Inspection Reports for The Oaks at Paso Robles
526 S River Rd, Paso Robles, CA 93446, United States, CA, 93446
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. However, some reports did identify issues, primarily related to medication management, timely incident reporting, hygiene supplies, and facility cleanliness. The most serious events included a medication error in March 2025 that posed an immediate health risk and a substantiated failure to administer prescribed medications over an extended period in early 2025. The facility also had deficiencies for delayed notification after a resident eloped and for not ensuring agency staff received required dementia training. The most recent report from September 4, 2025, showed some deficiencies but no severe enforcement actions or fines, suggesting some ongoing challenges but no worsening trend overall.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 84
Capacity: 120
Deficiencies: 0
Sep 4, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation conducted to investigate allegations that staff handled residents in a rough manner and yelled at residents.
Findings
After interviews with staff, residents, and the Administrator, and observations by the Licensing Program Analyst, the allegations were found to be unsubstantiated due to lack of sufficient evidence to prove the alleged violations occurred.
Complaint Details
The complaint alleged that Staff #1 forcefully pulled and grabbed residents from their wheelchairs, chairs, and beds, and yelled at residents telling them to wait despite having already waited. Interviews and observations did not substantiate these allegations.
Report Facts
Capacity: 120
Census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Garrett Haner-Tomasko | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 120
Deficiencies: 2
Sep 4, 2025
Visit Reason
The inspection was conducted as a Case Management - Incident visit following an incident where a resident with dementia was reported missing after leaving the facility unassisted.
Findings
The facility failed to notify the licensing agency within the required timeframe after the elopement incident, and an agency staff member assigned to the memory care unit did not receive required dementia training prior to working there.
Complaint Details
The visit was triggered by a complaint/incident report regarding Resident #1 who was reported missing on 08/24/2025 after leaving the facility unassisted. The complaint was substantiated by findings that the facility did not notify the licensing agency timely and failed to provide dementia training to agency staff.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify the licensing agency Officer of the Day no later than the next working day following an elopement incident. | Type B |
| Failure to ensure agency staff (S1) received required dementia training prior to working in the memory care unit. | Type B |
Report Facts
Incident report delay: 9
Capacity: 120
Census: 84
Plan of Correction Due Date: Sep 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met during inspection and admitted failure to notify licensing agency timely. |
| Garrett Haner-Tomasko | Licensing Program Analyst | Conducted the inspection visit. |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 120
Deficiencies: 0
Aug 27, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including resident pressure injuries due to staff neglect, unexplained injuries, and unmet toileting needs.
Findings
The investigation found the allegations unsubstantiated based on interviews with staff, the resident's primary care physician, hospice nurse, and family. No deficiencies were cited during the visit.
Complaint Details
The complaint included allegations that a resident sustained multiple pressure injuries due to staff neglect, unexplained injuries, and unmet toileting needs. The investigation determined these allegations to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 120
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analyst during the investigation |
| Garrett Haner-Tomasko | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 120
Deficiencies: 1
Aug 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including lack of toilet paper and soap in resident bathrooms, lack of activities for residents, and unmet oral hygiene needs.
Findings
The investigation substantiated that supplies necessary for maintenance of adequate hygiene practice, including soap and toilet paper, were not readily available to each resident, posing potential health and safety risks. Allegations regarding lack of activities and unmet oral hygiene needs were found to be unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding the lack of toilet paper and soap in resident bathrooms. Other allegations about lack of activities and unmet oral hygiene needs were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure supplies necessary for personal care and maintenance of adequate hygiene practice, such as soap and toilet paper, were readily available to each resident. | Type B |
Report Facts
Capacity: 120
Census: 85
Deficiency Plan of Correction Due Date: Sep 10, 2025
Toilet paper rolls observed: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analyst during investigation and involved in findings |
| Garrett Haner-Tomasko | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 120
Deficiencies: 0
Jul 23, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation conducted to investigate an allegation that staff did not treat a resident with dignity.
Findings
Based on interviews and record review, the allegation that the facility Executive Director did not treat a resident with dignity was found to be unsubstantiated, with no preponderance of evidence to prove the violation occurred.
Complaint Details
The complaint alleged that the Executive Director referred to Resident #1 in a derogatory way and did not treat the resident with dignity. Interviews with the resident, staff, and administrator revealed no evidence supporting the allegation. The complaint was found unsubstantiated.
