Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. However, some investigations substantiated issues with reporting incidents, timely medical care, and administrator duties, resulting in multiple deficiencies and civil penalties. The most recent report from October 31, 2025, cited a deficiency for failing to report three unwitnessed resident falls and included a civil penalty. Earlier reports also noted failures to report incidents promptly, delays in seeking emergency medical attention after falls, and pest control problems, though many complaints about medication management, hygiene, and environment were unsubstantiated. The facility’s record shows some serious issues related to reporting and resident care, but recent inspections reflect ongoing enforcement and corrective actions without license suspensions or fines beyond civil penalties.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
32% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 44
Capacity: 138
Deficiencies: 1
Oct 31, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report incidents involving residents' injuries and hospitalization as required by Section 87211(a)(1)(D) – Reporting Requirements. | Type B |
Report Facts
Residents involved in incidents: 3
Capacity: 138
Census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danna Romero | Medical Technician | Met with during the inspection and involved in the exit interview. |
| Jose Anguiano | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 200
Deficiencies: 0
Sep 24, 2025
Visit Reason
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.
Findings
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.
Complaint Details
The complaint was investigated and determined to be unfounded after verification that the alleged residents were not part of the facility.
Report Facts
Capacity: 200
Census: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elvira Gonzalez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Robin Culver | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 138
Deficiencies: 5
Sep 17, 2025
Visit Reason
An unannounced case management visit was conducted in connection with complaint #11-AS-20250909091421 to investigate compliance with Title 22 regulations.
Findings
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.
Complaint Details
The visit was triggered by complaint #11-AS-20250909091421. The investigation substantiated noncompliance with Title 22 regulations and identified deficiencies.
Severity Breakdown
Type B: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Observation of the Resident | — |
| Reporting Requirements | — |
| Care of Person with Dementia | — |
| Personnel Requirements-General | — |
| Administrator - Qualifications and Duties: The administrator failed to adhere to Title 22 regulations, resulting in multiple deficiencies and potential health and safety risk to residents. | Type B |
Report Facts
Capacity: 138
Census: 44
Plan of Correction Due Date: Oct 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robin Culver | Executive Director | Met during inspection and exit interview |
| Sandy Iraheta | Resident Coordinator | Met during inspection |
| Chanel Ann Sanchez | Administrator | Named in deficiency related to failure to comply with Title 22 regulations |
| Ernand Dabuet | Licensing Program Analyst | Conducted the inspection |
| Janae Hammond | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 138
Deficiencies: 1
Sep 12, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit Unusual Incident Reports for incidents involving Resident #1 on 09/06/25, 09/07/25, and 09/08/25 as required by CCR 82711(a)(1)(D). | Type A |
Report Facts
Facility Capacity: 138
Census: 44
Deficiencies cited: 1
Plan of Correction Due Date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Sandy Iraheta | Resident Coordinator | Facility staff member interviewed during the investigation and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 138
Deficiencies: 0
Aug 21, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 138
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Chanel Ann Sanchez | Administrator | Facility administrator present during the investigation and exit interview |
Inspection Report
Annual Inspection
Census: 40
Capacity: 138
Deficiencies: 0
Aug 6, 2025
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements for the facility.
Findings
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.
Report Facts
Remaining balance: 991
Number of staff records reviewed: 4
Number of resident records reviewed: 5
Number of medication administration records reviewed: 5
Number of bedrooms: 79
Number of common area bathrooms: 8
Number of full private bathrooms: 79
Hospice waiver capacity: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Administrator | Met with Licensing Program Analyst during inspection |
| Lizeth Villegas | Licensing Program Analyst | Conducted the inspection |
| Janae Hammond | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 81
Capacity: 200
Deficiencies: 0
Jul 16, 2025
Visit Reason
An unannounced annual continuation visit was conducted to evaluate the facility's compliance with licensing requirements and overall conditions.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. No deficiencies were identified during this inspection visit.
Report Facts
Licensed capacity: 200
Current census: 81
Hospice residents approved: 6
Hospice residents current: 3
Bedrooms: 37
Bathrooms: 47
Water temperature range (°F): 105.6 - 115.6
Room temperature range (°F): 70 - 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Administrator / Executive Director | Met with Licensing Program Analyst during inspection |
| Ernand Dabuet | Licensing Program Analyst | Conducted the inspection visit |
| Janae Hammond | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 138
Deficiencies: 0
Jul 3, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 138
Census: 38
Complaint Control Number: 11-AS-20250627133928
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 200
Deficiencies: 0
Jul 1, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 200
Census: 77
Staff interviewed: 6
Residents interviewed: 7
Pest control service frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Executive Director | Met with during investigation and exit interview |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 75
Capacity: 200
Deficiencies: 0
Jun 5, 2025
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing requirements.
Findings
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.
