Inspection Report Summary
Most inspections found no deficiencies, including the most recent report dated September 30, 2025, which was perfect and found no evidence supporting allegations about safeguarding residents' confidential information. However, earlier reports revealed some serious issues, such as substantiated physical abuse by a staff member in June 2025 that led to immediate termination and a Type A deficiency, and improper medication administration without resident consent in May 2025, also resulting in a Type A deficiency. Other deficiencies involved failure to seek timely medical care for a resident with injuries in 2024, which led to a $500 fine, and safety risks like an unlocked medication cart and environmental hazards identified in prior years. Several complaint investigations were unsubstantiated, including allegations about management availability, facility disrepair, and false advertising. The facility’s record shows some improvement over time, with recent investigations finding no deficiencies after earlier serious findings.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
83% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 88
Capacity: 106
Deficiencies: 0
Date: Sep 30, 2025
Visit Reason
An unannounced Initial 10-Day complaint investigation visit was conducted regarding the allegation that staff do not safeguard the residents' confidential information.
Complaint Details
The complaint alleged that staff did not safeguard residents' confidential information by allowing a third party business access to a resident’s personal information, resulting in the sale of the resident’s personal property. The investigation included interviews with staff, residents, witnesses, and review of documents. The allegation was found unsubstantiated due to lack of evidence.
Findings
The investigation found no preponderance of evidence to support the allegation. Staff, residents, and witnesses denied that staff provided residents' confidential information to third parties or were involved in selling residents' personal property. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 106
Census: 88
Staff interviewed: 6
Residents interviewed: 9
Witnesses interviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Konishi | Licensing Program Analyst | Conducted the complaint investigation |
| Daniel Orozco | Executive Director | Facility representative interviewed during the investigation |
| Cecilia Degraff | Administrator | Facility administrator named in the report |
| David Sicairos | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 106
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to an allegation that the facility did not have a designated substitute administrator.
Complaint Details
The complaint alleged that the facility did not have a designated substitute administrator and that no management was visible or available during a recent tour. The allegation was unsubstantiated based on staff and resident interviews, documentation review, and observations.
Findings
The investigation found that all seven staff interviewed denied the allegation and confirmed management was always available via phone and email. Four residents also denied the allegation, stating management was easily accessible. Documentation showed designated substitute administrators were authorized during the administrator's temporary absence. The allegation was unsubstantiated and no violations were observed.
Report Facts
Staff interviewed: 7
Residents interviewed: 4
Designation of responsibility forms: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Daniel Orozco | Associate Executive Director | Met with investigator and designated substitute administrator |
| Cecilia Degraff | Administrator | Facility administrator who designated substitutes during her absence |
| April Vargas | Executive Director | Designated substitute administrator during the administrator's absence |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 106
Deficiencies: 1
Date: Jun 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that a resident was being physically abused while in care.
Complaint Details
The complaint investigation was substantiated. The allegation was that a resident was physically abused by staff in the dementia wing. Evidence included staff interviews, record reviews, and a police incident report. The facility terminated the staff member involved. The police report and responsible party interview did not corroborate the allegation, but the preponderance of evidence supported substantiation.
Findings
The investigation substantiated the allegation that staff member S1 physically abused resident R1 by pushing them down into bed, handling them roughly during dressing, and forcefully sitting them down. No injuries were found, but S1's conduct was found to pose an immediate threat to residents' health and safety, resulting in termination of S1's employment and issuance of a Type A deficiency.
Deficiencies (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: (3) 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. This requirement was not met as evidenced by: S1 physically abused R1 which poses an immediate threat to the physical health, mental health, or safety of residents in care.
Report Facts
Deficiencies cited: 1
Capacity: 106
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Fernando Fierros | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Cecilia Degraff | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 106
Deficiencies: 1
Date: May 16, 2025
Visit Reason
The inspection was an unannounced Case Management Visit-Deficiency conducted on 05/16/2025, stemming from a subsequent complaint investigation regarding medication administration practices.
