Inspection Report Summary
Most inspections found deficiencies related to resident care and facility operations, with several substantiated complaints involving delayed medical attention, improper billing practices, and infection control lapses. The most serious issues occurred in late 2024 and early 2025, including a resident’s death linked to inadequate medical care, resulting in $15,000 in civil penalties. Other findings involved food safety violations and failure to prevent a resident from leaving unassisted, which posed an immediate health and safety risk. The facility showed some improvement when the most recent inspection on October 9, 2025, still cited deficiencies but focused mainly on staffing and supervision issues rather than medical neglect. Several complaint investigations were substantiated, while others, such as pest infestation claims, were unsubstantiated.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 78
Capacity: 86
Deficiencies: 2
Oct 9, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on an AWOL incident involving Resident 1 that occurred on 2025-09-30.
Findings
Deficiencies were observed and cited related to personnel requirements and failure to prevent Resident 1 from leaving the facility unassisted, which posed an immediate health and safety risk.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs. | Type A |
| Resident 1 AWOL'd from the facility despite being not allowed to leave unassisted, presenting an immediate health and safety risk. | Type A |
Report Facts
Capacity: 86
Census: 78
Plan of Correction Due Date: Oct 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the inspection and authored the report |
| Tha Chay | Administrator | Facility administrator met during inspection and responsible for corrective actions |
Inspection Report
Census: 76
Capacity: 86
Deficiencies: 0
Aug 7, 2025
Visit Reason
The visit was an unannounced case management visit to deliver an invite for an informal meeting scheduled for August 14, 2025, and to conduct a health and safety check of the facility.
Findings
No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. The health and safety check included overall safety of the facility, food supply, physical plant, and staffing.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced case management visit and met with facility staff. |
Inspection Report
Follow-Up
Census: 76
Capacity: 86
Deficiencies: 1
Jul 8, 2025
Visit Reason
An unannounced Plan of Correction (POC) visit was conducted to verify correction of citations issued during the licensing visit on 2025-05-08.
Findings
The deficiency cited under Title 22 Regulations has not been cleared. The facility submitted a request to appeal the citation, but the department did not have a record of the appeal. The POC visit was not completed and the department will review the situation to determine next steps.
Deficiencies (1)
| Description |
|---|
| Deficiency cited under Title 22 Regulations has not been cleared. |
Report Facts
Capacity: 86
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced POC visit |
| Lisa Rios | Licensing Program Manager | Named in the exit interview |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 86
Deficiencies: 1
May 8, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff were charging a resident for services not received.
Findings
The facility was found to be not following their approved plan of operation by implementing new levels of care descriptions and fees without prior approval from the licensing agency. The allegation was substantiated based on records and interviews.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation involved charging a resident for services not received.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee failed to maintain a current, written definitive plan of operation and operated the facility contrary to the approved plan by implementing new levels of care descriptions and fees without submitting them for approval. | Type B |
Report Facts
Capacity: 86
Census: 78
Deficiency Plan of Correction Due Date: May 19, 2025
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the complaint investigation and cited deficiencies |
| Lisa Rios | Licensing Program Manager | Named in report as Licensing Program Manager |
| Yanet Rico-Solis | Health and Wellness Director | Met with during the investigation |
Inspection Report
Annual Inspection
Census: 74
Capacity: 86
Deficiencies: 0
Feb 26, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with regulatory requirements.
Findings
The facility was found to be well-maintained, clean, and in compliance with health and safety regulations including fire safety and medication storage. No citations were issued during the inspection.
Report Facts
Client files reviewed: 15
Staff files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the annual inspection |
| Brittany Andrews | Administrator/Director | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Capacity: 86
Deficiencies: 5
Nov 26, 2024
Visit Reason
The inspection was an unannounced case management visit to follow up on an incident report related to a resident's death and failure to arrange medical services despite multiple pain complaints.
Findings
The facility was cited for failing to properly assess and meet the resident's medical needs, resulting in delayed medical attention and medication provision, which contributed to the resident's death. Civil penalties totaling $15,000 were issued, with $14,000 assessed on this visit.
