Deficiencies (last 5 years)
Deficiencies (over 5 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
86% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 374
Capacity: 436
Deficiencies: 0
Date: Feb 19, 2026
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to multiple allegations regarding staff actions affecting a resident, including damage to a personal item, failure to ensure attendance at a medical appointment, failure to ensure receipt of prescribed medication, and failure to pick up the resident from an appointment in a timely manner.
Complaint Details
The complaint investigation was substantiated for the allegation that staff damaged a resident's personal item (a duvet cover) by fading its color during washing, with a credit issued for replacement. The other allegations about medical appointment attendance, medication receipt, and transportation delays were unsubstantiated due to lack of sufficient evidence.
Findings
The allegation that staff damaged a resident's personal item was substantiated but considered a technical violation with no citations issued. The other allegations related to medical appointment attendance, medication administration, and timely transportation were unsubstantiated due to insufficient evidence. No deficiencies were cited.
Report Facts
Credit amount: 207.43
Medication delay days: 9
Medication delay days: 17
Lyft ride wait time: 75
Number of missed calls: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lourdes Bustamante | Administrator | Facility administrator involved in investigation and transportation resolution |
| Jessica Saks | Associate Executive Director | Met with Licensing Program Analyst during investigation |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 374
Capacity: 436
Deficiencies: 0
Date: Feb 19, 2026
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2025-11-04 regarding untimely food and laundry services for residents.
Complaint Details
The complaint alleged that staff were not providing residents with food and laundry services in a timely manner. After interviews and record reviews, both allegations were deemed unsubstantiated due to insufficient evidence.
Findings
The investigation found no sufficient evidence to substantiate the allegations that staff were not providing food and laundry services in a timely manner. Interviews with residents, visitors, and staff, as well as record reviews, confirmed no concerns with timely food or laundry service.
Report Facts
Capacity: 436
Census: 374
Number of residents interviewed: 5
Number of visitors interviewed: 2
Number of staff interviewed: 5
Meal service times: 7.52
Meal service times: 20.24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Allison Marty | Executive Director | Met with evaluator during entrance interview |
| Jessica Saks | Associate Executive Director | Met with evaluator during entrance interview and during investigation |
Inspection Report
Complaint Investigation
Census: 370
Capacity: 436
Deficiencies: 0
Date: Oct 30, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not ensure that a resident's medical equipment was operable.
Complaint Details
The complaint alleged that staff did not replace the tennis balls/gliders on Resident #1's walker, making it inoperable. The allegation was unsubstantiated after interviews with the resident, responsible party, and staff, and review of records showing the walker was operable and the gliders were replaced by the responsible party.
Findings
The investigation found that the resident's walker was operable despite missing tennis ball gliders for a few days. Interviews and record reviews indicated the walker was not provided by the facility and the missing gliders were replaced by the resident's responsible party. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 436
Census: 370
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Saks | Director of Nursing | Met with evaluator during investigation |
| Allison Marty | Executive Director | Met with evaluator during investigation |
Inspection Report
Complaint Investigation
Census: 370
Capacity: 436
Deficiencies: 0
Date: Oct 30, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that, due to lack of supervision, a resident injured another resident while in care.
Complaint Details
The complaint alleged that due to lack of supervision, Resident #1 injured Resident #2 by throwing an object causing a C1 fracture. Interviews and record reviews showed no evidence of lack of supervision or malicious intent. The allegation was unsubstantiated.
Findings
The investigation found that Resident #1 threw an object at Resident #2 causing injury, but there was insufficient evidence to support the allegation of lack of supervision. Both residents did not require supervision in common areas, and the facility responded effectively to the incident. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 436
Census: 370
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Saks | Director of Nursing | Met with Licensing Program Analyst upon arrival |
| Lourdes Bustamante | Administrator | Discussed allegation during investigation |
| Allison Marty | Executive Director | Arrived shortly after investigation began |
Inspection Report
Complaint Investigation
Census: 366
Capacity: 436
Deficiencies: 0
Date: Sep 3, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not clean a resident's room, were not following a resident's care plan, and were not changing a resident's clothing.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not cleaning a resident's room, not following the resident's care plan, and not changing the resident's clothing. Evidence did not support these claims.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations, interviews, and record reviews confirmed that the resident's room was clean, the resident received stand-by assistance with dressing as documented, and frequent safety checks were conducted. No deficiencies were cited.
