Inspection Reports for The Pinnacles at Burton

An unannounced case management visit was conducted to investigate the administrator's failure to comply with Title 22 reporting requirements related to three unwitnessed resident falls that were not reported to the Department.

The facility was found noncompliant with Title 22 regulations, specifically Section 87211(a)(1)(D) regarding reporting requirements. Three residents experienced unwitnessed falls that were not reported, posing a potential health and safety risk. A deficiency was cited and a civil penalty issued.

The investigation was triggered by observations of three residents experiencing unwitnessed falls on 09/11/2025, 09/12/2025, and 09/13/2025, which were not reported to the Department as required. The violation was substantiated and cited.

An unannounced complaint investigation visit was conducted to investigate allegations that residents sustained unexplained injuries and that staff did not prevent a resident from injuring another resident.

The investigation found that residents #1-#3 mentioned in the allegations were not listed on the facility roster and are not residents of the facility. Based on this information, the alleged violations were determined to be unfounded.

The complaint was investigated and determined to be unfounded after verification that the alleged residents were not part of the facility.

An unannounced case management visit was conducted in connection with complaint #11-AS-20250909091421 to investigate compliance with Title 22 regulations.

The facility was found not in compliance with Title 22 regulations, resulting in several deficiencies and a civil penalty. The administrator failed to meet qualifications and duties, posing a potential health and safety risk to residents.

The visit was triggered by complaint #11-AS-20250909091421. The investigation substantiated noncompliance with Title 22 regulations and identified deficiencies.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not report an incident involving a resident to Licensing.

The investigation substantiated that the facility failed to report incidents involving Resident #1, including elopements and hospitalizations, to Community Care Licensing as required. Interviews and record reviews confirmed the incidents and lack of reporting, posing an immediate health and safety risk.

The complaint alleged that the facility did not report incidents involving Resident #1 eloping from the premises and subsequent hospitalizations. The allegation was substantiated based on interviews, record reviews, and verification with the Community Care Licensing Regional Office.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-06-27 regarding medication mismanagement, uncomfortable room temperature, and unmet medical needs of residents.

Based on interviews with staff and residents, document reviews, and observations, the allegations were found to be unsubstantiated. Residents generally reported receiving their medications and medical assistance, and air conditioning units were observed to be working properly.

The complaint investigation addressed three allegations: 1) Staff mismanaging residents' medications, 2) Staff not ensuring residents have a comfortable temperature, and 3) Staff not ensuring residents' medical needs are met. The investigation found no preponderance of evidence to substantiate these allegations.

An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.

The inspection found no discrepancies in staff, resident, or medication administration records. Safety equipment such as fire extinguishers, smoke detectors, and alarms were operational, and the facility environment was free of hazards.

An unannounced annual continuation visit was conducted to evaluate the facility's compliance with licensing requirements and overall conditions.

The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. No deficiencies were identified during this inspection visit.

An unannounced complaint investigation visit was conducted in response to allegations received on 2025-06-27 regarding medication mismanagement, uncomfortable room temperature, and unmet medical needs of residents.

The investigation included interviews with staff and residents, review of resident records, and facility observations. All allegations were found to be unsubstantiated based on evidence that residents were assisted with medications and medical needs as prescribed, and that air conditioning units were functioning properly.

The complaint investigation addressed three allegations: 1) staff mismanaging residents' medications, 2) staff not ensuring residents have a comfortable temperature, and 3) staff not ensuring residents' medical needs are met. The findings concluded these allegations were unsubstantiated due to lack of preponderance of evidence.

The inspection was conducted in response to a complaint alleging that staff did not ensure the kitchen area was kept clean and free of pests.

The investigation included interviews, record reviews, and a facility tour. The majority of staff and residents did not corroborate the allegation, and no evidence of pest activity was observed during the inspection. The facility has a weekly pest control service and trained kitchen staff following safety protocols. The allegation was found to be unsubstantiated due to insufficient evidence.

The complaint alleged that the kitchen area was not kept clean and free of pests, with reports of food contamination by pests. Interviews with staff and residents, review of pest control agreements, and inspection of the kitchen found no current pest issues or contamination. The allegation was unsubstantiated.

An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.

No deficiencies were cited during this inspection visit. The facility was found to have accurate and complete resident and staff records, current licensing fees, and proper certifications and insurance coverage.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-02-04 regarding failure to seek timely emergency medical treatment, failure to notify resident's responsible party of condition changes, and failure to provide adequate food and fluids to a resident.