Report Facts
Capacity: 120
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Named in the complaint allegation and interviewed during the investigation |
| Garrett Haner-Tomasko | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 120
Deficiencies: 2
Jul 23, 2025
Visit Reason
Unannounced complaint investigation visit conducted to investigate multiple allegations including staff not providing timely assistance to residents, residents not being provided clean linens, and staff not keeping the facility free from odor.
Findings
The investigation substantiated that staff did not always respond to resident calls within 10 minutes, with multiple calls exceeding 20, 30, and 60 minutes. Several resident rooms were found with soiled linens and mattresses. A resident's room in memory care had a strong urine odor and visible damage due to urination. Other allegations such as staff leaving a resident in soiled clothing, call button accessibility, and staff not meeting residents' needs were found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations of delayed staff response to resident calls, unclean linens, and facility odor issues related to a resident urinating in their room. Other allegations regarding soiled clothing, call button accessibility, and unmet resident needs were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Residents wait for staff to respond to calls for assistance, with 130 calls over 10 minutes and some over 60 minutes; call system sometimes malfunctions. | Type B |
| Facility not clean and in good repair; 7 rooms had stained/soiled linens and mattresses; resident room with urine odor and damage to floor, baseboard, and paint. | Type B |
Report Facts
Resident census: 85
Total capacity: 120
Call response delays: 130
Call response delays over 20 minutes: 16
Call response delays over 30 minutes: 12
Call response delays over 60 minutes: 6
Rooms with soiled linens: 7
Rooms with stained mattresses: 6
Pendant calls from Resident #2 over 10 minutes: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analyst during investigation and provided information on facility policies and conditions |
| Garrett Haner-Tomasko | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Jul 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff was not allowing a resident a visitor, specifically a hospice volunteer who was a former employee of the facility.
Findings
The investigation found that the facility's Executive Director cited a conflict-of-interest company policy to deny the former employee hospice volunteer access to the resident. The allegation was deemed unsubstantiated based on the information obtained, and resident visitation rights were discussed with the Executive Director.
Complaint Details
The complaint alleged that staff was not allowing a resident a visitor, specifically a hospice volunteer who was a former employee. The allegation was investigated and found unsubstantiated.
Report Facts
Facility capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Executive Director/Administrator | Named in relation to the complaint investigation and findings regarding visitation policy |
| Garrett Haner-Tomasko | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 120
Deficiencies: 2
Mar 26, 2025
Visit Reason
The inspection was an unannounced Case Management visit triggered by a self-reported medication error where Resident 1 was given Resident 2's medication.
Findings
The facility was found to have a medication error where Staff 1 gave the wrong medications to Resident 1, posing an immediate health and safety risk. Additionally, centrally stored medications for Resident 2 were not properly recorded. Staff 1 was suspended and resigned effective 04/06/2025.
Complaint Details
The visit was complaint-related due to a medication error self-reported by the facility. Staff 1 administered the wrong medications to Resident 1, who was subsequently taken to the hospital and returned to the facility the same day. The medication error was substantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff 1 gave Resident 1 the wrong medications, posing an immediate health and safety risk to residents in care. | Type A |
| Resident 2's lorazepam and oxycodone were not centrally stored on the Centrally Stored Medications Record. | Type B |
Report Facts
Census: 80
Total Capacity: 120
Medication error date: Mar 23, 2025
Plan of Correction Due Date: Mar 27, 2025
Plan of Correction Due Date: Apr 9, 2025
Staff resignation date: Apr 6, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met during inspection and reported medication error |
| Maria Middleton | Resident Services Director | Reported medication error after Staff 1 realized mistake |
| Garrett Haner-Tomasko | Licensing Program Analyst | Conducted the inspection visit |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 120
Deficiencies: 2
Feb 27, 2025
Visit Reason
Unannounced complaint investigation visit triggered by an allegation that staff did not administer residents' medication at the facility.
Findings
The investigation substantiated the allegation that Resident 1 was not administered medication as prescribed over approximately 398 days. Medication audits revealed significant discrepancies between medication administration records and physical medication counts, indicating multiple missed medication doses.
