Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on May 1, 2025, which was clean and showed the facility maintained approved plans and proper safety measures. Several complaint investigations substantiated issues related to medication management, such as missed or delayed medications and a failure to assist residents with self-administered medications, posing health and safety risks. Other complaints about staff response times and incident reporting were also substantiated but were isolated and did not lead to fines or enforcement actions. Many other complaint investigations were unsubstantiated, including allegations of neglect, poor communication, and inadequate care. The facility’s record shows improvement over time, with the latest inspection free of deficiencies after earlier findings mostly focused on medication-related concerns.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 75
Capacity: 92
Deficiencies: 0
May 1, 2025
Visit Reason
The inspection was a Required - 1 Year unannounced visit conducted to evaluate compliance with licensing requirements for the assisted living facility, including the memory care unit.
Findings
The facility was found to have approved plans for dementia care, hospice waiver, fire clearance, emergency disaster, and infection control. Resident and staff files were complete, and safety measures such as evacuation chairs and locked medication rooms were in place. No deficiencies were cited during the inspection.
Report Facts
Residents with hospice waiver: 20
Fire clearance capacity: 92
Bedridden residents allowed: 20
Emergency shelter duration: 72
Resident files reviewed: 10
Staff files reviewed: 10
Stairwells with evacuation chairs: 3
Hot water temperature: 116.4
Hot water temperature: 118.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with Licensing Program Analyst during inspection and participated in facility tour |
| Abraham Bautista | Maintenance Director | Participated in facility tour with Licensing Program Analyst |
| Dina Alviso | Licensing Program Analyst | Conducted the Required - 1 Year inspection |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 92
Deficiencies: 1
Jan 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that staff did not provide residents' medications as prescribed.
Findings
The investigation substantiated the allegation that medication was not provided as prescribed. One resident missed medication for approximately two weeks due to lack of a physician's order, and another resident's refill medication was not picked up in a timely manner, posing a risk to resident health and safety.
Complaint Details
The complaint was substantiated. The allegation was that staff did not provide residents' medications as prescribed. The investigation confirmed missed medications due to lack of physician's order and delayed medication refill pickup.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87465(a)(4) Incidental Medical & Dental Care - The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by the resident's refill medication not being picked up in a timely manner, posing a risk to resident's health and safety. | Type A |
Report Facts
Facility capacity: 92
Deficiency count: 1
Plan of Correction due date: Jan 15, 2025
Training submission due date: Jan 27, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met during inspection and named in findings related to medication issues |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 62
Capacity: 92
Deficiencies: 0
Jun 20, 2024
Visit Reason
The inspection was an annual continuation case management visit conducted to evaluate compliance with licensing requirements and facility operations.
Findings
The facility was found to be in compliance with no deficiencies cited. The inspection confirmed the presence of approved plans for dementia care, hospice waiver, emergency disaster, infection control, and adequate supplies for shelter in place. Resident and staff files were complete and all medications and hazardous materials were securely stored.
Report Facts
Residents with hospice waiver: 20
Fire clearance capacity: 92
Bedridden capacity: 20
Shelter in place supply duration (hours): 72
Resident files reviewed: 7
Staff files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with Licensing Program Analyst during inspection |
| Dina Alviso | Licensing Program Analyst | Conducted the annual continuation inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 0
Jun 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff neglect resulted in a resident being hospitalized and sustaining a fracture while in care.
Findings
The investigation reviewed records, conducted interviews, and found no evidence to substantiate the allegations of staff neglect. The resident had a care plan in place, and no violations were found related to the incident.
Complaint Details
The complaint was unsubstantiated based on interviews, record reviews, and related information obtained during the investigation. There was no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 92
Census: 62
Date of fall incident: Jan 30, 2024
Hospital admission date: Feb 1, 2024
Discharge date: Apr 12, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with Licensing Program Analyst during investigation and mentioned in findings |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 0
Jun 20, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2024-01-29 regarding staff conduct, communication barriers, record keeping, and medication management at the facility.
Findings
The investigation found no substantiated evidence to support the allegations. Interviews, record reviews, and hospice agency input indicated no violations occurred, and staff communication and care practices were appropriate.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not providing a comfortable environment, rough handling of residents, communication barriers, inaccurate record keeping, and medication mismanagement. No identified staff or exact dates were provided, and evidence did not support the claims.
Report Facts
Capacity: 92
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Capacity: 92
Deficiencies: 0
May 7, 2024
Visit Reason
The inspection was a Required - 1 Year unannounced annual inspection conducted to evaluate the facility's compliance with regulatory requirements.
Findings
The facility was found to have approved plans for dementia care and hospice waiver, adequate fire clearance and safety equipment, sufficient lighting, clean kitchen and food supply, secured medications, unobstructed exits, and proper infection control and emergency plans. The inspection was not completed and will continue at a later date.
Report Facts
Approved hospice waiver residents: 20
Fire clearance capacity: 92
Bedridden residents capacity: 20
Number of stairwells with evacuation chairs: 4
Number of fire extinguishers: 18
Hot water temperature low: 112
Hot water temperature high: 113.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with Licensing Program Analyst during inspection |
| Dina Alviso | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 92
Deficiencies: 1
Dec 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted due to a complaint received on 08/28/2023 alleging staff mismanaged resident’s medication and other care-related issues.
