Inspection Report Summary
Most inspections found no deficiencies, with the facility generally maintaining compliance in annual inspections and case management visits. However, several complaint investigations substantiated issues primarily related to medication management and staffing, including repeated medication errors and insufficient staff training, which led to civil penalties of $250 and $500 in 2025 and 2024 respectively. Other substantiated concerns involved delayed response to resident call buttons and inadequate supervision contributing to a resident eloping in 2024. The most recent report from August 26, 2025, was a complaint investigation that found all allegations unsubstantiated, indicating improvement in those areas. Several complaint investigations over time were unsubstantiated or unfounded, showing mixed but generally improving compliance.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 157
Capacity: 199
Deficiencies: 0
Aug 26, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including violations of residents' personal rights, failure to provide incontinence care, failure to maintain facility cleanliness and repair, failure to address resident falls, and issuance of an unlawful eviction notice.
Findings
All allegations related to personal rights violations, incontinence care, facility cleanliness, and fall assistance were found to be unsubstantiated based on interviews, observations, and record reviews. The allegation regarding an unlawful eviction notice was found to be unfounded as the eviction notice was lawful and supported by documented resident drug use incidents.
Complaint Details
The complaint investigation was initiated based on allegations received on 2025-05-12. The investigation included interviews with staff and residents, review of documentation, and observations. The allegations of personal rights violations, inadequate incontinence care, poor facility maintenance, and failure to address falls were unsubstantiated. The allegation of unlawful eviction was unfounded, with evidence showing the eviction was due to resident drug use and was in compliance with regulations.
Report Facts
Capacity: 199
Census: 157
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Kristine Clawson | Executive Director | Facility representative met during the investigation and involved in findings delivery |
Inspection Report
Annual Inspection
Census: 154
Capacity: 199
Deficiencies: 0
Aug 5, 2025
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to ensure compliance with Title 22 regulations for the care home.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with properly furnished resident apartments, sanitary bathrooms, safe food storage, operational safety equipment, and locked medication storage. No deficiencies were cited during this visit.
Report Facts
Resident apartments observed: 6
Common area bathrooms observed: 2
Resident files reviewed: 8
Staff files reviewed: 4
Residents' medications reviewed: 2
Perishable food supply: 2
Non-perishable food supply: 7
Hot water temperature: 111
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kristine Clawson | Executive Director | Facility representative met during the inspection |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 199
Deficiencies: 2
Jul 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff were mismanaging residents' medications and that staff did not meet the qualifications to administer residents' medications.
Findings
The investigation substantiated the allegations that staff mismanaged medications, including a medication error where a resident ingested another resident's medications, and that one staff member did not complete required annual medication training for multiple years. Deficiencies were cited and a civil penalty of $250 was assessed for a repeat violation.
Complaint Details
The complaint was substantiated. Allegations included staff mismanaging residents' medications and staff not meeting qualifications to administer medications. The investigation included review of medication error reports, medication counts, training documentation, and interviews. A civil penalty was assessed for a repeat violation.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not ensure that 2 of 3 residents were receiving medications as prescribed, posing an immediate health, safety, and personal rights risk. | Type A |
| Facility did not ensure that 1 of 3 staff administering medications received training in accordance with the facility's Plan of Operation, posing a potential health, safety, and personal rights risk. | Type B |
Report Facts
Civil penalty amount: 250
Residents involved in medication error: 1
Medication discrepancies: 4
Staff missing annual training years: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Monitoring
Census: 157
Capacity: 199
Deficiencies: 0
Jul 8, 2025
Visit Reason
The visit was a case management health and safety check conducted by the Licensing Program Analyst following receipt of a death report for a resident.
Findings
No deficiencies were cited as a result of this unannounced case management health and safety check visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sharisse Toves | Resident Care Director | Met with Licensing Program Analyst during the case management health and safety check. |
| Michael Hood | Licensing Program Analyst | Conducted the case management health and safety check. |
| Kristine Clawson | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Census: 152
Capacity: 199
Deficiencies: 0
May 14, 2025
Visit Reason
The visit was an unannounced case management visit to confirm orders for immediate exclusion of an individual from all facilities.
Findings
The facility was informed of an immediate exclusion effective May 14, 2025, requiring removal of the individual S1 from any contact with clients and prohibiting physical presence in the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | ED | Met with Licensing Program Analysts during the visit and involved in the exclusion order discussion. |
| Lavinia Muscan | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Talwinder Bains | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 199
Deficiencies: 1
Mar 21, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff mismanaged residents' medication and did not report the incident.