Complaint Details
The complaint was substantiated. The allegation was that staff did not administer residents' medication, specifically Resident 1, over a period from July 2023 through October 2024. Evidence included interviews, medication audits, and physical medication counts confirming missed medication doses.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement a plan for incidental medical and dental care, resulting in Resident 1 missing hundreds of medication passes, posing imminent danger. | Type A |
| Failure to maintain centrally stored medication records (CSMR) as prior records were shredded, posing imminent danger to residents. | Type A |
Report Facts
Medication 1 pills sent: 450
Medication 1 pills returned: 18
Medication 2 pills sent: 450
Medication 2 pills returned: 106
Medication 3 pills sent: 540
Medication 3 pills returned: 176
Medication 4 pills sent: 540
Medication 4 pills returned: 245
Medication 5 pills sent: 450
Medication 5 pills returned: 365
Investigation period: 398
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analysts during investigation and involved in medication audit review |
| Mark Jeffries | Licensing Program Analyst | Conducted complaint investigation, interviews, medication audit, and physical medication counts |
| Kelly Burley | Licensing Program Manager | Oversaw complaint investigation and signed report |
| Staff 1 | Memory Care Director | Interviewed regarding medication records and administration |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 120
Deficiencies: 1
Feb 27, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations received on 2024-05-22 regarding sanitation, dietary needs, incontinence care, safety, and activities at the facility.
Findings
The complaint investigation substantiated that staff did not ensure the facility was maintained sanitary due to overwhelming ammonia odor and fecal matter in a resident's room. Other allegations regarding dietary needs, incontinence care, safe environment, and provision of activities were found unsubstantiated based on interviews, observations, and documentation.
Complaint Details
The complaint was substantiated regarding unsanitary conditions due to ammonia and fecal odors in Resident 1's room. Other allegations about dietary needs, incontinence care, safe environment, and activities were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, evidenced by ammonia-like smell in Resident 1's room. | Type B |
Report Facts
Capacity: 120
Census: 97
Deficiency due date: Mar 11, 2025
Diet and culinary services audit score: 95.45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with during inspection and referenced in findings |
| Mark Jeffries | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kelly Burley | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 120
Deficiencies: 0
Feb 27, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 08/15/2024 regarding medication administration, provision of drinking water, and incontinence care at the facility.
Findings
The investigation found insufficient evidence to substantiate the allegations that facility staff did not dispense medications according to physician's orders, did not ensure residents had drinking water, and did not meet residents' incontinence care needs. All allegations were determined to be unsubstantiated based on interviews, observations, documentation review, and staff statements.
Complaint Details
The complaint included allegations that staff did not dispense medications as prescribed, did not provide residents with drinking water, and failed to meet residents' incontinence care needs. The investigation was unsubstantiated due to lack of evidence supporting the allegations.
Report Facts
Capacity: 120
Census: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analysts during the investigation and provided statements regarding facility operations and housekeeping availability. |
| Mark Jeffries | Licensing Program Analyst | Conducted the complaint investigation, interviews, observations, and documentation review. |
Inspection Report
Annual Inspection
Census: 82
Capacity: 120
Deficiencies: 0
Feb 27, 2025
Visit Reason
The inspection was an unannounced annual facility inspection conducted to evaluate compliance and to deliver on three separate complaint findings.
Findings
The facility was inspected for physical plant and environment safety, infection control, personnel records and training, staffing, resident records and incident reports, resident rights information, planned activities, food service, incidental medical and dental services, disaster preparedness, and residents with special health needs. Overall, the facility met regulatory standards with no deficiencies explicitly stated in the report.
Report Facts
Staff count: 43
Administrator count: 1
Medication training hours: 8
Resident interviews: 5
Staff interviews: 4
Memory care rooms: 24
Resident rooms total: 97
PPE supply days: 30
Perishable food supply days: 2
Non-perishable food supply days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analysts during inspection |
| Maria Middleton | Director | Met with Licensing Program Analysts during inspection |
| Garrett Haner-Tomasko | Licensing Program Analyst | Conducted the inspection |
| Kelly Burley | Licensing Program Manager | Oversaw the licensing program |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 120
Deficiencies: 0
Jun 10, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations against facility staff including yelling at residents, rough handling, inadequate supervision, and lack of dignity and respect.
