Inspection Reports for The Pines, A Merrill Gardens Community
500 W Ranch View Dr, Rocklin, CA 95765, CA, 95765
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with routine annual visits and complaint investigations generally showing compliance with health, safety, and documentation requirements. The most recent report from October 23, 2025, was clean with no deficiencies noted. Some earlier complaint investigations substantiated issues related to visitor sign-in/out policy and eviction procedures, but these were minor and isolated. Medication management deficiencies were identified in 2023, including a serious medication error that caused hospitalization, but corrective actions and staff training were implemented afterward. The facility’s record shows improvement over time, with recent inspections free of deficiencies and most complaints unsubstantiated.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
85% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 120
Capacity: 142
Deficiencies: 0
Oct 23, 2025
Visit Reason
The inspection was an unannounced 1-year annual inspection conducted to evaluate compliance with licensing requirements.
Findings
The inspection found no health or safety concerns in the facility, with all resident and staff files complete and current. No deficiencies were issued during the inspection.
Report Facts
Residents in Memory Care Unit: 48
Residents in Assisted Living Unit: 42
Residents in Independent Living Unit: 30
Residents under hospice care: 13
Licensed non-ambulatory capacity: 127
Licensed bedridden capacity: 12
Hospice waiver capacity: 20
Fire system last serviced: Jun 18, 2025
Hot water temperature: 118
Resident files reviewed: 10
Staff files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Graham Gunby | Licensing Program Analyst | Conducted the inspection |
| Mira Marcus | Business Director | Met with Licensing Program Analyst during inspection |
| Henry Cole | Administrator | Facility Administrator |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 142
Deficiencies: 1
Jun 26, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation of unlawful eviction received on 2025-06-19.
Findings
The investigation substantiated the allegation of unlawful eviction due to the licensee's failure to provide a complete eviction letter with required details such as effective date, specific facts, and required statements, posing a potential risk to residents.
Complaint Details
The complaint was substantiated based on file review and interviews. The allegation of unlawful eviction was validated as the eviction letter was incomplete and did not meet regulatory requirements.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not comply with CCR 87224(d)(1)(D) Eviction Procedures by failing to include required information in the eviction notice, including effective date, specific facts, resources for alternative housing, and required statements. | Type B |
Report Facts
Capacity: 142
Census: 120
Deficiency count: 1
Plan of Correction Due Date: Jul 3, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Dana Garcia | Associate Governmental Program Analyst | Assisted in the complaint investigation |
| Henry Cole | Administrator | Facility administrator met during the investigation |
| Anthony Perez | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Annual Inspection
Census: 111
Capacity: 142
Deficiencies: 0
Oct 16, 2024
Visit Reason
Licensing Program Analyst Sabrina Calzada arrived unannounced to conduct a required annual inspection of the facility.
Findings
The facility was toured including Assisted Living and Memory Care Units with no health or safety concerns observed. Resident files, medications, and staff files were reviewed and found complete and compliant. No deficiencies were issued during the inspection.
Report Facts
Residents in Memory Care Unit: 41
Residents in Assisted Living Unit: 42
Residents in Independent Living Unit: 28
Residents under hospice care: 11
Fire extinguisher last service date: Jun 19, 2024
Hot water temperature: 116
Administrator's RCFE Certificate expiration: May 23, 2026
Resident files reviewed: 11
Staff files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the annual inspection |
| Maribeth Senty | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 142
Deficiencies: 0
Oct 16, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2024-07-15 regarding staff not preventing a resident from being harmed by another resident.
Findings
The investigation found that multiple staff intervened quickly during the incident, and based on police and hospital records, no egregious injury was sustained. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff did not prevent a resident from being harmed by another resident resulting in injury. The allegation was found unsubstantiated after review of video surveillance, interviews, and medical records.
Report Facts
Complaint received date: Jul 15, 2024
Incident date: Jul 13, 2024
Incident time: 751
Staff intervention time: 20
Resident monitoring duration: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation and annual inspection |
| Henry Cole | Administrator | Facility administrator met during investigation |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 142
Deficiencies: 0
Sep 3, 2024
Visit Reason
The visit was a case management inspection regarding an incident that occurred on 2024-08-23 involving a resident found injured outside the facility.
