Inspection Report Summary
Most inspections found no deficiencies, and the majority of complaint investigations were unsubstantiated, indicating generally good compliance with regulations. The most recent report from August 29, 2025, was clean with no deficiencies cited. Earlier reports identified a few isolated issues, including a substantiated deficiency in May 2025 for water temperatures being too low in resident rooms, which posed a health and safety risk, and a failure to follow proper eviction procedures found in late 2023 and early 2025 complaint investigations. There were no fines, license suspensions, or immediate jeopardy findings listed in the available reports. The facility’s record shows improvement over time, with recent inspections free of deficiencies after some earlier minor compliance concerns.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
0.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
47% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 64
Capacity: 136
Deficiencies: 0
Aug 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff do not accord dignity to residents and that staff are not preventing residents from harassing other residents.
Findings
The investigation found no preponderance of evidence to support the allegations. Interviews with staff and residents indicated that residents are generally treated with dignity and that staff provide supervision to prevent harassment. No deficiencies were cited during the visit.
Complaint Details
The complaint involved two main allegations: 1) staff do not accord dignity to residents, including locking the administrator's door and not addressing incidents; 2) staff are not preventing resident harassment, including incidents involving police response. The investigation included interviews, document reviews, and observations. The allegations were unsubstantiated due to lack of evidence.
Report Facts
Capacity: 136
Census: 64
Number of allegations: 2
Number of residents interviewed: 7
Number of staff interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Selena Cruz | Administrator Assistant | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 136
Deficiencies: 0
Aug 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of staff physically abusing a resident.
Findings
The investigation included interviews with residents and staff, a tour of the facility, and observations. The allegation was found to be unsubstantiated due to lack of preponderance of evidence to prove the alleged abuse occurred.
Complaint Details
The complaint alleged staff physically abused a resident. Interviews with residents and staff did not confirm the abuse. Staff reported alternate caregiving measures were implemented to prevent future occurrences. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 136
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Luz Emma Rose | Administrator | Facility Administrator present during investigation and exit interview |
| Theresa Cruz-Pascual | Wellness Director | Met Licensing Program Analyst during investigation |
| Afsaneh Zarabi | Receptionist | Receptionist who allowed entry to Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 136
Deficiencies: 0
Jul 16, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that staff physically abused a resident.
Findings
The investigation included interviews with residents and staff, observations, and document reviews. The allegation of physical abuse was found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged staff physically abused a resident. Interviews with residents and staff, as well as observations, did not support the allegation. The allegation was found unsubstantiated.
Report Facts
Capacity: 136
Census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Luz Emma Rose | Administrator | Facility administrator present during the investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 136
Deficiencies: 0
Jun 18, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-05-06 regarding staff not allowing a resident to sit with a significant other and staff making inappropriate comments about a resident.
Findings
The investigation included interviews with residents and staff, observations, and a facility tour. Both allegations were found to be unsubstantiated due to lack of preponderance of evidence proving the alleged violations did or did not occur.
Complaint Details
The complaint investigation was unsubstantiated. Allegation 1 involved staff not allowing a resident to sit with a significant other, which was found to have occurred only once and residents and staff confirmed freedom of seating with accommodations to prevent conflicts. Allegation 2 involved staff making inappropriate comments regarding a resident, which was denied by residents and staff and no complaints were reported.
Report Facts
Capacity: 136
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Luz Emma Rose | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 136
Deficiencies: 0
May 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-05-06 regarding allegations of staff not accepting a resident back into care following hospitalization, staff not treating residents with dignity or respect, and staff leaving residents in soiled diapers for an extended period of time.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with staff, residents, and review of records. No evidence or documentation supported the allegations, and no citations were issued.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included refusal of re-admission after hospitalization, mistreatment of residents, and failure to timely change soiled diapers. Interviews and record reviews did not support these allegations, and the preponderance of evidence standard was met to find the allegations unsubstantiated.
Report Facts
Capacity: 136
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
| Teresa Pascual | Wellness Director | Facility representative met during exit interview and delivery of findings |
| Luz Emma Rose | Administrator | Facility Administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 136
Deficiencies: 1
May 19, 2025
Visit Reason
The inspection visit was conducted to investigate multiple allegations received on 2024-08-13 regarding staff retaliation, yelling, verbal abuse, harassment, discrimination, theft, and facility disrepair at the Plaza at Westwood facility.