Findings
All allegations were investigated through interviews, documentation review, and facility inquiry. No sufficient evidence was found to substantiate any of the allegations, and all were determined to be unsubstantiated.
Complaint Details
The complaint included allegations that facility staff yelled at residents, handled a resident roughly, did not adequately supervise residents, and did not treat residents with dignity and respect. After investigation, all allegations were found unsubstantiated.
Report Facts
Capacity: 120
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Jeffries | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
| Carl Meyer | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 120
Deficiencies: 0
Jun 10, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including resident pressure injuries, fire safety precautions, food service issues, medication ordering timeliness, and assistance with doctor's appointments.
Findings
All allegations were investigated through interviews, observations, and documentation review. There was insufficient evidence to substantiate any of the allegations, including pressure injuries, fire safety violations, food service problems, medication delays, and lack of assistance with medical appointments. The report concludes all allegations are unsubstantiated.
Complaint Details
The complaint investigation was unannounced and addressed nine allegations including resident pressure injuries, fire safety, food service, medication ordering, and assistance with doctor's appointments. After thorough review and interviews with residents, staff, and administrators, all allegations were found unsubstantiated.
Report Facts
Facility capacity: 120
Resident census: 87
Fire extinguishers observed: 30
Medication review residents: 83
Medication review period: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Jeffries | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
| Carl Meyer | Administrator | Facility administrator met during the investigation |
| Peter J Bonilla | Administrator | Named as facility administrator in report header |
| Dr. Tisngson | Podiatrist, DPM | Provided podiatric evaluation and treatment to residents |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 120
Deficiencies: 0
May 22, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to an allegation that staff allowed a resident to continue self-neglect.
Findings
The investigation found that the resident (R1) had an incontinence problem but was independent and refused some assistance. Observations and interviews showed no evidence of neglect, and additional support was provided as part of the resident's care plan. The allegation was unsubstantiated.
Complaint Details
The complaint alleged that staff failed to observe a resident's continued self-neglect, including smelling of urine and being wet. The investigation included interviews with the resident, staff, and administrator, as well as observations of the resident's room and care. The complaint was found to be unsubstantiated.
Report Facts
Capacity: 120
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Jeffries | Licensing Program Analyst | Conducted the complaint investigation and issued final findings |
| Carl Meyer | Administrator | Facility administrator met during the investigation and provided information |
| Kelly Burley | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 120
Deficiencies: 0
May 22, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to an allegation that staff failed to observe residents' nail care needs.
Findings
The investigation found insufficient evidence to support the allegation that staff neglected residents' nail care needs. The complaint was unsubstantiated after interviews, medical record reviews, and observations.
Complaint Details
The complaint alleged that two residents were neglected to the point of having nail fungus. Interviews with staff and residents, review of medical records including podiatrist visits, and observations showed that one resident refused treatment and the other received podiatrist care. Staff were reported to provide adequate care and residents felt safe. The allegation was unsubstantiated.
Report Facts
Capacity: 120
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analyst during investigation |
| Mark Jeffries | Licensing Program Analyst | Conducted complaint investigation and issued report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 86
Capacity: 120
Deficiencies: 1
Feb 26, 2024
Visit Reason
The Licensing Program Analyst conducted an unannounced annual inspection of the facility to evaluate compliance with regulatory standards and review facility conditions.
Findings
The facility was generally found to be in good repair with proper equipment and safety measures in place. One citation was issued due to a resident file missing a Tuberculosis Test, but no other violations or technical issues were noted.
Deficiencies (1)
| Description |
|---|
| Resident 1 did not have a Tuberculosis Test on either of the LIC602s in their file. |
Report Facts
Fire extinguishers per floor: 8
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analyst during inspection. |
| Mark Jeffries | Licensing Program Analyst | Conducted the annual inspection and authored the report. |
| Kelly Burley | Licensing Program Manager | Supervisor of the Licensing Program Analyst and named in the report. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 120
Deficiencies: 0
Aug 22, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff were denying resident indoor visitations, not following resident's care plan, and not turning resident sufficiently.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Staff were not denying indoor visitations but required COVID-19 screening, which the complainant refused. Staff were following residents' care plans and providing timely assistance. There was no evidence that residents were not turned sufficiently.
Complaint Details
The complaint was unsubstantiated. Allegations included denial of indoor visitations, failure to follow care plans, and insufficient resident turning. Investigations included interviews, document reviews, and observation, concluding no violations.