Findings
The investigation substantiated the allegation that staff mismanaged residents' medication, finding that a resident did not receive medications as prescribed, posing an immediate health and safety risk. A deficiency was cited. Another allegation that staff did not report the incident was found to be unfounded.
Complaint Details
The complaint investigation was substantiated regarding medication mismanagement based on an incident where morning medications were found not taken in a resident's apartment. The facility conducted staff training following the incident. The allegation that staff did not report the incident was found to be unfounded.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure that a resident was receiving medications as prescribed, posing an immediate health, safety, and personal rights risk to residents in care. | Type A |
Report Facts
Capacity: 199
Census: 154
Deficiency count: 1
Plan of Correction Due Date: Mar 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristine Clawson | Executive Director | Facility representative met during investigation |
| Anthony Perez | Licensing Program Manager | Oversaw licensing program related to the investigation |
Inspection Report
Census: 143
Capacity: 199
Deficiencies: 0
Jan 21, 2025
Visit Reason
The visit was a case management follow-up regarding a potential fire on site triggered by smoke from a microwave incident involving a resident.
Findings
No fire was found on the premises, no damage was observed in the resident's apartment, and no deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the case management visit and inspection. |
| Kristine Clawson | Executive Director | Met with Licensing Program Analyst during the visit and provided information about the incident. |
Inspection Report
Enforcement
Census: 150
Capacity: 199
Deficiencies: 1
Oct 23, 2024
Visit Reason
The visit was conducted to issue a civil penalty related to a previous inspection conducted on 2024-08-21 for a violation involving the absence of supervision.
Findings
An immediate civil penalty of $500 was assessed for the violation of absence of supervision found during the inspection on 2024-08-21. The penalty was issued during the visit on 2024-10-23.
Deficiencies (1)
| Description |
|---|
| Violation involving the absence of supervision |
Report Facts
Civil penalty amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Issued civil penalty regarding inspection |
| Kristine Clawson | Executive Director | Met with Licensing Program Analyst during visit and acknowledged receipt of documents |
Inspection Report
Annual Inspection
Census: 148
Capacity: 199
Deficiencies: 0
Sep 24, 2024
Visit Reason
The inspection was a Required-1 Year unannounced visit conducted to ensure compliance with Title 22 regulations for the assisted living facility.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. Apartments and common areas were properly maintained, medication storage was secure, and safety equipment was operational.
Report Facts
Apartments inspected: 7
Bathrooms inspected: 2
Resident files reviewed: 4
Staff files reviewed: 4
Perishable food supply: 2
Non-perishable food supply: 7
Hot water temperature: 109.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristine Clawson | Administrator/Director | Facility administrator met during inspection |
| Cassandra Mikkelson | Licensing Program Analyst | Conducted the inspection |
| Michael Hood | Licensing Program Analyst | Conducted the inspection |
| Anthony Perez | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 199
Deficiencies: 2
Aug 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not prevent a resident from eloping.
Findings
The investigation found that the facility failed to properly supervise resident R1, who eloped from the facility and was found by police in a nearby field. The facility also delayed reporting the resident missing to 9-1-1, posing an immediate health, safety, and personal rights risk. The allegation was substantiated.
Complaint Details
The complaint was substantiated. The allegation was that staff did not prevent a resident from eloping. The resident was missing from approximately 6:00 PM until located by police at 8:00 PM. Staff delayed reporting the resident missing to 9-1-1, and the resident was found stuck in tall brambles behind the facility. The resident has since moved to a higher level of care.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not ensure that resident R1 was properly supervised, resulting in AWOL, posing an immediate health, safety, and personal rights risk. | Type A |
| Facility did not ensure to contact 9-1-1 timely after observing R1 AWOL from the facility, posing an immediate health, safety, and personal rights risk. | Type A |
Report Facts
Capacity: 199
Census: 185
Deficiencies cited: 2
Plan of Correction Due Date: Aug 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristine Clawson | Executive Director | Facility administrator interviewed during investigation |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 199
Deficiencies: 1
Jun 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not responding to call buttons in a timely manner.
Findings
The investigation substantiated the allegation that staff response times to resident call buttons were delayed, with documented response times exceeding 15 minutes and reaching as long as 107 minutes, posing potential health, safety, and personal rights risks to residents.