Findings
The investigation found insufficient evidence to substantiate allegations of staff retaliation, yelling, verbal abuse, harassment, discrimination, theft, and facility disrepair. However, the allegation that the licensee failed to ensure residents were provided with hot water was substantiated, with water temperatures in several rooms below the required range, posing a health and safety risk.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Zina Brown. Allegations included staff retaliation, yelling, verbal abuse, harassment, discrimination, theft of residents' belongings, facility disrepair, and failure to provide hot water. Interviews with staff and residents, facility tours, and document reviews were conducted. All allegations except the hot water issue were found unsubstantiated. The hot water allegation was substantiated based on water temperature measurements in multiple resident rooms.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Maintenance and operation of water supplies and plumbing fixtures did not meet required temperature range of 105°F to 120°F in resident rooms, posing a health and safety risk. | Type B |
Report Facts
Water temperature readings: 101.7
Water temperature readings: 99.3
Water temperature readings: 98.6
Water temperature readings: 104
Water temperature readings: 96.4
Water temperature readings: 108
Water temperature readings: 106.2
Water temperature readings: 106.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Teresa Pascual | Wellness Director | Facility representative met during the investigation and exit interview |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 136
Deficiencies: 0
May 13, 2025
Visit Reason
An unannounced visit was conducted to investigate complaints alleging that staff did not allow a resident to sit with their significant other and that staff made inappropriate comments regarding a resident.
Findings
Interviews with residents and staff, as well as observations during the visit, found that residents are allowed to sit wherever and with whomever they choose. Staff make efforts to accommodate seating preferences to prevent conflicts. No evidence was found to substantiate the allegations of inappropriate staff behavior or seating restrictions.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations did or did not occur.
Report Facts
Capacity: 136
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
| Luz Emma Rose | Administrator | Facility Administrator present during the investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 136
Deficiencies: 0
Mar 27, 2025
Visit Reason
Unannounced complaint investigation visit conducted to investigate multiple allegations including mold and chemical presence in resident rooms, improper room maintenance, verbal abuse, failure to seek emergency assistance, resident abuse, safeguarding of personal belongings, unlawful eviction, and refusal to provide documentation.
Findings
All allegations investigated were found to be unsubstantiated after interviews with residents and staff, facility tours, and document reviews. No evidence was found to support claims of mold, abuse, improper maintenance, or unlawful eviction. Emergency assistance was confirmed to have been called appropriately.
Complaint Details
The complaint investigation was triggered by multiple allegations including mold and chemicals in resident rooms, improper maintenance, verbal abuse, failure to seek emergency assistance, abuse of residents, failure to safeguard personal belongings, unlawful eviction, and refusal to provide requested documentation. After interviews with 6 clients and 5 staff members for each allegation, facility tours of 10 rooms, and review of relevant documents including court orders and SIR reports, all allegations were found to be unsubstantiated.
Report Facts
Emergency Assistance Calls: 4
Number of clients interviewed: 6
Number of staff interviewed: 5
Rooms toured: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sparkle Day | Licensing Program Analyst | Conducted the complaint investigation visit and interviews. |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation. |
| Theresa Pascual | Wellness Director | Met with Licensing Program Analyst during the visit and allowed entry. |
| Luz Rose | Administrator | Assisted with the visit and provided information regarding allegations. |
Inspection Report
Annual Inspection
Census: 64
Capacity: 136
Deficiencies: 0
Mar 27, 2025
Visit Reason
An unannounced annual comprehensive inspection was conducted to evaluate compliance with licensing requirements and assess the facility's conditions and operations.
Findings
The inspection found the facility to be clean, sanitary, and appropriately furnished with no deficiencies cited. Resident files, staff certifications, medication administration records, and physical plant conditions were all current and satisfactory.
Report Facts
Bedridden residents: 6
Hospice waiver residents: 12
Residents on hospice: 5
Residents receiving home health services: 5
Resident files reviewed: 7
Staff files reviewed: 7
Medication Administration Records audited: 7
Fire inspection date: Mar 17, 2025
Water temperature range (°F): 115.5-116.2
Facility temperature range (°F): 74-78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luz Emma Rose | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Bernadette Allen | Licensing Program Analyst | Conducted the inspection |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 136
Deficiencies: 0
Mar 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-05-09 regarding laundry service, housekeeping, mail delivery, medical care, and facility maintenance.