Findings
The resident was found in the parking lot with a rib fracture and UTI after leaving the facility unsupervised. The facility is following up with the resident's care team and has implemented 1:1 supervision during nighttime hours. No deficiencies were cited during the visit.
Complaint Details
The investigation was triggered by an incident where resident R1 left the facility unsupervised and was found injured. The resident had been assessed as not a wander risk and oriented, with no wandering behavior noted in recent physician reports.
Report Facts
Incident date: Aug 23, 2024
Supervision hours: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Parks | Licensing Program Analyst | Conducted the case management visit and investigation |
| Henry Cole | Administrator | Facility administrator met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 142
Deficiencies: 0
Jul 18, 2024
Visit Reason
The inspection was conducted as a case management visit to obtain additional information regarding an incident report submitted about a missing pill of Norco from the medication cart on 2024-07-12.
Findings
The facility followed its medication protocols, including increased security measures implemented in May 2024. Despite interviews and investigation, the missing medication was not found, and no deficiencies were cited in this report.
Complaint Details
The visit was triggered by a complaint related to a missing Norco pill. The investigation included interviews with staff and review of security footage, which was inconclusive. Staff member S1 resigned during the investigation. Resident R1 did not miss any doses. The complaint was not substantiated with definitive evidence.
Report Facts
Medication missing: 1
Capacity: 142
Census: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during inspection |
| Sabrina Calzada | Licensing Program Analyst | Conducted the case management inspection |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 142
Deficiencies: 0
Jun 11, 2024
Visit Reason
The inspection was conducted as a case management follow-up on an incident involving missing medication tablets reported in May 2024.
Findings
The facility discovered 10 tablets of PRN Norco 5/325 mg missing from the medication room. An internal investigation was conducted, corrective actions were taken with involved staff, and new key control procedures and cameras were implemented. No further medication losses were reported.
Complaint Details
The visit was triggered by a complaint regarding missing medication tablets. The investigation found that staff possibly kept unauthorized keys to the medication room. Corrective actions and preventive measures were implemented.
Report Facts
Tablets missing: 10
Tablets supply: 30
Medication administration frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during inspection and involved in incident notification |
| Sabrina Calzada | Licensing Program Analyst | Conducted the case management inspection |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 142
Deficiencies: 0
Jun 11, 2024
Visit Reason
The inspection was conducted as a case management visit to obtain additional information regarding two incident reports recently submitted to the Department.
Findings
The facility responded immediately and appropriately to the incidents involving two residents, submitting timely incident reports. No deficiencies were issued in this report.
Complaint Details
The inspection was triggered by two incidents: Resident 1 expressed suicidal ideation and was monitored with police and hospice involvement; Resident 2 fell, sustained injuries, was hospitalized briefly, and returned without follow-up appointments or new medications. Both incidents were handled appropriately.
Report Facts
Incident reports: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during inspection and provided information about incidents |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 142
Deficiencies: 1
Apr 26, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2024-04-09 regarding allegations that staff allowed a conserved resident to sign unauthorized forms and that staff were not properly trained.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations occurred. Staff were aware of the resident's Power of Attorney but not all staff were clear on the resident's conservatorship status. A citation was issued for not following visitor sign-in/out policy.
Complaint Details
The complaint alleged that staff allowed a conserved resident to sign unauthorized forms and that staff were not properly trained regarding conservatorship and document signing. The investigation concluded both allegations as unsubstantiated due to insufficient evidence.
Deficiencies (1)
| Description |
|---|
| Facility did not follow visitor policy requiring all visitors to sign in and out during each visit. |
Report Facts
Facility capacity: 142
Census: 120
Citation date: Apr 12, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during investigation and involved in findings |
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 120
Capacity: 142
Deficiencies: 0
Apr 26, 2024
Visit Reason
The inspection was conducted as a case management visit following the facility reporting an infectious disease outbreak involving one resident and multiple staff members.
Findings
The facility took immediate precautionary measures including isolating affected individuals, use of PPE, increased disinfection, and staff training. No deficiencies were issued during this inspection.
Report Facts
Infected individuals: 1
Infected individuals: 3
Expected clearance date: Apr 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during inspection and provided outbreak information |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Maribeth Senty | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 142
Deficiencies: 1
Apr 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2024-04-09 regarding the facility's failure to follow its visitor policy.
