyst during inspection and participated in exit interview
Raquel Martinez
Business Director
Participated in facility tour during inspection
Ana Soto
Licensing Program Analyst
Conducted the inspection and infection control survey
Janae Hammond
Licensing Program Manager
Named as Licensing Program Manager on report
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