Complaint Details
The complaint was substantiated based on interviews with staff and residents, and review of call button logs for multiple residents showing delayed response times. The allegation was that staff were not responding to call buttons in a timely manner.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide timely response to resident call buttons, resulting in delayed response times up to 107 minutes. | Type B |
Report Facts
Census: 164
Total Capacity: 199
Response Time: 107
Deficiency Due Date: Jul 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hood | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Nathan Condie | Administrator | Facility Administrator mentioned in relation to lack of written policy on call button response times |
| Kristine Clawson | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 200
Capacity: 199
Deficiencies: 0
Feb 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-12-01 alleging that facility staff restrained a resident by placing wheelchairs or obstacles to prevent the resident from getting out of bed.
Findings
The investigation included interviews with staff and residents, review of medical and incident records, and was unable to substantiate the allegation. The Department found insufficient evidence to prove the alleged violation occurred and classified the complaint as unsubstantiated.
Complaint Details
The complaint alleged that staff restrained a resident by placing wheelchairs or obstacles to prevent the resident from getting out of bed. The investigation included interviews with five staff members and two residents, review of the resident's physician report and level of care assessments, and examination of incident reports and medication records. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 199
Census: 200
Number of staff interviewed: 5
Number of residents interviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Shaunte Burnett | Business Director | Met with Licensing Program Analyst during investigation |
| Nathan Condie | Administrator | Facility administrator named in report |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 150
Capacity: 199
Deficiencies: 0
Sep 14, 2023
Visit Reason
The inspection was conducted as a required unannounced annual inspection of the facility.
Findings
The facility was toured and inspected including common areas, resident apartments, kitchen, dining, and medication storage. The facility appeared clean, well-maintained, and in substantial compliance with regulations. No deficiencies were cited during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Condie | Executive Director | Met with the Licensing Program Analyst during the inspection and reviewed the CARE Tool. |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 199
Deficiencies: 1
Jul 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 11/29/2022 regarding neglect of residents' needs and overmedication at the facility.
Findings
The investigation substantiated the allegation that facility staff neglected residents' needs, specifically failing to keep incontinent residents clean and dry, posing immediate health and safety risks. Another allegation regarding residents being overmedicated was found to be unsubstantiated with no deficiencies cited.
Complaint Details
The complaint investigation was substantiated for neglect related to residents being left in soiled briefs and inadequate toileting assistance, with staffing issues noted. The allegation of overmedication was unsubstantiated after review of medication records and interviews.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Managed incontinence - facility failed to ensure resident R5 was kept clean and dry, posing immediate health, safety, and personal rights risk. | Type A |
Report Facts
Capacity: 199
Census: 190
Staff per shift: 7
Residents not changed: 5
Staff interviewed: 6
Residents interviewed: 2
Plan of Correction Due Date: Aug 4, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Shaunte Burnett | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Nathan Condie | Administrator | Facility administrator named in report |
Inspection Report
Annual Inspection
Census: 127
Capacity: 199
Deficiencies: 0
Jul 26, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure compliance with health and safety standards.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Condie | Executive Director | Met with Licensing Program Analyst during inspection |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 199
Deficiencies: 0
Jun 9, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2022-02-02 alleging that a resident sustained a fracture while in care and unlawful eviction.
Findings
The investigation found that the resident did sustain fractures from a fall but the facility took appropriate measures and timely medical attention was provided. The allegation of resident fracture was unsubstantiated due to insufficient evidence of violation. The allegation of unlawful eviction was found to be unfounded, meaning it was false or without reasonable basis.
Complaint Details
The complaint involved two main allegations: 1) Resident sustained fracture while in care, and 2) Unlawful eviction. The fracture allegation was unsubstantiated after review of medical records and interviews. The unlawful eviction allegation was unfounded based on interviews and lack of eviction notice to the resident's responsible party.
Report Facts
Complaint received date: Feb 2, 2022
Facility capacity: 199
Census: 141
Incident date: Jan 21, 2022
Incident time: 1700
Reappraisal scheduled date: Feb 7, 2022
Visit start time: 1440
Visit end time: 1615
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Nathan Condie | Executive Director | Facility representative met during investigation |
| Kristina Waldlow | Resident Care Coordinator | Provided statements regarding resident transfer and care |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 199
Deficiencies: 0
Feb 15, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to complaints alleging that facility staff did not return to assist a resident resulting in a fall and that the facility did not notify the responsible party of a change in the resident's condition.
Findings
The investigation found both allegations to be unsubstantiated after reviewing resident records, physician reports, staff interviews, and facility documentation. The facility was unable to provide some call log documents, and some staff involved were no longer employed. Notifications to the resident's responsible party regarding changes in care were documented.