Report Facts
Visitor screenings: 1044
Facility capacity: 120
Resident census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analyst during investigation and provided statements regarding visitation and care plan allegations |
| Mark Jeffries | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 120
Deficiencies: 1
Jul 27, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including staff not following protocols to prevent the spread of COVID-19, insufficient staff to meet resident needs, and the facility not being kept clean and sanitary.
Findings
The allegation that staff did not follow COVID-19 protocols was substantiated based on interviews and admissions that the administrator allowed a family member to circumvent screening protocols. The allegations of insufficient staffing and the facility not being kept clean and sanitary were unsubstantiated based on documentation, interviews, and observations.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not follow COVID-19 protocols due to the administrator allowing a family member to enter through an unscreened exit door during June and July 2022. The allegations of insufficient staffing and cleanliness were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator allowed a family member to circumvent COVID-19 screening protocols for two months or more, posing a potential health risk to residents. | Type B |
Report Facts
Capacity: 120
Census: 87
Deficiency Type B: 1
Plan of Correction Due Date: Due date was 08/10/2023 as stated in the report
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ronald Freeman | Administrator | Named in finding for allowing family member to circumvent COVID-19 screening protocols |
| Carl Meyer | Administrator | Met with Licensing Program Analyst during inspection |
| Mark Jeffries | Licensing Program Analyst | Conducted the complaint investigation |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 81
Capacity: 120
Deficiencies: 0
Jan 12, 2023
Visit Reason
The visit was an unannounced annual infection control inspection and additionally included a subsequent initial complaint visit on a separate complaint.
Findings
The inspection found the facility to be clean, in good repair, with no citations or violations noted during the annual infection control portion or the cursory walk-through. All safety equipment was current and functional, and infection control measures were in place and adequate.
Report Facts
Capacity: 120
Census: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Meyer | Administrator | Met with Licensing Program Analyst during inspection |
| Mark Jeffries | Licensing Program Analyst | Conducted the inspection |
| Kelly Burley | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 63
Capacity: 120
Deficiencies: 0
Feb 16, 2022
Visit Reason
The inspection was a required unannounced 1-year infection control annual visit to assess compliance with infection control policies and procedures.
Findings
No deficiencies were observed during the visit. All infection control protocols were implemented and followed, including screening, symptom monitoring, PPE use, cleaning policies, and staff training.
Report Facts
PPE supply duration: 30
Inspection start time: 955
Inspection end time: 130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ron Freeman | Administrator | Met with Licensing Program Analysts during the inspection and oversees staffing and issues. |
| Amy Fanning | Resident Services Director, LVN | In charge of infection control and provides training and education to staff, residents, and visitors. |
Inspection Report
Original Licensing
Capacity: 120
Deficiencies: 0
Feb 17, 2021
Visit Reason
A Pre-Licensing Inspection was conducted virtually via FaceTime due to COVID-19 mitigation measures, following receipt of an application to operate a Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be new, clean, and operational with all areas meeting regulatory requirements. No hazards or obstacles were observed, and safety features such as fire sprinklers, detectors, emergency lighting, and secure medication rooms were in place. Social distancing measures for COVID-19 were noted to be addressed by the administrator.
Report Facts
Rooms: 97
Elevator weight capacity: 3500
Fire extinguisher count: 6
Facility temperature: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ronald Freeman | Administrator | Met with Licensing Program Analyst during pre-licensing inspection |
| Mark Jeffries | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Kelly Burley | Licensing Program Manager | Named in report header and footer |
Inspection Report
Original Licensing
Capacity: 120
Deficiencies: 0
Jan 13, 2021
Visit Reason
Initial licensing evaluation with new construction and delayed egress for a Residential Care Facility for the Elderly with dementia care program.
Findings
Applicant and administrator participated in a comprehensive licensing process (COMP II) confirming understanding of Title 22 regulations and facility operation requirements. The application document review and technical assistance were completed successfully.
Report Facts
Capacity: 120
Census: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ronald Freeman | Administrator | Facility administrator who participated in licensing process |
| Jude De La Concepcion | Licensing Program Manager | Named in report header |
| Bethany Hunter | Licensing Program Analyst | Conducted COMP II and signed report |
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