Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on July 15, 2025, which was clean and without citations. Earlier reports showed some isolated deficiencies related to water temperature hazards, pest presence in the kitchen, unsecured hazardous items, medication discrepancies, and incomplete staff certifications, but these issues were addressed over time. Several complaint investigations were unsubstantiated, including allegations about food safety, staffing, communication during outbreaks, and resident safety. One substantiated complaint in July 2023 involved a failure to call 9-1-1 promptly during a medical emergency, posing a health risk, but no fines or enforcement actions were listed in the available reports. Overall, the facility’s recent inspections indicate improvement and compliance with health and safety standards.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 138
Capacity: 170
Deficiencies: 0
Jul 15, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with Title 22 regulations and ensure the facility meets health and safety standards.
Findings
The facility was found to be in compliance with health and safety regulations, including proper food storage, clean and appropriately furnished resident rooms, adequate emergency equipment, and proper medication management. No citations were issued during this inspection.
Report Facts
Resident rooms inspected: 18
Resident records reviewed: 10
Personnel records reviewed: 10
Fire extinguisher last serviced: Aug 2, 2024
Last fire safety inspection date: Nov 7, 2024
Last emergency disaster drill date: Jun 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Spencer | Executive Director | Met with Licensing Program Analysts during the inspection and involved in facility tour. |
| Brian Balisi | Licensing Program Analyst | Conducted the inspection and reviewed records and facility compliance. |
| Martha Arroyo | Licensing Program Analyst | Conducted the inspection and toured the facility. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 170
Deficiencies: 0
Apr 3, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff were not safeguarding the facility grounds, not providing a safe environment for residents, and not safeguarding residents' personal belongings.
Findings
The investigation found no sufficient evidence to corroborate the allegations. Residents and staff interviewed reported no safety or security concerns, and the facility's policies and procedures regarding apartment entry and safeguarding personal belongings were reviewed and found compliant. Therefore, all allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not safeguarding facility grounds, not providing a safe environment, and not safeguarding residents' personal belongings. Interviews with residents and staff, document reviews, and physical tours did not provide sufficient evidence to prove the allegations.
Report Facts
Residents interviewed: 6
Staff interviewed: 6
Residents interviewed: 6
Staff interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Elizabeth Spencer | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 142
Capacity: 170
Deficiencies: 4
Jul 16, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure the facility is free of health and safety hazards.
Findings
The inspection found several deficiencies including excessively high hot water temperatures in resident rooms, a leaking ceiling in a common area, presence of fruit/drain flies in the kitchen area, and unsecured hazardous items in the fitness room. The facility was otherwise clean and well-maintained with appropriate resident activities and documentation.
Deficiencies (4)
| Description |
|---|
| Water in resident rooms F7 and E1 measured at 138.4 and 133.1 degrees F respectively, exceeding the allowed temperature range and posing an immediate safety risk. |
| Ceiling in the main building second floor common area was covered in plastic and leaking water for about a month, posing a potential health and safety risk. |
| Fruit/drain flies were observed in the kitchen and server station areas, posing a potential health and personal rights risk. |
| Fitness Room was unlocked and unattended with accessible scissors and screwdrivers; laundry detergent left unattended; staff office left unattended with personal items and COVID tests, posing potential safety risks. |
Report Facts
Water temperature in resident rooms: 138.4
Water temperature in resident rooms: 133.1
Census: 142
Total capacity: 170
Resident records reviewed: 10
Resident interviews: 6
Disaster drill date: Jul 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kristin Heffernan | Licensing Program Manager | Supervisor of the inspection |
| Edward Ocegueda | Associate Executive Director | Facility representative met during inspection and provided information on deficiencies and plans of correction |
| Elizabeth Spencer | Administrator/Director | Named as facility administrator; noted as unavailable during inspection |
Inspection Report
Follow-Up
Census: 141
Capacity: 170
Deficiencies: 0
Apr 23, 2024
Visit Reason
The visit was an unannounced Case Management – Incident follow-up to a self-reported incident that occurred on 2024-04-08 involving a resident who fell and was hospitalized.
Findings
No immediate health and safety hazards were identified during the visit. The Licensing Program Analyst interviewed staff, reviewed pertinent documents, and toured the facility. No citations were issued.
Report Facts
Incident date: Apr 8, 2024
Incident report fax date: Apr 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Spencer | Executive Director | Interviewed related to the incident and visit |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit |
| Miguel Lino | Business Office Manager | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 170
Deficiencies: 0
Apr 17, 2024
Visit Reason
The visit was conducted to investigate a complaint alleging that facility staff were not communicating with residents or their representatives regarding outbreak updates during a norovirus outbreak in November 2023.
