Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally consistent compliance with regulations. However, some investigations identified issues including medication errors, delayed medical care, facility cleanliness, elevator operability, and call system maintenance, with the most serious event occurring in November 2024 when the facility was cited for delayed medical attention to a resident who fell, posing an immediate health and safety risk. The most recent report from June 18, 2025, was clean with no deficiencies and found the staffing-related complaints about laundry and medication timing to be unsubstantiated. While some earlier reports showed isolated deficiencies mainly related to environment/safety and resident care, the facility appears to have improved over time, especially with the latest inspection showing no problems. Several complaints about resident care and facility conditions were investigated and not substantiated, reflecting a pattern of mostly unconfirmed concerns.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
86% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 138
Capacity: 160
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that, because of lack of staffing, residents were not receiving adequate laundry services and were not receiving medication on time.
Complaint Details
The complaint investigation was unsubstantiated. Allegations regarding inadequate laundry services and untimely medication administration due to staffing shortages were not supported by sufficient evidence.
Findings
The investigation included a facility tour, interviews with residents and staff, and record reviews. The allegations were found to be unsubstantiated as residents reported timely laundry service and medication administration, and there was insufficient evidence to prove the claims.
Report Facts
Capacity: 160
Census: 138
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named in report signature and oversight |
| Joy Carter | Administrator | Met with during the investigation |
| Sonia Garcia | Business Manager | Allowed entry and involved in investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 160
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff does not ensure residents' pendants are in good repair.
Complaint Details
The complaint was substantiated based on observations, interviews, and record review. The call system was found non-operational since 04/10/2025, and no incident reports were provided to the licensing office.
Findings
The investigation found that the facility's call system was not operational since April 10, 2025, and prior to that date, the system would not receive half of the calls. The allegation was substantiated and a deficiency was issued for failure to maintain the signal system, posing a potential health and safety risk.
Deficiencies (1)
The facility failed to maintain operations of the signal systems call for whole facility residents which poses potential health and safety risk to persons in care.
Report Facts
Capacity: 160
Census: 76
Plan of Correction Due Date: Apr 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Brenda Chan | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Aaron Windbigler | Regional Director of Operations | Met with the Licensing Program Analyst during the investigation |
| Natasha Prunty | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 160
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-01-13 regarding multiple allegations about facility conditions and staff performance.
Complaint Details
The complaint included allegations that staff did not keep the facility free of vermin, prevent malodorous elevators, provide lighting for residents, ensure access to water, and repair the microwave timely. Each allegation was investigated and found unsubstantiated.
Findings
All allegations including vermin control, elevator odors, lighting for residents, access to water, and microwave repair were investigated and found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 160
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Jessica Sanchez | Interim Executive Director | Met with Licensing Program Analyst during the inspection |
| Natasha Prunty | Administrator | Responded to questions regarding pest control and facility operations |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 160
Deficiencies: 3
Date: Apr 3, 2025
Visit Reason
Unannounced complaint investigation visit conducted in response to complaints received on 2025-01-13 regarding transportation to medical appointments and adherence to the provided menu for residents.
Complaint Details
Complaint investigation was conducted based on allegations received on 2025-01-13. Allegations included failure to transport residents to medical appointments, failure to follow provided menu, failure to ensure facility cleanliness, hot water delivery, and elevator operability. The first two allegations were unsubstantiated; the latter three were substantiated with cited regulatory violations.
Findings
The investigation found the allegations regarding transportation to medical appointments and menu adherence to be unsubstantiated due to lack of preponderance of evidence. However, three other allegations related to facility cleanliness, hot water delivery, and elevator operability were substantiated, citing violations of California Code of Regulations.
Deficiencies (3)
The facility failed to maintain bathroom floor clean and sanitary. Water leaks from the ceiling and wet floors created potential hazard.
One out of three elevators broke down with residents stuck in it, posing potential health and safety risk.
Facility staff failed to maintain faucet water temperature within required regulations, posing potential health and safety risk.
Report Facts
Capacity: 160
Census: 69
Deficiencies cited: 3
Plan of Correction Due Date: Apr 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Brenda Chan | Licensing Program Manager | Oversaw complaint investigation |
| Jessica Sanchez | Interim Executive Director | Facility representative met during inspection |
| Natasha Prunty | Administrator | Facility administrator named in report |
Inspection Report
Annual Inspection
Census: 81
Capacity: 160
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance with regulations and licensing requirements.