Findings
The investigation substantiated that the facility did not follow its visitor policy, as evidenced by visitors not signing in or out as required, posing a potential health and safety risk to residents.
Complaint Details
The complaint was substantiated based on video footage, visitor logs, and interviews showing that a male visitor did not sign in and a female visitor did not sign out on 4/8/24. The visitor log also showed 16 other visitors signed in and 5 who did not sign out.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with admission agreements by not ensuring all visitors signed in and out as required, posing a potential health and safety risk to residents. | Type B |
Report Facts
Visitors signed in: 16
Visitors not signed out: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Calzada | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Henry Cole | Administrator | Facility administrator met during the investigation and named in findings |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 123
Capacity: 142
Deficiencies: 0
Apr 9, 2024
Visit Reason
The inspection was an unannounced case management visit to follow up on two incident reports recently submitted to the Department.
Findings
The inspection reviewed two incidents: one involving a resident sent to the ER due to difficulty removing an eye contact lens, and another involving a resident found intoxicated and sent to the ER, who has since transferred to a skilled nursing facility. The Administrator discussed plans to obtain a doctor's order for a limited daily alcohol amount and emphasized timely incident report submission.
Report Facts
Incident report submission timeframe: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during inspection and discussed incidents. |
| Sabrina Calzada | Licensing Program Analyst | Conducted the unannounced case management inspection. |
| Maribeth Senty | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Follow-Up
Census: 117
Capacity: 142
Deficiencies: 0
Dec 6, 2023
Visit Reason
The visit was an unannounced case management follow-up on a prior complaint investigation (#59-AS-20230804135453) to assess compliance and facility conditions.
Findings
No deficiencies were cited during the inspection. The Licensing Program Analyst toured the memory care unit and observed that a resident room was unlocked and accessible from both doors.
Complaint Details
The visit was a follow-up on complaint investigation #59-AS-20230804135453.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during inspection and mentioned in report. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced case management visit and inspection. |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 142
Deficiencies: 0
Oct 4, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not ensure resident's nail care needs were met and that staff did not allow resident access to personal items.
Findings
Both allegations were investigated through interviews, documentation review, and observations. The complaint regarding nail care was found to be unfounded as podiatry care was documented and the resident received nail care. The allegation about restricting access to personal items was also found to be unfounded due to the resident's behavior of throwing items away and the facility's measures to protect belongings.
Complaint Details
The complaint investigation was triggered by allegations that staff did not ensure resident's nail care needs were met and restricted resident access to personal items. Both allegations were found to be unfounded after investigation.
Report Facts
Facility capacity: 142
Resident census: 124
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Henry Cole | Administrator | Met with Licensing Program Analyst during facility visit and provided information |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 126
Capacity: 142
Deficiencies: 0
Aug 24, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to ensure the health and safety of residents in care at the facility.
Findings
No deficiencies were cited during the inspection. The Licensing Program Analyst toured multiple areas of the facility, reviewed resident and staff files, and found no immediate health, safety, or personal rights violations.
Report Facts
Resident files reviewed: 12
Staff files reviewed: 6
Inspection duration hours: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during inspection |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the annual inspection |
| Troy Ordonez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 142
Deficiencies: 0
Jul 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility dishwasher was in disrepair and staff were not properly cleaning.
Findings
The Licensing Program Analyst toured the kitchen and facility, found the kitchen clean and sanitary, observed manual washing procedures, and confirmed the dishwasher was broken but a replacement had been ordered. The facility was clean and housekeeping was active. The allegations were found to be unfounded.
Complaint Details
The complaint investigation was unannounced and based on allegations regarding dishwasher disrepair and improper cleaning by staff. After investigation, the allegations were determined to be unfounded.
Report Facts
Capacity: 142
Census: 127
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the complaint investigation visit |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 142
Deficiencies: 0
Jun 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-07-12 alleging the facility did not conduct pre-admission appraisals, denied visitation, phone access, mail receipt, and privacy to residents.
Findings
The investigation found all allegations to be unfounded after reviewing records, interviewing residents, staff, and witnesses. The facility conducted pre-admission appraisals, residents received visitation and privacy, had mail forwarded to authorized representatives, and were not denied phone access.
