Inspection Reports for
The Oaks at Inglewood

The facility had an expired five-year sticker and annual sticker on the fire hydraulic system/fire riser, indicating needed repairs and a new fire clearance. This was identified as an immediate safety risk requiring correction.

During the visit, the Licensing Program Analyst observed an expired five-year sticker and the annual sticker on the fire hydraulic system/fire riser. The facility stated that work was completed by a local vendor but compliance stickers were not provided, indicating additional repairs are needed.

The facility was generally well maintained, clean, and compliant with fire safety and environmental regulations. However, deficiencies were found including unsecured toxins accessible to residents and the lack of an approved plan of operation for caring for residents diagnosed with Dementia.

The facility was generally well maintained, clean, and compliant with fire safety and environmental regulations. However, deficiencies were found including unsecured toxins accessible to residents and the lack of an approved plan of operation for caring for residents diagnosed with Dementia.

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.

Complaint was substantiated regarding billing for services not rendered and improper medication administration practices.

The investigation found that the facility did not reassess resident R1 before requiring medication assistance contrary to doctor's orders and followed a family member's wishes without proper medical authority, substantiating the complaint.

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.

The complaint was substantiated based on the preponderance of evidence standard. The facility had been previously cited for this violation on 05/08/2025 under control number 27-AS-20250508090354.

The investigation found that the facility implemented a new level of care description and fees without prior approval from the licensing agency, which is not in compliance with their approved plan of operation. The allegation was substantiated.

The complaint was substantiated based on the preponderance of evidence standard. The allegation involved charging a resident for services not received.

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.

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.

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.

The complaint investigation was substantiated for improper kitchen cleaning and food safety violations but unsubstantiated for pest infestation inside the facility.

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.

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.

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.

The investigation was triggered by an incident report concerning Resident 1's fall and subsequent death. The complaint was substantiated based on findings that the facility did not seek medical care despite repeated pain complaints, leading to the resident's death.

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 complications. One deficiency was cited related to failure to arrange appropriate medical care.

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.

The facility failed to follow the primary care physician's orders to have resident R1's left arm X-rayed after an incident on 2024-05-28, and deficiencies were cited related to this failure. The resident later had a fall resulting in a hip fracture.

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.

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.

The visit was complaint-related, investigating an incident report about Resident 1's fall and delayed medical care. The complaint was substantiated as the facility delayed medical assistance leading to hospitalization and death.

The investigation found that the facility delayed medical assistance to Resident 1, who experienced multiple complaints of pain without medical attention, resulting in hospitalization and death from septic shock and related conditions. Deficiencies were cited for failure to provide timely medical care and failure to observe and report changes in the resident's condition.

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.

The complaint investigation was substantiated. Staff were found not following infection control protocols, posing a potential threat to residents' health, safety, and personal rights.

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.