Findings
The investigation found no evidence to support any of the allegations. Interviews with staff and residents, facility tours, and document reviews indicated that laundry, housekeeping, mail delivery, medical care, and facility maintenance services were provided adequately and the facility was well maintained. All allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation was triggered by allegations that staff did not provide laundry service, housekeeping service, mail delivery, medical care, and that the facility was not maintained in good repair. After thorough investigation including interviews with 6 staff and 8 residents, tours of multiple rooms, and review of records, the allegations were found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 136
Census: 64
Staff interviewed: 6
Residents interviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luz Emma Rose | Administrator | Met with during inspection and exit interview |
| Maria Theresa Pascual | Wellness Director | Interviewed regarding laundry, mail, medical care, and facility maintenance |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on report |
| Troy Watson | Licensing Program Analyst | Conducted investigation and signed report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 136
Deficiencies: 1
Mar 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-02-13 regarding allegations including staff not accepting a resident back into care following hospitalization and staff attempting to administer medication by force.
Findings
The investigation substantiated the allegation that staff did not accept a resident back into care following hospitalization due to the resident needing a higher level of care, which the facility could not provide, citing violations of Title 22 regulations. The allegation that staff attempted to administer medication by force was unsubstantiated based on staff and resident interviews and document review.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not accept a resident back into care following hospitalization. Three of nine staff and three witnesses corroborated the allegation, while six staff had no knowledge. The facility failed to follow Title 22 regulations for residents needing a higher level of care. The allegation that staff attempted to administer medication by force was unsubstantiated with all staff denying the claim and residents confirming no forced medication administration.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow proper eviction procedures including lack of appropriate reappraisal and formal eviction documentation for resident displaced due to higher level of care needs. | Type B |
Report Facts
Capacity: 136
Census: 64
Deficiencies cited: 1
Plan of Correction Due Date: Mar 14, 2025
Fine amount: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
| Luz Rose | Administrator | Facility administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 136
Deficiencies: 0
Feb 13, 2025
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff were stealing residents' personal belongings while in care.
Findings
The investigation included interviews with staff and residents, review of records, and a facility tour. No evidence was found to support the allegation, and the complaint was determined to be unsubstantiated. No deficiencies were cited.
Complaint Details
The allegation was that staff stole residents' personal belongings, specifically money from a resident. Interviews with 5 staff members and 6 residents mostly denied the allegation, and no reports of missing items were found. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Staff interviewed: 5
Residents interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Pascual | Wellness Director | Met with during investigation and exit interview |
| Stephanie Cifuentes | Licensing Program Manager | Named in report signature |
| Elvira Gonzalez | Licensing Program Analyst | Conducted investigation and named in report signature |
Inspection Report
Complaint Investigation
Capacity: 136
Deficiencies: 0
Oct 25, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-02-13 alleging that staff did not accept a resident back into care following hospitalization and that staff attempted to administer a resident's medication by force.
Findings
The investigation included interviews with staff, residents, witnesses, and review of relevant records. There was insufficient evidence to substantiate either allegation, and both were determined to be unsubstantiated.
Complaint Details
The complaint involved two allegations: 1) Staff did not accept resident back into care following hospitalization, and 2) Staff attempted to administer resident’s medication by force. After interviews and record reviews, there was insufficient evidence to support either allegation, resulting in both being unsubstantiated.
Report Facts
Facility capacity: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luz Rose | Executive Director, Administrator | Interviewed regarding complaint allegations |
| Theresa Pascual | Wellness Director | Met with during inspection visit |
| Stephanie Cifuentes | Licensing Program Manager | Named in report signature and management |
| Troy Watson | Licensing Program Analyst | Conducted investigation and signed report |
Inspection Report
Annual Inspection
Census: 58
Capacity: 136
Deficiencies: 0
May 30, 2024
Visit Reason
The visit was an unannounced one-year inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies observed. The physical plant, resident rooms, bathrooms, kitchen, common areas, safety equipment, and medication storage were all inspected and found satisfactory.