Complaint Details
Complaint control number 25-AS-20220712132307 involved multiple allegations including failure to conduct pre-admission appraisals, denial of visitation, phone access, mail receipt, and privacy. All allegations were found to be unfounded.
Report Facts
Facility capacity: 142
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Executive Director | Met with Licensing Program Analyst during the investigation |
| DeAnna Williams-Lyons | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Mira Marcus | Business Office Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Census: 130
Capacity: 142
Deficiencies: 1
May 31, 2023
Visit Reason
The visit was an unannounced case management visit conducted to review deficiencies related to a medication error reported by the facility.
Findings
The facility failed to provide a resident (R1) with their prescribed Donepezil medication from February 1, 2023 through May 20, 2023 due to a medication technician inputting a discontinue order in error. The medication error was reported to the resident's physician and responsible party, and training was provided to staff as a result.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide R1 their medications as prescribed, posing an immediate health and safety risk to residents in care. | Type A |
Report Facts
Capacity: 142
Census: 130
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during the visit and involved in the medication error finding |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Troy Ordonez | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 142
Deficiencies: 1
Apr 14, 2023
Visit Reason
The visit was conducted as a complaint investigation due to a medication administration error involving resident R1, who was administered discontinued medications along with new medications, resulting in hypoglycemia and hospitalization with ICU admission.
Findings
The facility failed to follow its medication administration process, leading to a medication error that caused serious bodily injury to resident R1. Specifically, staff did not discontinue R1's discontinued medications on the MAR and failed to perform a second check comparing medication orders before administration.
Complaint Details
During the complaint investigation, it was substantiated that facility staff administered two discontinued medications along with two newly ordered medications to resident R1, causing hypoglycemia and hospitalization with ICU admission.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure and provide R1 medications according to medication administration process. | Type A |
Report Facts
Civil penalty amount: 500
Number of discontinued medications administered: 2
Number of newly ordered medications administered: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Executive Director | Met with Licensing Program Analyst during the visit and informed of the reason for the visit. |
| DeAnna Williams Lyons | Licensing Program Analyst | Conducted the complaint investigation and issued the citation. |
| Laura Munoz | Licensing Program Manager | Supervised the licensing evaluation and signed the report. |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 142
Deficiencies: 0
Apr 14, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff failed to follow medication orders leading to a resident's death.
Findings
The investigation found that two medications were not discontinued as ordered, and the resident was administered discontinued medications. However, based on document review and interviews, there was no evidence that this violation contributed to the resident's death, and the allegation was unsubstantiated.
Complaint Details
The complaint alleged that facility staff failed to follow medication orders leading to the death of Resident 1. The allegation was unsubstantiated after investigation.
Report Facts
Facility capacity: 142
Census: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DeAnna Williams-Lyons | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Henry Cole | Executive Director | Met with Licensing Program Analyst during the investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 127
Capacity: 142
Deficiencies: 0
Mar 1, 2023
Visit Reason
The inspection visit was an unannounced case management visit conducted to review an incident involving a resident who had a fall and subsequent injury.
Findings
The Licensing Program Analyst found no deficiencies during the inspection. The resident who fell was sent to the emergency room, diagnosed with a lumbar spinal fracture, received medication, and has not had a reoccurring fall.
Report Facts
Resident census: 127
Total capacity: 142
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | Administrator | Met with Licensing Program Analyst during inspection |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the case management visit |
| Troy Ordonez | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 103
Capacity: 142
Deficiencies: 0
Oct 12, 2022
Visit Reason
This was an unannounced annual inspection visit conducted as a required one-year evaluation of the facility.
Findings
The Licensing Program Analyst observed staff compliance with mask-wearing protocols and toured the facility with key staff. The facility includes assisted living and memory care units with various apartment types and common areas. No deficiencies were cited during this visit.
Report Facts
Capacity: 142
Census: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | General Manager | Spoke with Licensing Program Analyst during the visit |
| Katherine Kaveta | Garden House Director | Toured the facility with Licensing Program Analyst |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced annual visit |
| Troy Ordonez | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 142
Deficiencies: 2
Sep 8, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility was refusing resident visitation and calls, and not assisting a resident with glasses and hearing aid daily.