Complaint Details
The visit was triggered by a complaint investigation (Control Number: 28-AS-20250429162024) related to medication administration practices involving resident #1.
Findings
Staff camouflaged resident #1's medications into chocolate pudding without the resident's consent or a physician's order, violating regulations and posing an immediate risk to the health, safety, and personal rights of persons in care. A Type A deficiency was issued for this violation.
Deficiencies (1)
Staff camouflaged resident #1's medications in pudding without the resident's knowledge and consent, violating assistance with self-administration regulations.
Report Facts
Deficiencies cited: 1
Capacity: 106
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the unannounced Case Management Visit-Deficiency and issued the deficiency. |
| Deseree Suyat | Director of Nursing | Met with the Licensing Program Analyst during the inspection and was involved in staff interviews. |
| Tony Vasallo | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 106
Deficiencies: 0
Date: May 15, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility was in disrepair and that staff did not provide adequate supervision to residents in care.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included facility disrepair and inadequate staff supervision. Evidence showed the entrance door was repaired within 24 hours and staff coverage was adequate with 45-50 employees per shift. Police visits related to complaints did not disrupt operations and no further investigation was reported.
Findings
The investigation found that the front entrance door was functional and repaired promptly after a mechanical malfunction, and that the facility had adequate staff providing supervision to residents. Interviews and record reviews did not corroborate the allegations, resulting in the complaints being unsubstantiated.
Report Facts
Facility capacity: 106
Census: 90
Staff per shift: 45
Staff per shift: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Orozco | Associate Executive Director | Met with Licensing Program Analyst during the investigation and received the exit interview and report copy |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 106
Deficiencies: 0
Date: May 1, 2025
Visit Reason
The inspection was an unannounced 10-day complaint investigation visit triggered by an allegation that the licensee was falsely advertising, promoting, and holding themselves out as providing special care.
Complaint Details
The allegation was that the licensee was falsely advertising and promoting special care, with staff making misleading statements and behaving unprofessionally. Five out of five staff and seven out of seven residents interviewed denied the allegation. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Findings
After interviews with staff and residents, review of promotional materials, and facility tour, there was insufficient evidence to substantiate the allegation. Staff and residents denied the claims, and the services listed in promotional materials were confirmed to be provided.
Report Facts
Staff interviewed: 5
Residents interviewed: 7
Complaint investigation duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation |
| Gabriela Castro | Licensing Program Analyst | Conducted the complaint investigation |
| Cecilia DeGraff | Executive Director | Facility representative who assisted with the investigation |
| David Sicairos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 89
Capacity: 106
Deficiencies: 0
Date: Jan 27, 2025
Visit Reason
The inspection was a required annual unannounced visit to evaluate compliance with licensing regulations and facility operations.
Findings
The facility was found to be in compliance with infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, residents' rights, planned activities, food service, incidental medical and dental care, disaster preparedness, and care for residents with special health needs. No deficiencies were cited during this inspection.
Report Facts
Staff members on roster: 139
Staff files reviewed: 10
Resident files reviewed: 10
Licensed capacity: 106
Current census: 89
Fire inspection date: Sep 5, 2024
Liability insurance coverage: 1000000
Liability insurance aggregate: 3000000
Liability insurance expiration date: Jun 1, 2025
Fire and disaster drills last conducted: Jan 21, 2025
Administrator certificate expiration: Apr 27, 2026
Medication supply reviewed: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cecilia DeGraff | Senior Executive Director | Met with Licensing Program Analyst during inspection and received report copy |
| Bennette Pena | Licensing Program Analyst | Conducted the required annual inspection |
| David Sicairos | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 106
Deficiencies: 0
Date: Jan 27, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that facility staff were not providing adequate transportation services to residents, specifically that multiple medical appointments were turned down or rescheduled due to staff misuse of the company vehicle.