Complaint Details
The visit was complaint-related, following an incident report and investigation of a resident's death. The complaint was substantiated, resulting in citations and civil penalties.
Deficiencies (5)
| Description |
|---|
| Failure to properly assess the resident’s needs and develop a plan of care to meet their needs. |
| Failure to get timely medical attention for resident despite long-standing complaints of pain. |
| Resident’s medications were not all available until after 5 days post admission to facility. |
| Resident’s medications that were not provided were crucial for cardiac, pain control, and post-procedure antibiotic. |
| Facility failed to recognize resident's complaints, symptoms, and change in condition that resulted in death. |
Report Facts
Civil penalty amount: 15000
Immediate civil penalty previously issued: 1000
Civil penalty issued on 11/26/2024: 14000
Facility capacity: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced case management visit and signed the report |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the case |
| Brittany Andrews | Administrator | Facility administrator named in the report header |
Inspection Report
Plan of Correction
Census: 70
Capacity: 86
Deficiencies: 0
Oct 10, 2024
Visit Reason
An unannounced Plan of Correction (POC) visit was conducted to verify correction of citations issued during the licensing visit on 2024-09-24.
Findings
Deficiencies cited under Title 22 Regulations have been cleared. The Administrator/Licensee complied with the terms of the POC by the due date, and the facility was provided a POC cleared letter.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Made the unannounced POC visit to verify correction of citations. |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 86
Deficiencies: 1
Sep 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-06-20 regarding improper cleaning of the facility kitchen and pest infestation concerns.
Findings
The investigation substantiated that the facility was not in compliance with regulatory requirements for maintaining a clean and sanitary kitchen, including issues with food storage, expired and unlabeled food, and unsanitary bread storage areas. The facility was also out of compliance with required consultation services for food safety. However, the allegation regarding pest infestation inside the facility was unsubstantiated as pests were only observed outside and ongoing pest control services were confirmed.
Complaint Details
The complaint investigation was substantiated for improper kitchen cleaning and food safety violations but unsubstantiated for pest infestation inside the facility.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain a clean and sanitary kitchen with proper food storage, including expired food, unlabeled food, unsanitary bread storage area, and open containers. | Type B |
Report Facts
Capacity: 86
Census: 73
Deficiencies cited: 1
Plan of Correction Due Date: Oct 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Lisa Rios | Licensing Program Manager | Named in report as Licensing Program Manager |
| Brittany Andrews | Administrator | Facility administrator named in the report |
Inspection Report
Follow-Up
Census: 79
Capacity: 86
Deficiencies: 0
Aug 22, 2024
Visit Reason
An unannounced Plan of Correction (POC) visit was conducted to verify correction of citations issued during the licensing visit on 2024-06-17.
Findings
Deficiencies cited under Title 22 Regulations have been cleared. The Administrator/Licensee complied with the terms of the POC by the due date, and the facility was provided a POC cleared letter.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Made the unannounced POC visit to verify correction of citations. |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 86
Deficiencies: 1
Aug 8, 2024
Visit Reason
The visit was an unannounced case management inspection to follow up on an incident report regarding Resident 1's fall and subsequent death.
Findings
The investigation found that despite Resident 1's repeated complaints of pain on six occasions, the facility failed to seek medical attention or contact the physician, which contributed to the resident's death from septic shock and related conditions.
Complaint Details
The investigation was triggered by a complaint related to an incident where Resident 1 fell and hit her head, leading to hospitalization and death. The complaint was substantiated based on failure to provide appropriate medical care.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care: The licensee failed to arrange or assist in arranging medical care appropriate to the conditions and needs of residents, as evidenced by failure to obtain medical care for Resident 1's repeated pain complaints. | Type A |
Report Facts
Resident pain complaints: 6
Facility capacity: 86
Resident census: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the investigation and inspection |
| Lisa Rios | Licensing Program Manager | Oversaw the inspection and exit interview |
| Tha Chay | Facility staff met during inspection | |
| Brittany Andrews | Administrator | Facility administrator named in report header |
Inspection Report
Follow-Up
Census: 73
Capacity: 86
Deficiencies: 1
Jun 17, 2024
Visit Reason
The visit was an unannounced Case Management follow-up on an incident dated 2024-06-11 involving a resident fall with a fracture.