Report Facts
Residents on hospice: 4
Residents with dementia: 2
Residents receiving home health services: 7
Resident-bedrooms: 68
Bathrooms: 74
Residents' medication files reviewed: 10
Staff files reviewed: 5
Residents interviewed: 5
Staff interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luz Emma Rose | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Sparkle Day | Licensing Program Analyst | Conducted the inspection visit |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 136
Deficiencies: 0
Mar 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 2024-03-11 regarding resident care, maintenance, abuse, emergency assistance, safeguarding belongings, unlawful eviction, and documentation requests at Plaza at Westwood.
Findings
The investigation included interviews with residents, staff, and the administrator, as well as a tour of the facility and review of relevant records. All allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred.
Complaint Details
The complaint investigation addressed nine allegations: failure to keep rooms free from mold and chemicals, improper room maintenance, verbal abuse, failure to seek emergency assistance, resident abuse, failure to safeguard personal belongings, unlawful eviction, refusal to provide requested documentation, and staff abuse. All allegations were found unsubstantiated after interviews and observations.
Report Facts
Residents interviewed: 6
Staff interviewed: 6
Rooms toured: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Luz Rose | Executive Director | Facility representative interviewed during investigation |
| Virginia Zenteno | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 136
Deficiencies: 0
Jan 18, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff do not ensure resident's rooms are maintained clean.
Findings
The investigation found the facility to be clean and sanitary with no evidence supporting the allegation. Resident rooms inspected were clean and in good repair, and staff and residents confirmed regular cleaning practices. The allegation was determined to be unsubstantiated.
Complaint Details
The allegation was that resident rooms were dirty, unsanitary, and cluttered to the point of being a safety issue. After inspection, interviews, and document review, no evidence was found to support the allegation, resulting in an unsubstantiated finding.
Report Facts
Resident rooms inspected: 7
Staff interviewed: 7
Residents interviewed: 7
Residents preferring to clean themselves: 3
Capacity: 136
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Luz Rose | Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 136
Deficiencies: 0
Oct 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations including staff leaving residents soiled for extended periods, malodorous odor in the facility, facility disrepair, and presence of pests.
Findings
The investigation found no evidence to support the allegations. Staff and residents denied neglect or unsanitary conditions, the facility was found clean and well-maintained, and pest control measures were in place. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint included allegations that staff left residents soiled for extended periods, the facility had a malodorous odor, was in disrepair, and had pests. Interviews with staff and residents, inspections of the facility and resident rooms, and review of records found no evidence to substantiate these allegations. The complaint was unsubstantiated.
Report Facts
Staff interviewed: 6
Residents interviewed: 8
Staff per shift: 3
Staff per shift: 2
Staff per shift: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
| Luz Rose | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 136
Deficiencies: 0
Oct 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-08-29 regarding staff mistreatment, dignity and respect issues, locking a resident out of their room, and removal of resident's personal belongings without consent.
Findings
The investigation included interviews with residents, staff, and review of records. No evidence was found to support the allegations; all claims were unsubstantiated based on observations, interviews, and documentation reviewed.
Complaint Details
The complaint involved four allegations: 1) Staff handles residents in a rough manner; 2) Staff do not treat residents with dignity and respect; 3) Staff locked the resident out of the room; 4) Staff removed and withheld resident’s personal belongings without consent. After investigation including interviews with 8 residents and 6 staff, review of incident reports, legal documents, and observations, all allegations were found unsubstantiated due to lack of evidence.
Report Facts
Residents interviewed: 8
Staff interviewed: 6
Incident reports involving resident #1: 27
Unpaid services amount: 21869.13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation report |
| Luz Rose | Executive Director | Facility representative met during the investigation |
| Virginia Zenteno | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 136
Deficiencies: 2
Oct 6, 2023
Visit Reason
The inspection visit was conducted as a case management investigation associated with complaint #11-AS-20230829161007 regarding unreported incidents involving a resident and issues with eviction procedures.
Findings
The facility failed to report incidents involving a resident to Community Care Licensing and did not comply with eviction procedure regulations by not resubmitting corrections for approval before proceeding with eviction. These violations posed potential health and safety risks to residents.