Findings
The facility was found to be clean, in good repair, and compliant with safety and health regulations. No deficiencies were issued during this inspection. Residents and staff files were reviewed and found to be up to date.
Report Facts
Facility capacity: 160
Census: 81
Inspection start time: 1130
Inspection end time: 1700
Fire extinguisher service date: Oct 4, 2024
Refrigerator temperature: 39
Freezer temperature: -2
Form submission deadline: Jan 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Prunty | Administrator | Met with Licensing Program Analyst during inspection |
| Vadim Gorban | Licensing Program Analyst | Conducted the inspection |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 160
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
The visit was conducted in regard to an incident report about a medication error that occurred on 2024-12-28, where a resident was given the wrong medications.
Complaint Details
Visit was complaint-related due to an incident report of a medication error on 2024-12-28. Resident was monitored and no adverse side effects were observed.
Findings
The facility failed to ensure that resident R1 received medication as prescribed, resulting in the resident taking wrong medications which posed a potential health and safety risk. No adverse side effects were observed during monitoring.
Deficiencies (1)
Facility failed to ensure R1 medication as prescribed; resident took wrong medications (dose of Mitrazapine and Risperidone instead of prescribed Ramipril) posing potential health and safety risk.
Report Facts
Capacity: 160
Census: 81
Deficiencies cited: 1
Plan of Correction Due Date: Jan 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Montellano | Administrator/Director | Facility administrator notified of licensing visit |
| Eva Reiter | Resident Services Director | Met with during inspection |
| Vadim Gorban | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brenda Chan | Licensing Program Manager/Supervisor | Supervisor of the inspection and named in deficiency section |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 160
Deficiencies: 3
Date: Nov 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-06-26 regarding failure to seek timely medical attention, failure to provide refund to resident's responsible person, and failure to follow admissions agreement.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to seek timely medical attention for a resident who fell and was in visible pain, failure to provide refund to the resident's responsible party, and failure to follow the admissions agreement. The facility acknowledged owing a refund of 40% of the community fee but had not paid it. The resident was taken to the hospital late in the day after the fall, confirming delayed medical care.
Findings
The investigation substantiated all allegations: the facility failed to provide timely medical care to a resident who fell and was in visible pain, failed to refund 40% of the community fee to the resident's responsible party as required, and did not follow the admissions agreement regarding refunds. Deficiencies were cited related to incidental medical care, refund processing, and admission agreement compliance.
Deficiencies (3)
Resident 1 fell on 01/14/2024 around 05:00 a.m., despite being in visible pain was not provided medical care until 8 p.m., which poses an immediate, health, safety or personal rights risk to resident in care.
The facility has not refunded portion of 'Community fee' to Resident 1's Responsible Party more than 15 days after the passing of Resident 1, which poses a potential, health, safety, or personal rights risk to residents in care.
Resident 1's Admission Agreement reads 40 percent of 'Community Fee' should be refunded. Resident 1's Responsible Party has not received refund, which poses a potential, health, safety, or personal rights risk to residents in care.
Report Facts
Refund amount: 2400
Facility capacity: 160
Census: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Aaron Windbigler | Regional Director of Operations | Met with Licensing Program Analyst during the investigation and exit interview |
| Brenda Chan | Licensing Program Manager | Named in relation to the licensing program management and report |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 160
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 08/12/2024 regarding resident care issues including being left in soiled diapers and sustaining pressure sores.
Complaint Details
The complaint involved two allegations: staff left a resident in soiled diapers resulting in a rash, and a resident sustained a pressure sore while in care. Both allegations were unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Records and interviews indicated residents were attended every couple of hours, and no deficiencies were observed during the visit.
Report Facts
Capacity: 160
Census: 153
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
| Eva Reiter | Resident Services Director | Met with Licensing Program Analyst during investigation |
| Anthony Montellano | Administrator | Facility administrator contacted and notified during investigation |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 160
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
The visit was an unannounced case management inspection triggered by an incident involving a water shut off on October 26, 2024, which was not reported to the Licensing Regional office as required.
Complaint Details
The visit was complaint-related due to an incident on October 26, 2024, involving a water shut off that was not reported by the facility as required. The deficiency was substantiated and cited.
Findings
The facility failed to submit a required written report to the licensing agency regarding the water shut off incident, posing a potential health and safety risk to residents. This deficiency was cited under reporting requirements.
Deficiencies (1)
Failure to provide a written report to Licensing office regarding water shut off for a couple of hours on October 26, 2024, posing potential health and safety risk to persons in care.