Report Facts
Capacity: 436
Census: 366
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 371
Capacity: 436
Deficiencies: 0
Date: Aug 19, 2025
Visit Reason
The inspection was an unannounced Case Management - Annual Continuation visit to evaluate the facility's compliance with licensing requirements and health and safety regulations.
Findings
The facility was found to be in compliance with Title 22 Regulations, with no citations issued. Observations included adequate facility layout, sufficient food supply, well-equipped resident rooms and bathrooms, functional emergency systems, and clear outdoor areas. Interviews with residents and staff were conducted.
Report Facts
Resident rooms toured: 37
Resident rooms in Memory Care Unit: 4
Additional resident rooms toured: 33
Residents interviewed: 5
Staff interviewed: 6
Fire extinguisher service date: Apr 22, 2025
Hot water temperature range: 109.2-116.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with Licensing Program Analyst during inspection |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during inspection |
| Miguel Castenada | Director of Plant Operations | Participated in physical plant tour during inspection |
| Angela Barutyan | Licensing Program Analyst | Conducted the inspection visit |
| Kristin Heffernan | Licensing Program Manager | Named in report header |
| Edgar Antonyan | Los Angeles County Public Health Environmental Health Specialist | Participated in physical plant tour during inspection |
Inspection Report
Annual Inspection
Census: 371
Capacity: 436
Deficiencies: 0
Date: Aug 19, 2025
Visit Reason
The inspection visit was a Case Management - Annual Continuation visit conducted unannounced to evaluate compliance with licensing requirements and ensure health and safety standards at the facility.
Findings
The facility was toured extensively including resident rooms, bathrooms, common areas, and outdoor areas. No citations were issued. The facility was found to be in compliance with Title 22 regulations, with adequate safety measures, functional equipment, and proper emergency systems in place.
Report Facts
Resident rooms toured: 37
Memory Care Unit rooms toured: 4
Additional resident rooms toured: 33
Residents interviewed: 5
Staff interviewed: 6
Facility buildings: 3
Facility units: 336
Fire extinguisher service date: Apr 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with during entrance interview and inspection |
| Allison Marty | Executive Director | Met with during entrance interview and inspection |
| Miguel Castenada | Director of Plant Operations | Participated in physical plant tour |
| Angela Barutyan | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Annual Inspection
Census: 369
Capacity: 436
Deficiencies: 1
Date: Aug 5, 2025
Visit Reason
The inspection was an unannounced Case Management - Annual Continuation visit to review the facility's compliance with licensing requirements, including infection control and emergency disaster planning.
Findings
The facility's infection control policies and emergency disaster plan were found adequate, with regular drills and equipment testing. However, a deficiency was cited due to four out of seven care staff files missing valid first aid certification, posing a potential health and safety risk.
Deficiencies (1)
Four out of seven care staff files were missing valid first aid certification from a qualified agency.
Report Facts
Staff files missing valid first aid certification: 4
Resident records reviewed: 10
Staff records reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Marty | Executive Director | Met with Licensing Program Analysts during inspection |
| Lourdes Bustamante | Administrator/Director | Named as facility administrator/director |
| Angela Barutyan | Licensing Program Analyst | Conducted inspection and signed report |
| Emily Peraldi | Licensing Program Analyst | Conducted inspection |
| Kristin Heffernan | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 369
Capacity: 436
Deficiencies: 1
Date: Aug 5, 2025
Visit Reason
The inspection was an unannounced Case Management - Annual Continuation visit to review the facility's compliance with licensing requirements, including infection control, emergency disaster planning, and staff and resident record reviews.
Findings
The facility's infection control practices and emergency disaster plan were found adequate. However, four out of seven care staff files were missing valid first aid certification, which was cited as a deficiency posing a potential health and safety risk.
Deficiencies (1)
Four out of seven care staff files were missing valid first aid certification from a qualified agency.
Report Facts
Staff files missing valid first aid certification: 4
Resident records reviewed: 10
Staff records reviewed: 10
Capacity: 436
Census: 369
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Marty | Executive Director | Met with Licensing Program Analysts during inspection |
| Lourdes Bustamante | Administrator | Named as facility administrator in report |
| Angela Barutyan | Licensing Program Analyst | Conducted inspection and signed report |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 363
Capacity: 436
Deficiencies: 0
Date: Jun 13, 2025
Visit Reason
Licensing Program Analyst Emily Peraldi conducted an unannounced required annual visit to the facility to evaluate compliance with licensing requirements.