Complaint Details
The complaint alleged that between 01/13/2025 and 01/22/2025, multiple medical appointments were turned down or rescheduled due to a staff member using the medical transportation company vehicle for personal purposes. The investigation found insufficient evidence to substantiate this allegation.
Findings
The investigation included interviews with staff and residents, review of transportation logs and related documents, and found no evidence to support the allegation. Staff and residents denied cancellations or rescheduling due to vehicle unavailability, and the transportation log showed no such disruptions. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 106
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation |
| Cecilia DeGraff | Senior Executive Director | Facility representative met during investigation |
| David Sicairos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 106
Deficiencies: 1
Date: May 23, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that a resident sustained unexplained injuries while in care and that staff did not seek medical assistance in a timely manner.
Complaint Details
The complaint was substantiated. The resident sustained unexplained injuries including fractured ribs, a wrist injury, and a minor toe injury. The facility did not seek medical assistance in a timely manner. The resident was not identified as a fall risk despite having multiple risk factors such as confusion, use of a walker, advanced age, and psychotropic medication use.
Findings
The investigation substantiated that the resident sustained fractured ribs, a wrist injury, and a minor toe injury while in care, and the facility failed to seek timely medical assistance. The facility also failed to develop a care plan addressing the resident as a fall risk despite multiple risk factors.
Deficiencies (1)
Facility failed to develop a care plan based on the resident’s specific needs and to address the resident as a fall risk.
Report Facts
Civil Penalty: 500
Capacity: 106
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luis Mora | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation. |
| Cecilia DeGraff | Executive Director | Facility administrator met during the investigation. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 106
Deficiencies: 3
Date: Apr 25, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that a resident sustained unexplained injuries while in care and that staff did not seek medical assistance in a timely manner, as well as allegations regarding failure to notify the resident's authorized representative of an injury and unmet hygiene needs.
Complaint Details
The complaint investigation was substantiated for allegations that the resident sustained unexplained injuries and that staff did not seek medical assistance in a timely manner. The allegations that staff did not notify the resident's authorized representative and that the resident's hygiene needs were not met were unsubstantiated.
Findings
The investigation substantiated that the resident sustained fractured ribs, a wrist injury, and a minor toe injury while in care, and that the facility did not seek timely medical assistance. The resident was not identified as a fall risk despite multiple risk factors. The allegation that staff failed to notify the resident's authorized representative was unsubstantiated, as a voicemail was left. The allegation regarding unmet hygiene needs was also unsubstantiated. An immediate civil penalty of $500 was issued due to the substantiated deficiencies.
Deficiencies (3)
Resident sustained unexplained injuries while in care and facility did not seek medical assistance in a timely manner.
Facility did not comply with Title 22 Section 87468.1(a)(2) regarding safe, healthful and comfortable accommodations, furnishings and equipment.
Facility did not comply with Title 22 Section 87465(a)(1) regarding arranging or assisting in arranging medical and dental care appropriate to residents' needs.
Report Facts
Civil Penalty: 500
Capacity: 106
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Luis Mora | Licensing Program Analyst | Conducted the complaint investigation and interviews. |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation. |
| Cecilia DeGraff | Executive Director | Facility administrator met during the investigation. |
Inspection Report
Annual Inspection
Census: 86
Capacity: 106
Deficiencies: 1
Date: Feb 13, 2024
Visit Reason
The Licensing Program Analyst conducted the required annual unannounced inspection to evaluate compliance with regulatory requirements for the facility licensed to serve elderly residents.
Findings
The facility was generally compliant with infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, residents' rights, planned activities, food service, disaster preparedness, and care for residents with special health needs. One deficiency was cited regarding an unlocked medication cart posing a safety risk, which was immediately corrected by staff locking the cart.
Deficiencies (1)
Medication cart filled with prescribed medication belonging to various residents was found unlocked and unattended in the hallway, posing an immediate health, safety, or personal rights risk.