Report Facts
Hospice residents: 3
Licensed ambulatory residents: 40
Licensed non-ambulatory residents: 160
Hospice approved capacity: 6
Bedrooms: 37
Bathrooms: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Ernand Dabuet | Licensing Program Analyst | Conducted the inspection visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 200
Deficiencies: 2
Mar 21, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee failed to immediately telephone 9-1-1 after a resident suffered a head injury fall, posing a potential health and safety risk. | Type B |
| Licensee failed to ensure residents were regularly observed for changes in physical and mental condition, resulting in unmet needs not being addressed. | Type B |
Report Facts
Capacity: 200
Census: 70
Deficiencies cited: 2
Plan of Correction Due Date: Mar 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Executive Director | Met with Licensing Program Analyst during investigation and participated in exit interview |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 200
Deficiencies: 1
Mar 19, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide copies of resident records in a timely manner, violating confidentiality and record-keeping requirements under CCR 87506(c)(1). | Type B |
Report Facts
Capacity: 200
Census: 30
Plan of Correction Due Date: Mar 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 200
Deficiencies: 1
Feb 14, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not comply with the requirement to keep all kitchen areas clean and free of litter, rodents, vermin and insects, evidenced by live and dead vermin in the kitchen area. | Type B |
Report Facts
Capacity: 200
Census: 65
Deficiencies cited: 1
Plan of Correction Due Date: Mar 4, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Executive Director/Administrator | Named in relation to findings and exit interviews |
| Socorro Leandro | Licensing Program Analyst | Conducted the complaint investigation |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 30
Capacity: 138
Deficiencies: 0
Jan 10, 2025
Visit Reason
An unannounced case management visit was conducted regarding the relocation of 30 residents from Ceila facility due to a mandatory evacuation Fire Advisory.
Findings
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.
Report Facts
Residents relocated: 30
Ambulatory residents: 16
Non-ambulatory residents: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Administrator | Met with Licensing Program Analyst during visit |
| Yolanda Rosser | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Follow-Up
Census: 24
Capacity: 138
Deficiencies: 1
Oct 30, 2024
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Failure to submit an Unusual Incident Report for missing surplus medications discovered during audits on 2024-05-08. |
Report Facts
Missing medication count: 50
Missing medication count: 195
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Administrator | Interviewed regarding missing medication incident and facility operations |
| Shirley Gonzalez | LVN | Interviewed regarding missing medication incident and reporting to pharmacy and physician |
| Yolanda Rosser | Licensing Program Analyst | Conducted the case management follow-up visit and inspection |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 138
Deficiencies: 0
Oct 22, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were not feeding a resident in care and were neglecting the residents.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 138
Census: 24
Staffing: 3
Staffing: 1
Resident Interviews: 6
Staff Interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Administrator | Met with during investigation and named in findings |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 24
Capacity: 138
Deficiencies: 0
Jul 29, 2024
Visit Reason
The inspection was an unannounced annual required visit conducted to assess compliance with regulatory standards using the CARE Inspection Tool.
Findings
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.
Report Facts
Rooms inspected: 7
Residents' service files reviewed: 5
Staff personnel files reviewed: 5
Fire/Disaster Drills date: Jun 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the inspection and authored the report |
| Chanel Ann Sanchez | Administrator | Facility Administrator met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 138
Deficiencies: 0
Jul 17, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Resident census: 24
Facility capacity: 138
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chanel Ann Sanchez | Administrator | Met with Licensing Program Analyst during investigation |
| Socorro Leandro | Licensing Program Analyst | Conducted the complaint investigation |
| Ulysses Coronel | Licensing Program Manager | Named in report signature section |
Inspection Report
Annual Inspection
Census: 67
Capacity: 200
Deficiencies: 0
Jun 14, 2024
Visit Reason
The inspection was an unannounced annual visit conducted using the full CAREs tool to assess compliance and facility conditions.
Findings
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.
Report Facts
Residents present: 67
Licensed capacity: 200
Fire drill date: May 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David España | Licensing Program Analyst | Conducted the inspection and risk assessment |
| Chanel Sanchez | Administrator | Met with Licensing Program Analyst during inspection and participated in tours |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 200
Deficiencies: 0
Dec 7, 2023
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 200
Census: 50
Staff interviewed: 6
Residents interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernice Pulanco | Administrator | Facility administrator present during investigation and exit interview |
| Antonine Richard | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Robin Culver | Regional Executive Director | Joined the investigator and administrator during the visit |
Inspection Report
Annual Inspection
Census: 40
Capacity: 138
Deficiencies: 0
Sep 2, 2023
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with Title 22 regulations. No deficiencies or citations were observed during the inspection.
Report Facts
Rooms inspected: 7
Residents' service files reviewed: 5
Staff personnel files reviewed: 5
Fire/Disaster Drills date: Aug 20, 2023
Annual fire clearance date: Jun 23, 2023
Water temperature range (Fahrenheit): 109.5°F to 114.2°F
Room temperature range (Fahrenheit): 76°F to 78°F
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ariella Benbassat | Administrator | Met with Licensing Program Analyst during inspection |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection |
| Eva M Alvarez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 200
Deficiencies: 2
Jul 21, 2023
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Knowledge of the requirements for providing care and supervision appropriate to the residents was not met as evidenced by the facility sending resident #1 to hospital 2 weeks after initial fall. | Type B |
| The licensee shall ensure that residents are regularly observed for changes in physical condition. This was not met as evidenced by the facility sending resident #1 to hospital 2 weeks after initial fall. | Type B |
Report Facts
Capacity: 200
Census: 55
Plan of Correction Due Date: Aug 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Dennis Douglas | Investigator | Conducted interviews and record reviews during the investigation |
| Bernice Polanco | Administrator | Facility administrator met with during the investigation and exit interview |
Inspection Report
Annual Inspection
Census: 56
Capacity: 200
Deficiencies: 3
Jul 5, 2023
Visit Reason
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.