Findings
The investigation found that the Executive Director and staff did provide continuous updates to residents and families regarding the outbreak through letters, phone calls, and in-person communication. Twelve residents interviewed confirmed receiving updates and reported no concerns with how the outbreak was handled. Therefore, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that the facility staff failed to communicate outbreak updates to residents and their representatives during a norovirus outbreak starting around 11/17/2023. The allegation was investigated through interviews and record reviews and was found to be unsubstantiated.
Report Facts
Residents interviewed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Spencer | Executive Director | Met during investigation and named in communication findings regarding outbreak updates |
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation visit |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 170
Deficiencies: 0
Aug 31, 2023
Visit Reason
The inspection was conducted as an unannounced Case Management - Incident visit following a Report of Suspected Dependent Adult/Elder Abuse alleging a sexual relationship between a resident and staff member.
Findings
No immediate health and safety concerns were observed during the inspection. Further investigation is needed.
Complaint Details
The complaint involved an allegation that Resident #1 engaged in a sexual relationship with Staff #1. The allegation was reported on 08/23/2023 and an interview was conducted with the Executive Director during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Spencer | Executive Director | Met with Licensing Program Analyst during inspection and involved in interview regarding complaint. |
| Emily Peraldi | Licensing Program Analyst | Conducted the unannounced Case Management - Incident inspection. |
| Kristin Heffernan | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 170
Deficiencies: 0
Jul 27, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff do not ensure the safety of food served to residents and do not maintain food service equipment.
Findings
The investigation found no evidence to support the allegations. Food safety and equipment maintenance were observed to be adequate, with no resident complaints or issues noted. Both allegations were deemed unsubstantiated.
Complaint Details
The complaint alleged that staff do not ensure the safety of food served to residents and do not maintain food service equipment. After inspection, interviews, and document review, the allegations were found unsubstantiated.
Report Facts
Capacity: 170
Census: 128
Complaint Control Number: 29-AS-20230724105236
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Spencer | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 170
Deficiencies: 1
Jul 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 02/22/2023 concerning staff response times, verbal and psychological abuse, and rate increases without valid reasons at the facility.
Findings
The investigation found insufficient evidence to substantiate claims of verbal and psychological abuse and untimely staff response to resident calls. The allegation of an unjustified rate increase was also unsubstantiated. However, the claim that the resident did not receive timely medical care was substantiated due to staff failing to call 9-1-1 during a medical emergency and instead contacting the resident's responsible party.
Complaint Details
The complaint investigation addressed allegations that staff did not respond timely to resident calls, verbally and psychologically abused the resident, increased rates without valid reasons, and failed to provide timely medical care. The first three allegations were unsubstantiated, while the failure to provide timely medical care was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately telephone 9-1-1 when a resident experienced chest pains, posing an imminent threat to resident health. | Type A |
Report Facts
Census: 129
Total Capacity: 170
Average pendant presses per day: 16.8
Average response time (minutes): 8
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Elizabeth Spencer | Executive Director | Facility administrator met during investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 170
Deficiencies: 0
Jul 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-01-27 regarding insufficient staffing, resident injuries from a fall, residents left unattended, and untimely staff response to resident alerts.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Staffing was generally adequate with occasional use of agency or management staff to cover absences. Resident #1's fall and injuries were documented, but evidence did not prove neglect. Pendant response times were generally within 4-8 minutes with some sporadic delays. Residents reported timely staff responses and denied being left unattended or soiled for extended periods. No deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included insufficient staffing, resident injuries from a fall, residents left unattended, and staff not responding timely to resident alerts. Interviews, record reviews, and pendant log analysis did not support these claims.
Report Facts
Capacity: 170
Census: 128
Pendant response time: 4
Pendant response time: 8
Pendant response time: 15
Date complaint received: Jan 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Elizabeth Spencer | Executive Director | Facility administrator met during investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 127
Capacity: 170
Deficiencies: 2
Jul 12, 2023
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was generally found to be clean, safe, and in good repair with appropriate supplies and activities. However, deficiencies were cited related to medication administration discrepancies and incomplete staff first aid certifications.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Medication count was off for 1 out of 5 residents, posing an immediate health and safety risk. | Type A |
| Three out of six staff files lacked valid first aid certification, posing a potential health and safety risk. | Type B |
Report Facts
Residents' records reviewed: 6
Personnel records reviewed: 6
Residents' units toured: 13
Restrooms observed: 13
Residents with medication discrepancy: 1
Staff lacking valid first aid certification: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Spencer | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 170
Deficiencies: 0
May 11, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that facility staff were not replacing or reimbursing residents for lost items.