Complaint Details
The visit was complaint-related under complaint #11-AS-20230829161007. The complaint involved failure to report incidents and improper eviction procedures. The notice of eviction was determined invalid. Substantiation status is not explicitly stated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee failed to report incident involving resident #1 within required timeframe, posing potential health and safety risk. | Type B |
| Licensee failed to resubmit eviction notice corrections for department approval and proceeded with eviction, posing potential health and safety risk. | Type B |
Report Facts
Incident reports: 27
Plan of Correction due date: Oct 20, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the case management inspection visit and authored the report |
| Luz Rose | Executive Director | Met with Licensing Program Analyst during inspection and received report |
| Ulysses Coronel | Licensing Program Manager | Notified the facility in writing about failure to meet eviction procedures |
| Janae Hammond | Licensing Program Manager | Supervisor and Licensing Evaluator named in the report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 136
Deficiencies: 0
Sep 27, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to gather information regarding allegations that staff does not keep residents' rooms clean and does not treat residents with dignity or respect.
Findings
The investigation included interviews with staff and residents and observations of the facility. Both allegations were found to be unsubstantiated due to insufficient evidence. No deficiencies were cited.
Complaint Details
The complaint investigation was triggered by allegations that staff does not keep residents' rooms clean and does not treat residents with dignity or respect. After interviews with 4 staff members and 7 residents, and facility observations, the allegations were found unsubstantiated.
Report Facts
Capacity: 136
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Kelley Koul | Administrator | Facility Administrator who assisted with the visit |
| Luz E. Rose | Met with Licensing Program Analyst during the visit and received the report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 136
Deficiencies: 0
Aug 9, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff do not treat residents with respect and do not meet dietary needs of residents.
Findings
The investigation found insufficient evidence to substantiate the allegations. Some residents reported concerns about staff attitude, but the majority and staff denied disrespect or verbal abuse. Regarding dietary needs, most residents were satisfied with meal options and food quality, though a few noted issues with seasoning. Overall, both allegations were found to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegation #1 involved staff disrespect towards residents; some residents reported rudeness by the Administrator, but most did not observe verbal abuse. Allegation #2 involved unmet dietary needs; most residents confirmed meal options and food quality were adequate, with some noting seasoning concerns. Staff training records and dietary service contracts were reviewed.
Report Facts
Residents interviewed: 8
Staff interviewed: 5
Capacity: 136
Census: 64
Date complaint received: Jan 23, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Kelley Koul | Administrator | Facility Administrator named in the report |
| Theresa Pascual | Wellness Director | Staff member interviewed during the investigation |
| Virginia Zenteno | Administrator | Administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 136
Deficiencies: 0
May 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not provide a comfortable and safe environment for residents while in care.
Findings
The investigation included interviews with staff and residents, a tour of the facility, and review of records. The allegations were found to be unsubstantiated as there was insufficient evidence to prove that staff failed to provide a comfortable and safe environment for residents.
Complaint Details
The complaint alleged that staff tried to access residents' bank account PINs, were mean, and that a resident feared not being allowed to return after leaving the facility. Interviews with four staff and eight residents denied these allegations. No residents lost money or valuables, and residents are free to leave and return. The allegations were unsubstantiated based on the preponderance of evidence standard.
Report Facts
Capacity: 136
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Zenteno | Administrator | Met with Licensing Program Analyst during the complaint investigation and assisted with the visit |
| Lourdes Montoya | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Cifuentes | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 136
Deficiencies: 0
May 30, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-02-03 regarding allegations of staff injuring a resident, making inappropriate comments, and not assisting a resident in a timely manner.
Findings
The investigation included interviews with staff and residents, review of records, and observations. All allegations were found to be unsubstantiated due to insufficient evidence to corroborate the claims.
Complaint Details
The complaint involved three allegations: staff injured a resident by twisting a finger; staff made inappropriate comments to a resident; and staff did not assist a resident in a timely manner after a fall. Interviews and records review did not provide sufficient evidence to substantiate any of the allegations. The findings were unsubstantiated.
Report Facts
Facility capacity: 136
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lourdes Montoya | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Virginia Zenteno | Administrator | Facility administrator who assisted with the visit and exit interview |
| Kelley Koul | Administrator | Named as facility administrator in report header |
Inspection Report
Annual Inspection
Census: 62
Capacity: 136
Deficiencies: 0
May 15, 2023
Visit Reason
An unannounced annual visit was conducted by Licensing Program Analyst Wendy Gibbs to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be well-maintained with no observed deficiencies. All areas including resident rooms, bathrooms, kitchen, common rooms, and safety equipment were inspected and found in good condition. Infection control policies were followed and staff were knowledgeable about policies and resident rights.