Report Facts
Deficiency due date: Nov 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the inspection and authored the report |
| Brenda Chan | Licensing Program Manager | Supervisor overseeing the inspection |
| Natasha Prunty | Administrator | Facility administrator met during the inspection |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 160
Deficiencies: 1
Date: Oct 29, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 10/25/2024 alleging the facility tested positive for black mold and asbestos.
Complaint Details
The complaint alleging the facility tested positive for black mold and asbestos was substantiated based on observations, document review, and staff interviews.
Findings
The investigation substantiated the allegation that black mold and asbestos were present in the administrative offices on the first floor. Mold remediation and asbestos abatement began in September 2024, and repairs to the affected area were completed.
Deficiencies (1)
87303 Maintenance and Operation. The facility was not clean, safe, sanitary, and in good repair due to presence of asbestos and black mold in the administrative offices posing potential health and safety risks.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Oct 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Eva Reiter | Resident Services Director | Met with during the investigation and interviewed |
| Anthony Montellano | Administrator | Facility administrator at time of investigation |
| Natasha Prunty | Administrator | Notified of Licensing visit and attended the visit |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 160
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2024-07-18 regarding multiple allegations including pressure injuries, mal odors, dental care, and room temperature issues.
Complaint Details
The complaint included allegations that a resident developed multiple pressure injuries, staff did not ensure the facility was free of mal odors, dental care needs were not met, and rooms were not kept at comfortable temperatures. The complaint was found to be unsubstantiated based on observations, interviews, and record reviews.
Findings
The investigation found no evidence to support the allegations. The facility was observed to be free of odors and maintained comfortable temperatures, residents received dental care, and no pressure injuries were noted. The allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 160
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Donna Lao | Memory Care Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Follow-Up
Census: 82
Capacity: 160
Deficiencies: 1
Date: Sep 6, 2024
Visit Reason
The inspection was conducted as a follow-up on an incident that occurred on 2024-08-12 involving a care provider sharing inappropriate videos with residents.
Findings
A deficiency was cited for violation of personal rights where a staff member shared inappropriate video content with residents, posing potential health and safety risks. The staff member was suspended and later terminated.
Deficiencies (1)
87468.1 Personal rights. Residents were exposed to inappropriate video content shared by a staff member, posing potential health and safety risks.
Report Facts
Deficiency Type: 1
Capacity: 160
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eva Reiter | Resident Services Director | Met with Licensing Program Analyst during inspection |
| Anthony Montellano | Administrator/Director | Named as facility administrator |
| Vadim Gorban | Licensing Program Analyst | Conducted the inspection |
| Brenda Chan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 160
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff were retaliating due to a complaint filed against the facility.
Complaint Details
Allegation that facility staff is retaliating due to complaint filed against the facility was investigated and found unsubstantiated.
Findings
The investigation included a facility tour, safety checks, and interviews with staff, the administrator, and residents. No evidence of retaliation was found, and the allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 160
Census: 184
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eva Reitler | Resident Services Director | Met with during inspection and notified of Licensing visit |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation visit |
| Anthony Montellano | Administrator | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 160
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 2024-04-22 regarding staff not ensuring the roof was fixed timely.
Complaint Details
The complaint alleged that staff did not ensure the roof was fixed timely. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found the allegation to be unsubstantiated based on observations and record review, determining that the licensed portion of the facility was not in need of roof repairs at the time of inspection.
Report Facts
Complaint Control Number: 24
Capacity: 160
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Reiter | Resident Services Director | Met with during the inspection |
| Donna Lao | Memory Care Director | Met with during the inspection |
Inspection Report
Complaint Investigation
Census: 217
Capacity: 160
Deficiencies: 2
Date: Mar 29, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2024-02-12 regarding inadequate food, lack of hot water, unresponsiveness to resident pendants, and mismanagement of medications and records.
Complaint Details
The complaint investigation was unannounced and conducted by Evaluator Sarah Hurt. The complaint control number is 24-AS-20240212083924. The allegations included inadequate food, lack of hot water, unresponsiveness to resident pendants, mismanagement of medications, and mismanagement of records. The medication and records mismanagement allegations were substantiated, while the others were unsubstantiated.
Findings
The investigation found the allegations of inadequate food, lack of hot water, and unresponsiveness to resident pendants to be unsubstantiated due to insufficient evidence. However, the allegations of mismanagement of residents' medications and records were substantiated, with specific deficiencies noted in medication administration and documentation.