Findings
The facility failed to follow the primary care physician's orders to have the resident's left arm X-rayed after a reported injury, resulting in deficiencies cited during the visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility not following the doctors orders and not taking R1 to have a X-ray on the left arm at the request of the PCP. | Type B |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Lisa Rios | Licensing Program Manager | Supervisor and Licensing Evaluator |
| Brittany Andrews | Administrator | Facility Administrator named in report header |
Inspection Report
Census: 78
Capacity: 86
Deficiencies: 0
Apr 18, 2024
Visit Reason
An unannounced case management visit was conducted to follow up on an incident involving a resident who had an unwitnessed fall resulting in a head injury requiring staples.
Findings
The Licensing Program Analyst reviewed the resident's file, medical records, and service plans, finding that the facility is exercising best practices in addressing the resident's fall risk and service needs.
Report Facts
Incident date: Apr 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the unannounced case management visit |
| Brittany Andrews | Administrator | Facility administrator mentioned in the report |
Inspection Report
Annual Inspection
Census: 56
Capacity: 86
Deficiencies: 0
Feb 16, 2024
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct an Annual Inspection of the assisted living facility on 02/16/2024.
Findings
The facility was found to be well maintained, clean, and in compliance with health and safety regulations. No citations were given after inspection of the physical plant, resident and staff files, medication storage, and safety equipment.
Report Facts
Client files reviewed: 15
Staff files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the annual inspection |
| Brittany Andrews | Administrator | Facility administrator mentioned in report |
| Tha Chay | Met with Licensing Program Analyst during inspection | |
| Lisa Rios | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 86
Deficiencies: 2
Jan 19, 2024
Visit Reason
The visit was an unannounced case management inspection to follow up on an incident report regarding Resident 1's fall and subsequent medical issues leading to hospitalization and death.
Findings
The investigation found that the facility delayed medical assistance to Resident 1 despite multiple complaints of pain, resulting in hospitalization and death due to septic shock and related complications. The facility also failed to recognize changes in Resident 1's condition and notify the physician or responsible party.
Complaint Details
The visit was complaint-related, following an incident report about Resident 1's fall and subsequent medical neglect. The complaint was substantiated as the facility delayed medical assistance and failed to recognize the resident's change in condition, contributing to the resident's death.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee failed to immediately telephone 9-1-1 when an injury or other circumstance resulted in an imminent threat to a resident’s health, causing delayed medical assistance to Resident 1. | Type A |
| The licensee failed to regularly observe and document changes in Resident 1’s condition and did not bring these changes to the attention of the resident's physician or responsible party. | Type A |
Report Facts
Capacity: 86
Census: 77
Plan of Correction Due Date: Jan 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the investigation and signed the report |
| Lisa Rios | Licensing Program Manager | Supervisor overseeing the investigation |
| Brittany Andrews | Administrator | Facility administrator during the inspection |
Inspection Report
Annual Inspection
Census: 77
Capacity: 86
Deficiencies: 2
Jan 31, 2023
Visit Reason
The inspection was an unannounced required one-year annual visit to evaluate compliance with regulatory standards at the assisted living facility.
Findings
The facility was generally well maintained, sanitary, and compliant with safety equipment requirements. However, deficiencies were cited related to missing initial personal property inventories in resident files and lack of updated resident evaluations, posing potential risks to resident health, safety, and personal rights.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| 3 of 3 resident files lacked record of any inventory conducted upon admission, violating theft and loss program requirements. | Type B |
| Resident file for one resident lacked an updated appraisal since 3/17/21, violating requirements for resident participation in decision making. | Type B |
Report Facts
Resident files reviewed: 3
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Andrews | Executive Director | Met with Licensing Program Analyst during inspection |
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Liza King | Licensing Program Manager | Supervised the inspection |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 86
Deficiencies: 1
Jan 12, 2023
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff were not following infection control protocol.