Report Facts
Residents reviewed: 5
Staff reviewed: 5
Medications reviewed: 6
Bathrooms: 74
Resident bedrooms inspected: 6
Fire extinguishers last serviced: Jan 31, 2023
Backup generator last inspected: Mar 31, 2023
Smoke/CO detectors last inspected: Jan 31, 2023
Emergency drills conducted: 3
Elevator last inspected: Mar 29, 2023
PPE supply: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Zenteno | Administrator | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Wendy Gibbs | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 136
Deficiencies: 0
May 5, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff failed to treat residents with dignity and respect.
Findings
Interviews with staff and residents revealed no evidence supporting the allegation. Staff and residents consistently stated that residents are treated with dignity and respect, and no inappropriate or abusive behavior was observed. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff failed to treat residents with dignity and respect. The investigation included interviews with staff and residents, review of records, and observations. The allegation was found to be unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 136
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Cifuentes | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Virginia Zenteno | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Kelley Koul | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 136
Deficiencies: 0
Apr 6, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including inadequate care and supervision, leaving a resident in urine after falling, untimely medication administration, and unclean facility conditions.
Findings
The investigation found insufficient evidence to support any of the allegations. Interviews with staff and residents, facility tour, and record reviews indicated that residents received adequate care and supervision, timely medication, and the facility was maintained clean and sanitary. No deficiencies were cited.
Complaint Details
The complaint alleged that staff did not provide adequate care and supervision, left a resident in urine for an extended period after falling, failed to ensure timely medication administration, and did not maintain a clean and sanitary facility. All allegations were unsubstantiated based on interviews, observations, and record reviews.
Report Facts
Capacity: 136
Census: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Zenteno | Administrator | Met with Licensing Program Analyst during the investigation and provided information regarding allegations |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 136
Deficiencies: 0
Mar 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the licensee does not ensure the facility has a certified administrator.
Findings
The investigation included interviews and record reviews, revealing that the administrator is certified, always present, accessible, and has the required documentation. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that the licensee does not ensure the facility has a certified administrator. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 136
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Zenteno | Administrator | Named as the certified administrator involved in the complaint investigation |
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 136
Deficiencies: 0
Feb 15, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility failed to follow Covid-19 protocols.
Findings
The investigation included interviews with the administrator, licensee, staff, and residents, as well as review of mitigation plans and Covid-19 records. The facility was found to be in full compliance with Covid-19 protocols, including isolation of positive residents and staff training. There was insufficient evidence to support the allegation, and no deficiencies were cited.
Complaint Details
The allegation that the facility failed to follow Covid-19 protocols was unsubstantiated based on interviews and records review.
Report Facts
Capacity: 136
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Zenteno | Administrator | Interviewed during the complaint investigation and assisted with the visit |
| Steven Aron | Licensee | Interviewed during the complaint investigation and confirmed Covid-19 status |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 136
Deficiencies: 0
Feb 15, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2023-02-09 alleging that the licensee does not ensure the facility has a certified administrator.
Findings
The investigation included interviews, record reviews, and a facility tour. It was found that the administrator is always present, accessible, and holds a valid certificate. The allegation was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that the facility did not have a certified administrator. The investigation found the administrator to be certified and accessible. The allegation was unsubstantiated.
Report Facts
Capacity: 136
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Soto | Licensing Program Analyst | Conducted the complaint investigation |
| Virginia Zenteno | Administrator | Facility administrator interviewed during investigation |
| Kelley Koul | Administrator | Named as administrator in report header |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 136
Deficiencies: 0
Jan 11, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff were not wearing masks.
Findings
The investigation found that staff, residents, and visitors were observed wearing masks as required, and the facility had an approved Mitigation Plan and Infection Control Plan. Interviews with staff and residents denied the allegations, and there was insufficient evidence to substantiate the complaint.
Complaint Details
The complaint alleging staff were not wearing masks was unsubstantiated based on interviews, observations, and review of documentation.
Report Facts
Capacity: 136
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit |
| Virginia Zenteno | Executive Director | Met with Licensing Program Analyst and provided information during the investigation |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 136
Deficiencies: 0
Nov 29, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that staff forced a resident to walk without needed assistance and that staff were confining a resident to their bed while in care.