Deficiencies (2)
Resident 4 was not provided prescribed medication as facility did not provide the medication to person responsible for administering; Resident 5 has not been given prescribed weekly medication for more than 2 weeks.
Resident 4's medication was being stored by the facility with no Centrally Stored Medication Record; Resident 6's medication stored by the facility is not logged on the Centrally Stored Medication log.
Report Facts
Capacity: 160
Census: 217
Deficiency due date: Mar 30, 2024
Deficiency due date: Apr 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Billy Mitchell | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 217
Capacity: 160
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
The visit was an unannounced Required Annual Inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and compliant with safety and care standards. No deficiencies were cited during the inspection.
Report Facts
Capacity: 160
Census: 217
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Census: 215
Capacity: 160
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
The visit was an unannounced Case Management visit to relay information about an Immediate Exclusion order for a staff member (S1).
Findings
No deficiencies were cited during this Case Management visit. The Executive Director was advised to disassociate the excluded staff member from the facility staff roster and guardian.
Report Facts
Capacity: 160
Census: 215
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | Executive Director | Met with Licensing Program Analyst during the visit and discussed the exclusion order for staff member S1 |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 160
Deficiencies: 0
Date: May 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not properly addressing scabies.
Complaint Details
The complaint was found to be unfounded and dismissed after review of medical records and interviews.
Findings
The investigation found that Resident R1 did not have scabies or a contagious skin condition, and the complaint was determined to be unfounded with no deficiencies cited.
Report Facts
Facility capacity: 160
Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Beau Ayers | Acting Executive Director | Facility representative met during the investigation |
| Anthony Montellano | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 72
Capacity: 160
Deficiencies: 0
Date: Feb 22, 2023
Visit Reason
The inspection was an unannounced annual required inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with infection control practices, with no deficiencies observed during the inspection.
Report Facts
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Montellano | Administrator | Named as facility administrator |
| Billy Mitchell | Executive Director | Met with Licensing Program Analysts during inspection |
| Alex Hernandez | Maintenance Director | Accompanied Licensing Program Analysts on facility tour |
| Melinda Medina | Licensing Program Analyst | Conducted the inspection |
| D. Ayers | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Census: 72
Capacity: 160
Deficiencies: 0
Date: Feb 22, 2023
Visit Reason
An unannounced Case Management visit was conducted to follow up on an incident involving resident R1 that occurred on 2023-02-19.
Findings
No deficiencies were cited during the Case Management visit. The incident involved R1 being transported to the hospital and admitted for treatment, with an expected return to the facility on or about 2023-02-25.
Report Facts
Incident date: Feb 19, 2023
Expected return date: Feb 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lillian Bennett-Russell | Memory Care Director | Met with Licensing Program Analysts during the Case Management visit |
| Melinda Medina | Licensing Program Analyst | Conducted the Case Management visit |
| D. Ayers | Licensing Program Analyst | Conducted the Case Management visit |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 160
Deficiencies: 0
Date: Dec 2, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff did not administer a resident's medications as required and did not provide adequate supervision to a resident.
Complaint Details
The complaint investigation was unannounced and initiated based on a complaint received on 11/28/2022. The allegation that staff did not administer a resident's medications as required was unsubstantiated. The allegation that staff did not provide adequate supervision to a resident was unfounded.
Findings
The investigation found that the allegation regarding medication administration was unsubstantiated as the resident self-managed medication until a new order was received and staff then administered medications as ordered. The allegation regarding inadequate supervision was found to be unfounded based on interviews and facility tour, confirming resident safety checks were conducted each shift.
Report Facts
Capacity: 160
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Candice Moses | Interim Executive Director | Met with Licensing Program Analyst during the investigation |
| Anthony Montellano | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 160
Deficiencies: 0
Date: Aug 29, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2020-05-20 alleging that staff were not administering medications per doctor's orders, not meeting basic service needs of residents, and failing to provide supervision resulting in multiple falls.
Complaint Details
The complaint was unsubstantiated after investigation, meaning there was insufficient evidence to prove the alleged violations occurred.
Findings
The investigation included interviews and document reviews, and the allegations could not be confirmed or corroborated. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 160
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Montellano | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 160
Deficiencies: 0
Date: Aug 29, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2020-04-20 alleging rough handling of residents, skin tears, forced medication, unresponsiveness to pain complaints, non-working call pendents, denial of telephone calls, and improper oxygen administration.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove that the alleged violations did or did not occur.