The investigation substantiated neglect and lack of care and supervision related to a resident's fall with head impact where timely medical attention was not sought, and the resident's change in condition was not promptly noticed by staff. Allegations regarding failure to provide adequate food and fluids were unsubstantiated due to insufficient evidence. Deficiencies were cited for failure to immediately call 911 and failure to regularly observe residents for changes in condition.

The complaint alleged that staff did not seek timely emergency medical treatment for a resident after an unwitnessed fall with head impact on 2025-01-25 and subsequent incoherence on 2025-01-27, and did not notify the resident's responsible party of condition changes. Additional allegations included failure to provide adequate food and fluids. The investigation found neglect and lack of care and supervision substantiated for the medical treatment and notification allegations, but insufficient evidence to substantiate the food and fluid allegations.

An unannounced complaint investigation visit was conducted due to an allegation that the licensee did not provide copies of resident records in a timely manner.

The investigation found that the facility staff failed to provide complete resident records to the designated representative despite multiple requests and follow-ups. The allegation was substantiated based on interviews, document reviews, and evidence gathered.

The complaint alleged that the licensee did not provide copies of resident (R#1)'s records in a timely manner despite multiple requests from the resident's Power of Attorney (W#1). The investigation confirmed partial records were sent but the complete records were not provided, substantiating the complaint.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 08/08/2024 regarding medication administration, resident hygiene, soiling, medical attention after falls, running water availability, and pest control.

All allegations except one were found unsubstantiated after interviews with residents and staff and record reviews. The allegation that the facility did not keep the premises free of pests was substantiated based on observations of live and dead vermin in the kitchen and pest control records indicating worsening cockroach activity.

The complaint investigation was unannounced and conducted due to allegations including failure to administer medication as prescribed, failure to maintain resident hygiene, leaving residents soiled, failure to provide medical attention after falls, lack of running water, and failure to keep the facility free of pests. All allegations except the pest control issue were unsubstantiated.

An unannounced case management visit was conducted regarding the relocation of 30 residents from Ceila facility due to a mandatory evacuation Fire Advisory.

During the visit, a health and safety check was conducted with no concerns observed. The facility was found to have sufficient beds, supplies, staffing, and accommodations for the relocated residents, with medications and files properly transferred and stored.

The visit was a case management follow-up on an incident report dated 2024-05-08 regarding missing Oxycodone 325 mg tablets belonging to Resident #1.

The inspection found that the facility conducts medication audits during shift changes but did not include surplus medications in regular audits. On 2024-05-07 and 2024-05-08, significant quantities of Oxycodone tablets were missing from Resident #1's surplus medication. Law enforcement was notified and visited the facility. The facility did not submit an Unusual Incident Report for the missing tablets. No citations were issued during this visit.

An unannounced complaint investigation was conducted in response to allegations that staff were not feeding a resident in care and were neglecting the residents.

The investigation included interviews with the administrator, residents, and staff, as well as review of menus, personnel reports, and resident records. The evidence did not support the allegations, and the complaint was found to be unsubstantiated.

The complaint alleged that staff were not feeding a resident and were neglecting residents in care. After investigation, including interviews and records review, the allegations were found to be unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced annual required visit conducted to assess compliance with regulatory standards using the CARE Inspection Tool.

The facility was found to be sanitary, appropriately furnished, and compliant with Title 22 regulations. No deficiencies were observed, and no citations were issued during the inspection.

The visit was an unannounced complaint investigation conducted in response to allegations that staff did not ensure the facility elevator was in good repair resulting in a resident injury, and that staff did not inform the resident's responsible party.

The investigation found that the elevator was in good repair with recent maintenance and inspection, and that the resident's responsible party had been notified on the day of the incident. Both allegations were unsubstantiated and no deficiencies were cited.

The complaint investigation was unsubstantiated. Allegations included elevator disrepair causing injury and failure to notify resident's responsible party. Evidence did not support the allegations.

The inspection was an unannounced annual visit conducted using the full CAREs tool to assess compliance and facility conditions.

The Licensing Program Analyst did not observe any deficiencies during the inspection; therefore, no citations were issued. The facility was found clear of COVID-19 infection and had an approved mitigation plan.

The inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-11-29 regarding inadequate food service, cleanliness, medication administration, and nighttime supervision at the facility.