Complaint Details
The complaint alleged that facility staff left a resident unassisted in the shower resulting in a fall and that the facility failed to notify the responsible party of changes in the resident's condition. The investigation found insufficient evidence to substantiate these allegations, concluding them as unsubstantiated.
Report Facts
Facility capacity: 199
Resident census: 14
Complaint receipt date: Aug 13, 2021
Incident date: Jan 22, 2021
Level of care assessments: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nathan Condie | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristina Wardlow | Resident Care Director | Provided interview statements regarding resident assessments and notification procedures |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 129
Capacity: 199
Deficiencies: 0
Aug 23, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain, conducted to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Condie | Executive Director | Met with Licensing Program Analyst during inspection |
| Ryan Mussata | Executive Director | Met with Licensing Program Analyst during inspection |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 199
Deficiencies: 1
Aug 12, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2021-04-15 alleging inadequate care and supervision, insufficient staffing, and inadequate food service to residents.
Findings
The investigation substantiated allegations of inadequate care and supervision, insufficient staffing, and inadequate food service, citing delays and missed assistance to residents and meal issues. Other allegations including resident death, reappraisal, staff yelling, and inadequate record keeping were unsubstantiated or unfounded. The facility was found to be clean and well maintained with some inoperable kitchen equipment but alternative equipment available.
Complaint Details
The complaint investigation was substantiated for allegations of inadequate care and supervision, insufficient staffing, and inadequate food service. The complaint was unsubstantiated for allegations of resident death, lack of resident reappraisal, staff yelling at residents, and inadequate record keeping. The complaint of facility disrepair was found to be unfounded.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Requirements – General (a): Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. This requirement is not met based on records and statements that found delays and, at times, delayed or missed ADLs and delayed or missed meal due to insufficient staff. This posed an immediate risk to residents health and safety. | Type A |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Aug 26, 2021
Resident call response instances: 42
Staff interviewed: 6
Residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Maribeth Senty | Licensing Program Manager | Oversaw the complaint investigation report |
| Ryan Mussata | Interim Executive Director | Met with Licensing Program Analyst during the investigation and provided information on staffing and operations |
| Jasmine Ridenour | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 199
Deficiencies: 0
Jul 29, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations of personal rights violations, lack of supervision resulting in resident wandering, and lack of staff training.
Findings
The investigation found no substantiated evidence to support the allegations. Staff interviews and record reviews indicated that residents involved were transferred out due to change of conditions, and no violations were confirmed. No deficiencies were cited during the exit interview.
Complaint Details
The complaint alleged staff were yelling at residents, residents were wandering away from the facility due to lack of supervision, and staff lacked proper training. The findings were unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 199
Census: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melana Llopis | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jasmine Ridenour | Administrator | Facility administrator involved in the investigation |
| Ryan Mussato | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 199
Deficiencies: 1
Jun 3, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2020-12-18 alleging that staff did not administer a resident's medication per physician's order.
Findings
The investigation found that the medication was signed off by staff as given, but medication notes indicated the resident refused the medication on two occasions. The facility's medication refusal policy was reviewed, and the complaint was determined to be unsubstantiated due to insufficient evidence to prove the alleged violation occurred.
Complaint Details
The complaint was unsubstantiated. Although the allegation may have been valid, there was not a preponderance of evidence to prove the violation occurred.
Deficiencies (1)
| Description |
|---|
| Staff did not administer resident’s medication per physician’s order. |
Report Facts
Facility capacity: 199
Census: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Mussato | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jasmine Ridenour | Previous Executive Director | Interviewed regarding facility’s medication refusal policy |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 199
Deficiencies: 1
Jun 3, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 2020-12-18 regarding staff failure to notify a resident's responsible party of missed medication.
Findings
The investigation found that staff did not notify the resident's responsible party or primary care physician about missed medication despite documentation showing medication refusal. The allegation was substantiated based on interviews and record reviews. Deficiencies were cited related to failure to provide required reports to the licensing agency and responsible parties within seven days.
Complaint Details
Complaint was substantiated. The allegation that staff did not notify the resident's responsible party of missed medication was found valid based on evidence including interviews and document reviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit written reports to the licensing agency and responsible party within seven days of occurrence regarding incidents threatening resident welfare, including failure to provide proof of communications with resident's responsible party and primary care physician. | Type B |
Report Facts
Capacity: 199
Census: 108
Deficiency due date: Jun 11, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jasmine Ridenour | Executive Director | Interviewed regarding medication notification practices and deficiency findings |
| Ryan Mussato | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Sarena Keosavang | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Anthony Perez | Licensing Program Manager | Oversaw complaint investigation |
Loading inspection reports...