Findings
After conducting interviews and reviewing relevant documents and records, the department determined that the allegations could not be confirmed or corroborated and the complaint was unsubstantiated.
Report Facts
Complaint Control Number: 26
Complaint Control Number Suffix: 20200420143926
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Montellano | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 85
Capacity: 160
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
An unannounced Annual Required Infection Control Inspection was conducted to assess compliance with infection control practices and visitation guidelines.
Findings
The facility was found to be in compliance with required infection control practices, including COVID screening, PPE supply, and signage. No deficiencies were observed during the inspection.
Report Facts
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Montellano | Executive Director | Met during facility tour and interview |
| Beau Ayers | Regional Vice President of Operations | Met during facility tour |
| Melinda Medina | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 160
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that staff did not ensure the facility was free from vermin.
Complaint Details
Complaint alleging staff did not ensure the facility was free from vermin. The complaint was found to be unfounded and dismissed.
Findings
The investigation found that although the facility had a continuing problem with vermin, it was maintaining monthly pest control services. The complaint was determined to be unfounded and was dismissed.
Report Facts
Capacity: 160
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Montellano | Administrator | Met with during the investigation and notified of the visit purpose |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 160
Deficiencies: 0
Date: Jun 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-06-10 regarding residents being left in soiled undergarments, staff laughing at residents, unsanitary conditions, and vermin presence.
Complaint Details
The complaint investigation was unsubstantiated for allegations of residents left in soiled undergarments and staff laughing at residents. The complaint regarding unsanitary conditions was unfounded, and the complaint about vermin was acknowledged but addressed by pest control services.
Findings
The investigation found insufficient evidence to substantiate the allegations of residents being left in soiled undergarments and staff laughing at residents, resulting in an unsubstantiated finding. The complaints about the facility being unsanitary were found to be unfounded, while the presence of vermin was acknowledged but mitigated by regular pest control services.
Report Facts
Capacity: 160
Census: 85
Housekeeping Staff: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Montellano | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 194
Capacity: 160
Deficiencies: 0
Date: Apr 3, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2020-11-23 alleging improper resident reassessment, unsanitary conditions, unmet resident needs, and threats of eviction.
Complaint Details
The complaint included allegations that staff did not properly reassess a resident, resident's room smelled foul and was unsanitary, staff did not meet residents' needs, and staff threatened residents with eviction. The investigation concluded these allegations were unsubstantiated due to lack of evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. No deficiencies were cited, and the complaint was determined to be unsubstantiated.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Beau A. Ayers | Administrator | Facility Administrator involved in the investigation |
| Lori Trindade | Sales Director | Met with Licensing Program Analyst during the investigation visit |
Inspection Report
Complaint Investigation
Census: 194
Capacity: 160
Deficiencies: 0
Date: Apr 3, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-01-10 alleging the facility was unclean, failed to meet residents' hygiene needs, had insufficient staffing, and untrained staff.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence. Allegations included unclean facility, failure to meet hygiene needs, insufficient staffing, and untrained staff. No deficiencies were cited.
Findings
The investigation found feces in a resident's toilet and some dust on the floor but noted the resident was independent in personal care. Staffing and training allegations were not substantiated based on staff interviews. No deficiencies were cited and the complaint was found to be unsubstantiated.
Report Facts
Complaint Control Number: 26
Estimated Days of Completion: 90
Census: 194
Total Capacity: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Beau A. Ayers | Administrator | Facility administrator contacted during investigation |
| Lori Trindade | Sales Director | Met with Licensing Program Analyst during investigation |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 77
Capacity: 125
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
The visit was a Technical Assist (TA) conducted via Zoom to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities.
Findings
The Licensing Program Analyst and Program Clinical Consultant reviewed facility policies and procedures including screening, disinfecting, staffing, training, PPE usage, and resident activities. Recommendations were made regarding posting Donning and Doffing signage, maintaining covered trash cans for contaminated PPE, and social distancing in Memory Care areas.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beau A. Ayers | Executive Director/Administrator | Met with Licensing Program Analyst during the Technical Assist visit. |
| Marybeth Donovan | Licensing Program Analyst | Conducted the Technical Assist visit and reviewed facility policies. |
| Barbara Elenteny | Program Clinical Consultant (PCC) Nurse | Participated in the Technical Assist visit reviewing infection control guidelines. |
| Sarah Yip | Licensing Program Manager | Participated in the Technical Assist visit. |
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