The investigation included interviews with staff and residents, observations, and record reviews. All allegations were found to be unsubstantiated due to insufficient evidence to prove violations occurred.

The complaint investigation addressed four allegations: inadequate food service, lack of cleanliness, improper medication administration, and inadequate nighttime supervision. After interviews and observations, all allegations were determined to be unsubstantiated.

An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations.

The facility was found to be sanitary, appropriately furnished, and compliant with Title 22 regulations. No deficiencies or citations were observed during the inspection.

The inspection was an unannounced complaint investigation conducted due to an allegation that a resident sustained multiple fractures while in care and that the facility did not seek timely medical attention for the resident.

The investigation found that the resident experienced two unwitnessed falls within two weeks, with medical assessments by staff determining no need for emergency services at the time. The resident was taken to the hospital two weeks after the initial fall and was found to have multiple fractures. The allegation of multiple fractures was unsubstantiated due to lack of evidence on when the injuries occurred, but the allegation that the facility did not seek timely medical attention was substantiated. A deficiency was cited related to failure to provide timely medical care.

The complaint alleged that a resident sustained multiple fractures while in care and that the facility did not seek timely medical attention. The allegation of multiple fractures was unsubstantiated, but the allegation regarding failure to seek timely medical attention was substantiated based on investigation findings and evidence.

The visit was an unannounced annual inspection conducted by Licensing Program Analyst David España to evaluate compliance with regulatory requirements at the Beverly Hills Carmel Retirement Hotel.

The inspection found several deficiencies including an uneven porch floor and wasp nests accessible to residents, lack of a required complaint poster in the main entryway, and an outdated Emergency Disaster Plan. Other areas such as linens, bathrooms, kitchen, common rooms, safety equipment, resident and staff files, and medication storage were found to be in good condition.

The visit was an unannounced annual inspection conducted by Licensing Program Analyst David España to evaluate the facility's compliance with licensing requirements.

No deficiencies were observed during the inspection, and no citations were issued. Due to time constraints, a subsequent visit is required.

The visit was an unannounced annual inspection with a primary focus on infection control using CARE tools.

The facility was found to be in good condition with no deficiencies observed. Infection control practices were adequate, all resident and common areas were well maintained, and safety equipment was up to date.

The inspection was an unannounced annual required visit including an infection control inspection to evaluate compliance with regulations.

No deficiencies were observed during the inspection, and no citations were issued. The facility was found to be in good repair with proper infection control practices, adequate supplies, and safety measures in place.

The inspection was an unannounced complaint investigation conducted in response to a complaint received on 2021-03-25 alleging that the facility does not provide a safe environment for residents and lacks night supervision.

The investigation included interviews, record reviews, and facility tours. It was found that one resident has a mental disorder causing yelling and screaming, but this was not due to distress and the facility has a care plan in place. The facility does have adequate night supervision with staff present 24/7. The allegations were not substantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated. Allegation #1 regarding unsafe environment was not supported by evidence as the resident's behavior was related to a known mental condition and managed by the facility. Allegation #2 regarding lack of night supervision was disproven by staff schedules and interviews confirming adequate night staffing.

The inspection was an unannounced complaint investigation conducted in response to a complaint received on 2021-03-29 alleging that residents were not served nutritious meals, rooms were not cleaned, laundry services were inadequate, and staff withheld food from residents.

The investigation included interviews, record reviews, and facility tours. The findings did not substantiate the allegations; meals were found to be nutritious, rooms and common areas were clean, laundry services were adequate, and no food was withheld from residents.

The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred. Allegations included residents not served nutritious meals, unclean rooms, inadequate laundry services, and staff withholding food, all of which were found unsupported by interviews and observations.

An unannounced annual required infection control visit was conducted to evaluate the facility's compliance with regulations and infection control practices.

No deficiencies were observed during the inspection. The facility was found to be in good repair with proper infection control measures, adequate supplies, and compliance with safety regulations.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation of illegal eviction received on 10/06/2020.

The allegation of illegal eviction was substantiated. The investigation found that a resident was sent to the hospital due to needing a higher level of care and was not able to return to the facility. The facility failed to conduct a reassessment and did not contact the resident's family regarding the worsening condition, which posed a potential health and safety risk.

The complaint was substantiated. The allegation was that a resident was illegally evicted by being sent to the hospital and not allowed to return due to needing a higher level of care. The investigation confirmed the facility did not perform required reassessments and failed to communicate with the resident's family.