Report Facts
Facility licensed capacity: 106
Resident census: 86
Plan of Correction due date: Feb 14, 2024
Staff files reviewed: 10
Resident files reviewed: 10
Perishable food supply: 2
Non-perishable food supply: 7
Administrator certificate expiration: Apr 27, 2024
Last disaster drill date: Jan 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cecilia DeGraff | Administrator / Executive Director | Facility Administrator involved in medication cart deficiency correction and exit interview |
| Tena Herrera | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| David Sicairos | Supervisor | Supervisor overseeing the licensing evaluation |
| Daniel Orozco | Haven Manager | Assisted with the facility tour during inspection |
Inspection Report
Annual Inspection
Census: 84
Capacity: 106
Deficiencies: 0
Date: Jan 21, 2023
Visit Reason
An unannounced required Annual Visit focusing on COVID-19 Infection Control Practices was conducted to evaluate compliance with infection control and facility regulations.
Findings
The facility was found to be in compliance with all regulations, including proper water temperatures, clean and equipped bathrooms, operational signal systems, safe food storage, and fire safety measures. No deficiencies were observed during the visit.
Report Facts
Water temperature: 105
Water temperature: 105.4
Water temperature: 114.8
Water temperature: 105
Water temperature: 118.2
Water temperature: 113.2
Water temperature: 106.7
Water temperature: 105.2
Water temperature: 105.7
Water temperature: 105.6
Capacity: 106
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the unannounced required Annual Visit |
| Cecilia Degraff | Executive Director | Facility Executive Director who assisted in the tour |
| Daniel Orozco | Haven Program Manager | Met Licensing Program Analyst and explained purpose of visit |
| Tony Vasallo | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 106
Deficiencies: 0
Date: May 12, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that facility staff dropped a resident resulting in injury, that the resident had a pressure injury while in care, and that the resident had torn, ripped, or stretched out clothing.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a resident being dropped causing injury, having a pressure injury, and having torn clothing. Interviews with staff, the resident, and family, as well as record reviews, did not substantiate the allegations.
Findings
The investigation found that the resident had a fall but was not dropped by staff, sustained a small scrap on the knee not diagnosed as a pressure injury, and had older clothing but was not pulled from clothing during care. All allegations were unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 106
Resident census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tony Vasallo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cecilia Degraff | Administrator | Facility administrator met during the investigation |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 84
Capacity: 106
Deficiencies: 3
Date: Mar 3, 2022
Visit Reason
The inspection was a Required - 1 Year unannounced visit to evaluate compliance with regulations, including infection control, physical plant safety, medication, and food supplies.
Findings
The facility was found to have deficiencies related to hot water temperatures exceeding Title 22 Regulation guidelines, presence of toxic substances accessible to residents, and missing prescribed PRN medications for a resident. These deficiencies posed immediate health and safety risks but citations were cleared at the time of visit.
Deficiencies (3)
Hot water temperature throughout the facility exceeded the maximum allowed 120 degrees F, with measurements up to 123.9 degrees F posing immediate health and safety risks.
Peroxide Multi Surface Cleaner/Disinfectant Spray and Vision Lens Cleaner were found in a resident area accessible to residents, posing immediate health and safety risks.
PRN medications prescribed by Resident 1's physician were missing from the facility, posing immediate health and safety risks.
Report Facts
Hot water temperature: 123.9
Facility capacity: 106
Census: 84
Plan of Correction Due Date: Mar 3, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joe Katrdzhyan | Licensing Evaluator | Conducted the inspection and authored the report |
| Wei Siew Ho | Supervisor | Supervised the inspection |
| Stephanie Peck | Director of Nursing | Met with Licensing Program Analyst during inspection |
| Daniel Orozco | Wellness Nurse | Met with Licensing Program Analyst during inspection |
| Cecilia Degraff | Executive Director | Assisted with the inspection visit |
Viewing
Loading inspection reports...