Findings
The investigation substantiated the allegations that the facility restricted visitation without prior notice and failed to assist a resident with their hearing aid as prescribed, posing potential health and safety risks to residents in care.
Complaint Details
The complaint was substantiated based on evidence that the facility required visitors to contact the resident's Power of Attorney prior to visitation and failed to assist the resident with hearing aid use as prescribed.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not ensure resident was able to visit with visitors without prior notice, violating personal rights. | Type B |
| Staff failed to assist resident with hearing aid as prescribed, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 142
Census: 129
Plan of Correction Due Date: Sep 23, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | General Manager | Met with Licensing Program Analyst during investigation and mentioned in findings |
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 142
Deficiencies: 1
Sep 8, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility was restricting visits.
Findings
The investigation found the allegation to be substantiated based on observations and interviews, confirming that the facility had a protocol requiring visitors to contact the resident's Power of Attorney prior to visitation, which was later rescinded. Despite substantiation, no new citation was issued as the facility had been cited for a similar allegation on the same day in a different complaint.
Complaint Details
The complaint was substantiated, meaning the allegation was valid based on the preponderance of evidence. The allegation involved the facility restricting visits by requiring visitors to notify the resident's Power of Attorney before visitation. The facility had been previously cited for a similar issue.
Severity Breakdown
Substantiated: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility was restricting visits by requiring visitors to contact the resident's Power of Attorney prior to visitation. | Substantiated |
Report Facts
Facility capacity: 142
Census: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Henry Cole | General Manager | Met with Licensing Program Analyst during investigation and involved in findings |
| Cassie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 142
Deficiencies: 0
Feb 16, 2022
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation of illegal eviction received on 01/25/2022.
Findings
The investigation found that the facility did not issue a written eviction notice to resident R1, and the complaint was determined to be unfounded. The resident was sent to the hospital due to a change in condition and was subsequently placed in a new facility due to increased care needs and safety concerns.
Complaint Details
The complaint alleged illegal eviction of resident R1. The investigation included record reviews and interviews, concluding that no eviction notice was given and the complaint was unfounded.
Report Facts
Facility capacity: 142
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Robertson | General Manager | Met with Licensing Program Analyst during investigation and involved in discussion regarding resident R1's placement |
| DeAnna Williams-Lyons | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 142
Deficiencies: 0
Nov 4, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 09/13/2021 alleging the facility did not obtain all required admission documentation prior to admitting residents.
Findings
The investigation found that the facility had obtained all required admission documentation for residents R1 and R2 at the time of admission. The complaint was determined to be unfounded.
Complaint Details
The complaint alleged the facility accepted residents R1 and R2 without proper admission documentation. The complaint was investigated and found to be unfounded.
Report Facts
Facility capacity: 142
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DeAnna Williams-Lyons | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| John Robertson | General Manager | Met with Licensing Program Analyst during the investigation |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Cartin Jankowski | Community Relations Director | Met with Licensing Program Analyst and informed her of the reason for the visit |
Inspection Report
Annual Inspection
Census: 116
Capacity: 142
Deficiencies: 0
Oct 19, 2021
Visit Reason
The visit was an unannounced required 1-year inspection conducted to evaluate compliance with licensing regulations and COVID-19 protocols.
Findings
No deficiencies were cited during the inspection. Staff and resident files were reviewed and found to be in compliance with required documentation and training. Common areas were clean and in good repair.
Report Facts
Capacity: 142
Census: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Robertson | General Manager | Met with Licensing Program Analyst during inspection and received report copy |
| DeAnna Williams-Lyons | Licensing Program Analyst | Conducted the inspection and authored the report |
| Laura Munoz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 142
Deficiencies: 0
Jun 23, 2021
Visit Reason
The inspection visit was conducted to investigate a complaint of neglect of a resident received on 2021-03-11.
Findings
The investigation reviewed medical reports, nursing notes, care plans, staff schedules, and conducted staff interviews. The allegation of neglect was found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint allegation of neglect of a resident was investigated and found to be unsubstantiated.
Report Facts
Capacity: 142
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Lusby | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| John Robertson | Administrator | Facility administrator met during the investigation |
| Anthony Perez | Licensing Program Manager | Named in report signature and oversight |
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