Findings
The investigation substantiated that staff were not following COVID mitigation protocols, including incorrect mask usage, inconsistent isolation periods for COVID positive residents, lack of temperature monitoring, and absence of identifying signs outside COVID positive resident rooms.
Complaint Details
The complaint investigation was substantiated. Staff were found not following infection control protocols, posing a potential threat to residents' health, safety, and personal rights.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents in all residential care facilities for the elderly shall have safe, healthful and comfortable accommodations; this requirement was not met due to staff wearing masks incorrectly, lack of PPE and signage outside COVID positive resident rooms, and inconsistent handling of resident monitoring and isolation times. | Type B |
Report Facts
Capacity: 86
Census: 75
Plan of Correction Due Date: Jan 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Andrews | Administrator | Met with Licensing Program Analyst during investigation |
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation |
| Liza King | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 72
Capacity: 86
Deficiencies: 0
Mar 29, 2022
Visit Reason
Unannounced 1-year required inspection conducted to evaluate compliance with licensing requirements for the assisted living facility.
Findings
No deficiencies were cited during the inspection. The facility was found to maintain adequate safety measures, proper environmental conditions, and complete documentation including resident and staff records.
Report Facts
Resident files reviewed: 5
Staff records reviewed: 5
Fire extinguisher last serviced: Mar 22, 2022
Emergency Disaster Plan last posted: Mar 14, 2022
Fire drill last conducted: Mar 23, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Diane Wright | Executive Director | Met with Licensing Program Analyst during inspection and holds certificate #60336316740 |
| Treana White | Licensing Program Analyst | Conducted the inspection |
| Liza King | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 69
Capacity: 86
Deficiencies: 0
Nov 9, 2021
Visit Reason
The visit was an unannounced Required 1-year Annual inspection conducted to evaluate compliance with regulatory standards for the assisted living facility.
Findings
No deficiencies were observed or cited during the inspection. The facility was found to be clean, in good repair, and compliant with safety, medication storage, food supply, and COVID-19 precaution requirements.
Report Facts
Facility capacity: 86
Census: 69
Temperature inside facility: 75
Hot water temperature: 108
Fire extinguisher last inspection date: Oct 6, 2021
Fire suppression system last inspection: 202107
Elevator last inspection date: Oct 31, 2021
PPE supply: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Diane Wright | Administrator | Facility Administrator met during inspection |
| Ashley Boothe | Licensing Program Analyst | Conducted the inspection |
| Liza King | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 86
Deficiencies: 0
Oct 21, 2021
Visit Reason
Unannounced case management visit following an incident report submitted to the department.
Findings
No deficiencies were observed or cited during the visit. One incident involving a resident's change in condition was reviewed, and the resident was offered increased care but was moved out by family the same day.
Complaint Details
Visit was triggered by an incident report. The incident involved Resident one (R1) showing symptoms of primary diagnosis as updated on the most recent physician's report. The resident was offered increased level of care but was moved out by family to avoid increased fees. No deficiencies were cited.
Report Facts
Census: 69
Total Capacity: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Boothe | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed incident report |
| Diane Wright | Administrator | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 86
Deficiencies: 0
Aug 16, 2021
Visit Reason
The visit was a case management inspection following an incident report and Elder Abuse Report submitted to the Regional Office on 2021-08-13 involving a physical altercation between two residents.
Findings
The Licensing Program Analyst found that Resident one grabbed Resident two's wrist causing bruising and swelling. The facility notified law enforcement, responsible parties, and physicians. No deficiencies were observed or cited during the visit.
Complaint Details
The visit was triggered by a complaint involving a physical altercation between two residents, with one resident admitting fault. The complaint was investigated through interviews and record reviews, and no deficiencies were cited.
Report Facts
Census: 66
Total Capacity: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Blaine Lyons | Executive Director | Contacted for COVID screening and involved in follow-up actions regarding resident behaviors |
| Ashley Boothe | Licensing Program Analyst | Conducted the case management visit and investigation |
| Liza King | Licensing Program Manager | Named in the report as Licensing Program Manager |
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