Findings
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.
Deficiencies (3)
| Description |
|---|
| Uneven porch floor and wasps/hornet nests accessible to residents posing potential health and safety risks. |
| Front entryway did not have a PUB 475 complaint poster meeting size requirements (20" x 26"). |
| Outdated Emergency Disaster Plan for Residential Care (LIC 610E). |
Report Facts
Residents reviewed: 5
Staff files reviewed: 5
Perishable food supply: 4
Non-perishable food supply: 7
Fire extinguisher last serviced: 2023
Sprinkler system last serviced: 2023
Elevator last maintenance: 2023
Emergency drill last conducted: 2023
Liability insurance expiration: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David España | Licensing Program Analyst | Conducted the inspection and documented findings. |
| Bernice Pulanco | Administrator | Met with LPA during inspection and involved in observations and interviews. |
| Ulysses Coronel | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 55
Capacity: 200
Deficiencies: 0
Jun 28, 2023
Visit Reason
The visit was an unannounced annual inspection conducted by Licensing Program Analyst David España to evaluate the facility's compliance with licensing requirements.
Findings
No deficiencies were observed during the inspection, and no citations were issued. Due to time constraints, a subsequent visit is required.
Report Facts
Residents ambulatory: 7
Residents non-ambulatory: 48
Bedrooms: 37
Bathrooms: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David España | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Bernice Pulanco | Administrator | Met with Licensing Program Analyst during the inspection and participated in the exit interview |
| Boris Tamasi | Business Manager | Met with Licensing Program Analyst during the inspection and toured the facility |
Inspection Report
Annual Inspection
Census: 54
Capacity: 200
Deficiencies: 0
Dec 28, 2022
Visit Reason
The visit was an unannounced annual inspection with a primary focus on infection control using CARE tools.
Findings
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.
Report Facts
Residents reviewed: 6
Staff files reviewed: 5
Water temperature range: 114.6
Water temperature range: 118.9
Food supply duration: 4
Food supply duration: 7
PPE supply duration: 60
Fire extinguisher last serviced: Mar 4, 2022
Fire department inspection date: May 18, 2022
Elevator maintenance date: Jul 27, 2022
Emergency drill date: Dec 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernice Pulanco | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Wendy Gibbs | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 40
Capacity: 138
Deficiencies: 0
Jul 30, 2021
Visit Reason
The inspection was an unannounced annual required visit including an infection control inspection to evaluate compliance with regulations.
Findings
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.
Report Facts
Residents ambulatory: 19
Residents non-ambulatory: 22
Bedrooms: 79
Common area bathrooms: 8
Full private bathrooms: 79
Fire extinguishers: 6
Hot water temperature: 111
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ariella BenBassat | Administrator | Met during inspection and participated in exit interview |
| Ana Soto | Licensing Program Analyst | Conducted the inspection |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 200
Deficiencies: 0
Jun 24, 2021
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 200
Census: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation |
| Bernice Pulanco | Administrator | Facility administrator interviewed during investigation |
| Joy Alvarado | Former Administrator | Former facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 138
Deficiencies: 0
Jun 24, 2021
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 138
Census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation |
| Ariella Benbassat | Administrator | Facility administrator involved in interviews and exit interview |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 51
Capacity: 200
Deficiencies: 0
Jun 24, 2021
Visit Reason
An unannounced annual required infection control visit was conducted to evaluate the facility's compliance with regulations and infection control practices.
Findings
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.
Report Facts
Residents ambulatory: 6
Residents non-ambulatory: 45
Bedrooms: 37
Bathrooms: 47
Fire extinguishers: 8
PPE supply duration: 30
Hot water temperature: 118
Residents files reviewed: 5
Staff files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernice Pulanco | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Ana Soto | Licensing Program Analyst | Conducted the inspection visit |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 200
Deficiencies: 2
Jun 11, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation of illegal eviction received on 10/06/2020.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The pre-admission appraisal was not updated as frequently as necessary to note significant changes in the resident's condition, posing a potential health and safety risk. | Type B |
| The administrator failed to provide or ensure services with appropriate regard for residents' physical and mental well-being, including failure to conduct pre-admission appraisals and reappraisals. | Type B |
Report Facts
Facility Capacity: 200
Deficiency Count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jennifer Jones | Licensing Program Analyst | Initiated a subsequent complaint investigation and delivered findings |
| Bernice Pulanco | Administrator | Met with Licensing Program Analyst during visit and received findings |
| Joy Alvarado | Administrator | Interviewed during initial complaint investigation |
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