Findings
The investigation found that the facility has Theft and Loss policies included in the resident handbook and admission agreement, and makes reasonable efforts to safeguard residents' property. Interviews and record reviews did not provide sufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Complaint Details
The complaint alleged that the facility does not follow regulations regarding Theft & Loss by not replacing or reimbursing residents for lost items. The allegation was unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 170
Census: 124
Complaint Control Number: 29-AS-20230508162415
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Elizabeth Spencer | Executive Director | Interviewed regarding Theft and Loss policies and procedures |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 170
Deficiencies: 1
Aug 23, 2022
Visit Reason
The visit was an unannounced Case Management - Incident visit to conclude findings from an investigation that began on 2022-05-26 regarding an allegation that Resident #1 had engaged in a sexual relationship with Staff #1.
Findings
The investigation found insufficient evidence to support the allegation of sexual abuse but sufficient evidence that Staff #1 had inappropriate contact with residents (hugging and kissing on the forehead) and accepted gifts from residents. Staff #1 was placed on administrative leave and subsequently resigned.
Complaint Details
The complaint investigation was triggered by a Report of Suspected Dependent Adult/Elder Abuse alleging a sexual relationship between Resident #1 and Staff #1. The allegation was not substantiated as sexual abuse, but inappropriate contact and acceptance of gifts by Staff #1 was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87468.1(a)(1) Personal Rights of Residents in All Facilities. Residents shall be accorded dignity in their personal relationships with staff, residents, and others. This requirement was not met as Staff #1 admitted to hugging and kissing Resident #1 on the forehead and accepting gifts from residents, posing an immediate personal rights risk. | Type A |
Report Facts
Facility Capacity: 170
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Spencer | Executive Director | Met with Licensing Program Analyst during the visit |
| Ashley Smith | Licensing Program Analyst | Conducted the investigation and inspection visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 150
Capacity: 170
Deficiencies: 0
Jun 24, 2022
Visit Reason
The visit was a required unannounced annual inspection with an emphasis on infection control practices and procedures.
Findings
The facility was found to be in compliance with Title 22 Regulations with no health or safety hazards observed. Infection control practices were adequate, PPE supplies were sufficient, and the facility had managed COVID-19 cases in compliance with local health department requirements. No deficiencies were observed during the visit.
Report Facts
Capacity: 170
Census: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Spencer | Executive Director | Met with Licensing Program Analyst during inspection and discussed infection control practices |
| Ashley Smith | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 170
Deficiencies: 1
Jun 1, 2022
Visit Reason
The inspection was conducted due to complaints alleging neglect resulting in a resident's pressure injury progressing to a stage 3 injury and failure to safeguard a resident's personal belongings, specifically an air mattress.
Findings
The investigation found insufficient evidence to substantiate neglect regarding the progression of the pressure injury, which was regularly monitored by home health professionals. However, the allegation that staff failed to safeguard the resident's personal belongings was substantiated, as the air mattress was lost for several days due to staff oversight.
Complaint Details
The complaint investigation was triggered by allegations that neglect caused a resident's pressure injury to worsen from stage 2 to stage 3 and that the facility failed to safeguard the resident's personal belongings, specifically an air mattress. The pressure injury neglect allegation was unsubstantiated, while the failure to safeguard belongings was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87217(b) Safeguards for Resident Cash, Personal Property, and Valuables - failure to safeguard resident's air mattress, posing a potential personal rights risk. | Type B |
Report Facts
Capacity: 170
Census: 147
Deficiency count: 1
Plan of Correction Due Date: Jun 10, 2022
Air mattress missing duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Elizabeth Spencer | Executive Director | Facility representative met during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 170
Deficiencies: 0
May 26, 2022
Visit Reason
The visit was an unannounced Case Management - Incident visit triggered by a Report of Suspected Dependent Adult/Elder Abuse and a Special Incident Report regarding an alleged violation of personal rights against Resident #1.
Findings
No health and safety hazards were noted at the time of the visit, and no citations were issued. The incident was referred to the Community Care Licensing Investigation's Branch for further investigation before findings are delivered.
Complaint Details
The complaint involved an alleged violation of personal rights against Resident #1. The incident was cross reported to the local ombudsman office and the local police department. The investigation is ongoing and assigned to Investigator Edward Hector.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Prisila Bustos | Assisted Living Director | Met with Licensing Program Analyst during the visit and explained the reason for the visit. |
| Elizabeth Spencer | Executive Director | Named as Executive Director; was out of the community at the time of the visit and received a copy of the signed report. |
| Ashley Smith | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Edward Hector | Investigator | Assigned to investigate the incident referred to the Community Care Licensing Investigation's Branch. |
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