Findings
The investigation substantiated the allegation that staff mismanaged a resident's medication by continuing to provide medication three times a day instead of the new order of one pill a day from 8/1/23 through 8/21/23. Other allegations regarding medical attention, care records, incontinent care, hygiene, and meal provision were found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for the allegation of medication mismanagement. Other allegations including failure to seek medical attention, lack of care records, untimely incontinent care, hygiene needs, and meal provision were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A plan for incidental medical and dental care was not developed as required; the licensee failed to assist residents with self-administered medications as needed, evidenced by medication mismanagement. | Type A |
Report Facts
Civil penalty amount: 250
Deficiency citation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with Licensing Program Analyst during the investigation and named in findings. |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation. |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 92
Deficiencies: 1
Oct 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2023-08-09 regarding staff not responding to a resident's emergency pendant.
Findings
The investigation substantiated that staff failed to respond timely to a resident's emergency call pendant, posing a health and safety risk. Other allegations regarding care plan adherence, staff training, and food quality were unsubstantiated.
Complaint Details
The complaint alleging staff were not responding to resident's emergency pendant was substantiated based on record reviews and interviews. Other allegations about care plan adherence, staff training, and food quality were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure staff are responding to emergency call bell alarm(s) in a timely manner. | Type A |
Report Facts
Capacity: 92
Census: 46
Plan of Correction Due Date: Oct 20, 2023
Training Proof Submission Date: Oct 31, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Eric Perry | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 92
Deficiencies: 1
Aug 10, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff were not providing medication as prescribed.
Findings
The investigation substantiated the allegation that a resident did not receive medications as prescribed on 7/29 and 7/30 due to medications not being refilled in time, posing a health and safety risk.
Complaint Details
The complaint alleging that facility staff were not providing medication as prescribed was substantiated based on interviews, record reviews, and evidence obtained during the investigation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee failed to assist residents with self-administered medications as needed, as evidenced by a resident not receiving medications on 7/29 and 7/30 due to untimely refills. | Type A |
Report Facts
Capacity: 92
Census: 40
Deficiency citation: 1
Plan of Correction due date: Aug 11, 2023
Training proof submission date: Aug 28, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Gladys Finch | Resident Care Coordinator | Interviewed during investigation and participated in exit interview |
| Ruby Cuevas | Memory Care Director | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 92
Deficiencies: 1
Aug 10, 2023
Visit Reason
The inspection was a Case Management - Incident visit conducted to cite a deficiency found during an earlier complaint investigation on the same day, unrelated to the original complaint.
Findings
An incident report for resident R1 was not completed correctly, omitting that two days of missed PM medications occurred instead of one. This failure to report accurately is a health and safety risk and a deficiency was cited under reporting requirements.
Complaint Details
This case management inspection was conducted following a complaint investigation earlier on 08/10/2023. The cited deficiency was unrelated to the original complaint.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incident report on R1 omitted that it was two days, not one, of missed PM medications, failing to meet reporting requirements. | Type B |
Report Facts
Plan of Correction Due Date: Aug 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gladys Finch | Resident Care Coordinator | Met during inspection and exit interview |
| Dina Alviso | Licensing Program Analyst | Conducted inspection and signed report |
| Hope DeBenedetti | Licensing Program Manager | Supervisor named in report |
Inspection Report
Original Licensing
Capacity: 92
Deficiencies: 0
May 11, 2023
Visit Reason
The inspection was a prelicensing visit to evaluate the facility for assisted living and memory care services with a requested capacity of 92 residents.
Findings
The facility was found to have no apparent health hazards or concerns. All safety features, including fire extinguishers, evacuation chairs, emergency call systems, and locked medication rooms, were in place and compliant. The facility had sufficient furnishings, emergency supplies, and accessible resident amenities.
Report Facts
Fire extinguishers: 18
Fire clearance approval date: Apr 21, 2023
Hot water temperature: 113
Capacity breakdown: 66
Capacity breakdown: 26
Stairwells with evacuation chairs: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Reyes | Principal | Met with Licensing Program Analyst during prelicensing inspection. |
| Alana Reyes | Regional Manager | Met with Licensing Program Analyst during prelicensing inspection. |
| Lisa DiBartolo | Administrator | Hired Administrator present during prelicensing inspection. |
Inspection Report
Original Licensing
Capacity: 92
Deficiencies: 0
Nov 1, 2022
Visit Reason
Initial licensing evaluation conducted via telephone call with applicant/administrator to confirm understanding of licensing requirements and program policies.
Findings
Applicant and administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, staff qualifications, program policies, and other regulatory requirements. No clients were in care at the time of the evaluation.
Report Facts
Capacity: 92
Census: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alana Reyes | Administrator | Applicant/administrator participating in licensing evaluation |
| Jason Reyes | Applicant/administrator | Applicant/administrator participating in licensing evaluation |
| Jude De La Concepcion | Licensing Program Manager | Named in report header and signature section |
| Maria Ejaz | Licensing Program Analyst | Named in report header and signature section |
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