Inspection Report Summary
Most inspections found deficiencies related primarily to medication management, resident safety, and staff training, with several complaint investigations substantiated. The facility faced immediate health and safety risks in memory care due to unsecured windows and doors, and insufficient trained staff, with these serious issues noted in late 2024. More recent reports from August 27, 2025, continued to cite deficiencies involving late incident reporting and failure to report a resident’s elopement promptly, but no new immediate jeopardy findings or fines were listed. Several complaints about pest control were unsubstantiated, and the facility has taken corrective actions such as staff termination and additional training in response to incidents. The most recent inspection on August 27, 2025, still found some deficiencies, indicating ongoing challenges, though there is no clear pattern of worsening or improvement over time.
Deficiencies (last 3 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a August 2025 inspection.
Census over time
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and signed the report |
| Deborah Bradley | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Ricardo Romero | Interim Executive Director | Met with Licensing Program Analyst during inspection |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Deborah Bradley | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Ricardo Romero | Interim Executive Director | Met with Licensing Program Analyst during inspection |
| Joseph Villanueva | Administrator/Director | Facility Administrator/Director |
| S1 | Interviewed regarding conversations with resident's family about elopements |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Administrator/Director | Named as facility administrator |
| Deborah Bradley | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Ricardo Romero | Interim Executive Director | Met with Licensing Program Analyst during inspection |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bennett Fong | Licensing Program Manager | Oversaw the complaint investigation |
| Deborah Bradley | Assistant Executive Director | Met with Licensing Program Analyst during investigation |
| Ricardo Romero | Interim Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the complaint investigation |
| Deborah Bradley | Assistant Executive Director | Met with Licensing Program Analyst during investigation |
| Ricardo Romero | Interim Executive Director | Met with Licensing Program Analyst during investigation |
| Bennett Fong | Licensing Program Manager | Named in report signature |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Interim Executive Director | Met with Licensing Program Analysts during inspection |
| Deborah Bradley | Assistant Executive Director | Accompanied Licensing Program Analysts during facility tour |
| Kelley Jeffries | Care Specialist | Met with Licensing Program Analysts and explained purpose of visit |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Administrator | Met with Licensing Program Analysts during the inspection. |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Executive Director | Met with Licensing Program Analysts during the inspection and named in findings related to facility management. |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Bennett Fong | Licensing Program Manager | Named as supervisor and licensing program manager in the report. |
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Executive Director | Met during inspection and discussed Plan of Correction status. |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and communicated with facility regarding deficiencies and Plan of Correction. |
| Bennett Fong | Licensing Program Manager | Named as supervisor in the report. |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Executive Director | Met with Licensing Program Analysts during inspection and agreed to plans of correction. |
| Grace Luk | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Executive Director | Met with Licensing Program Analysts during inspection |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted inspection and cited deficiency |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Executive Director | Met with Licensing Program Analysts during investigation |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Bennett Fong | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Executive Director | Met with Licensing Program Analyst during the visit and involved in the investigation |
| Lori Alexander | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Executive Director | Met with Licensing Program Analyst during inspection and provided information about the incident and training |
| Lori Alexander | Licensing Program Analyst | Conducted the unannounced Case Management visit and evaluation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Executive Director | Met with Licensing Program Analyst during the visit |
| Lori Alexander | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Executive Director | Met with Licensing Program Analyst during inspection and discussed incident |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Joseph Villanueva | Executive Director | Met with Licensing Program Analyst during the visit |
| Deborah Bradley | Assistant Executive Director | Met with Licensing Program Analyst to discuss the incident |
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| Deborah Bradley | Interim Executive Director | Met with Licensing Program Analysts during inspection |
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| Deborah Bradley | Interim Executive Director | Participated in the pre-licensing inspection and demonstrated knowledge of regulations. |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the Component III Review during the pre-licensing inspection. |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| Deborah Bradley | Administrator | Administrator who participated in the Component II interview and exit interview. |
| Andrew Kohlberg | Applicant | Applicant who participated in the Component II interview. |
| Darla Neeley | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Celia Phomphachanh | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
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