Findings
The investigation included interviews with residents and staff, a tour of the facility, and review of records. The preponderance of evidence standard was not met to prove the allegations; therefore, the complaint was unsubstantiated.
Complaint Details
The complaint alleged that staff forced a resident to walk without needed assistance and confined a resident to their bed. Interviews with residents and staff, as well as record reviews, did not substantiate these allegations. The resident in question was bedridden and required assistance, and staff reported respecting the resident's wishes regarding mobility.
Report Facts
Residents interviewed: 5
Staff interviewed: 4
Facility capacity: 136
Census: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
| Virginia Zenteno | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 136
Deficiencies: 0
Nov 9, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations of inadequate staffing to meet residents' needs and failure to provide requested documents to a resident's representative.
Findings
The investigation found that one out of six residents and two out of four staff confirmed staffing shortages, but agency staff were used to fill vacancies. The allegation regarding failure to provide requested documents was not substantiated as records showed documents were sent. Overall, the allegations were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint involved allegations of inadequate staffing and failure to provide requested documents. Interviews with residents and staff yielded mixed confirmations on staffing shortages. Document review showed incident reports were faxed to the resident's representative. The allegations were determined unsubstantiated.
Report Facts
Residents interviewed: 6
Staff interviewed: 4
Facility capacity: 136
Current census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Virginia Zenteno | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 136
Deficiencies: 0
Aug 11, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that the facility mismanaged a resident's medical information and failed to ensure that a resident received physical therapy services.
Findings
The investigation included interviews with residents and staff, record reviews, and observations. No evidence was found to substantiate the allegations, and the preponderance of evidence standard was not met, resulting in the allegations being unsubstantiated.
Complaint Details
The complaint alleged that the facility mismanaged resident medical information and failed to ensure physical therapy services were provided as recommended. Interviews with residents and staff, as well as record reviews, did not confirm these allegations. The complaint was determined to be unsubstantiated.
Report Facts
Residents interviewed: 5
Staff interviewed: 4
Physical therapy visits approved: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Theresa Pascual | Wellness Director | Met with Licensing Program Analyst during investigation |
| Kelley Koul | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 136
Deficiencies: 0
Jun 13, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not following COVID-19 procedures and were retaliating against residents.
Findings
The investigation found that staff were following COVID-19 procedures, including weekly testing and timely notification of positive cases, and that staff did not retaliate against residents. Interviews with staff and residents, observations, and record reviews did not substantiate the allegations.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not following COVID-19 procedures and staff retaliating against residents. Interviews with staff and residents, observations, and record reviews found no evidence to support the allegations.
Report Facts
Capacity: 136
Census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelley Koul | Administrator | Met with Licensing Program Analyst and provided statements regarding COVID-19 procedures and facility operations |
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Angela J Kendrick | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 136
Deficiencies: 0
May 23, 2022
Visit Reason
An unannounced complaint investigation was conducted to address an allegation that a resident was physically attacked by another resident on more than one occasion.
Findings
The investigation included interviews with staff and residents, a walkthrough, and record review. Staff generally did not witness physical attacks, and no visible bruising was observed on the alleged victim. Residents gave conflicting accounts, with the alleged victim reporting multiple assaults and the alleged perpetrator denying involvement. The allegation was determined to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that a resident was physically attacked by another resident multiple times. The allegation was found unsubstantiated after investigation, as the preponderance of evidence standard was not met.
Report Facts
Capacity: 136
Census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kelly Koul | Administrator | Met with Licensing Program Analyst during investigation |
| Ulysses Coronel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 41
Capacity: 136
Deficiencies: 0
Apr 19, 2021
Visit Reason
The inspection was conducted as a pre-licensing evaluation for a change of ownership application for a Residential Care Facility for the Elderly to serve seniors and seniors with dementia, ages 60 years and greater.
Findings
The facility was found to be in substantial compliance with no deficiencies observed during the pre-licensing inspection. The facility has adequate accommodations, safety measures, and supplies as required by applicable laws and regulations.
Report Facts
Requested capacity: 136
Bathrooms: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Troy Agard | Licensing Program Analyst | Conducted the pre-licensing evaluation visit |
| Angela J Kendrick | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Virginia Zenteno | Administrator | Facility Administrator |
| Sholomo Steven Aron | Licensee Representative | Met with during the inspection via FaceTime |
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