Findings
The Licensing Program Analyst reviewed medication and medication documentation for eleven residents and observed that medications were properly documented and assisted with as prescribed. Medications were securely stored. The inspection was not completed due to time constraints and will be resumed at a later date.
Report Facts
Residents reviewed for medication documentation: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the inspection and medication review |
| Jessica Saks | Wellness Director | Assisted with medication and medication documentation review |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during inspection |
| Lourdes Bustamante | Administrator/Director | Facility Administrator/Director |
Inspection Report
Complaint Investigation
Census: 363
Capacity: 436
Deficiencies: 2
Date: Jun 13, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-06-10 alleging that facility staff did not properly assist a resident with self-administration of medications and that reporting requirements were not being met.
Complaint Details
The complaint was substantiated. Allegations included improper assistance with medication self-administration and failure to meet reporting requirements. The medication error involved giving half the prescribed dose of Escitalopram. The facility self-reported the error and conducted staff training. The failure to report medication refusal was also substantiated.
Findings
The investigation substantiated that staff did not properly assist Resident #1 with medication administration as prescribed, resulting in a medication error. Additionally, the facility failed to report a medication refusal to the resident's responsible person as required.
Deficiencies (2)
Staff did not properly assist Resident #1 with self-administered medications as prescribed, posing an immediate health and safety risk.
Facility failed to report Resident #1's medication refusal to the responsible person, posing a potential health, safety, or personal rights risk.
Report Facts
Capacity: 436
Census: 363
Medication dosage error: 5
Medication prescribed dosage: 10
Plan of Correction due date: 1
Plan of Correction due date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Wellness Director | Interviewed regarding medication error and reporting failures |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 363
Capacity: 436
Deficiencies: 0
Date: Jun 13, 2025
Visit Reason
Licensing Program Analyst Emily Peraldi conducted an unannounced required annual visit to this facility to evaluate compliance with licensing requirements.
Findings
The inspection included a physical plant tour and a review of medication and medication documentation for eleven residents, which were found to be properly documented and assisted as prescribed. Medications were securely stored. The inspection was not completed due to time constraints and will be continued at a later date.
Report Facts
Residents reviewed for medication documentation: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the unannounced required annual visit and inspection |
| Jessica Saks | Wellness Director | Met with the Licensing Program Analyst and assisted with the physical plant tour and medication review |
| Allison Marty | Executive Director | Met with the Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 363
Capacity: 436
Deficiencies: 0
Date: May 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that a resident eloped without supervision while in care.
Complaint Details
The complaint alleged that Resident #1 eloped without supervision while in care. The investigation determined the allegation was unsubstantiated as the resident did not leave the facility unsupervised and was not missing for an extended period.
Findings
The investigation found that the resident left the memory care unit unsupervised on two occasions but did not leave the facility grounds and was found unharmed. The incidents did not meet the regulatory definition of elopement, and there was insufficient evidence to substantiate the allegation. No deficiencies were cited.
Report Facts
Facility capacity: 436
Census: 363
Dates of incidents: Incidents occurred on 2025-04-24 and 2025-05-01
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Lourdes Bustamante | Administrator/Director of Hospitality | Met with Licensing Program Analyst during investigation |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during investigation |
| Jessica Saks | Director of Nursing | Conducted physical plant tour with Licensing Program Analyst |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 363
Capacity: 436
Deficiencies: 1
Date: May 21, 2025
Visit Reason
The visit was conducted as a Case Management - Deficiencies inspection in conjunction with a complaint investigation to issue a citation for a deficiency observed during the initial complaint investigation.
Complaint Details
The visit was triggered by Complaint Control # 29-AS-20250515120119. The complaint involved residents leaving the memory care unit unsupervised, which was substantiated by staff and responsible parties' interviews and observations.
Findings
The facility was found noncompliant as two residents (R1 and R2) left the memory care unit unsupervised via elevator on multiple occasions, posing a potential health, safety, and personal rights risk. The memory care exit doors to the elevator were not supervised at all times and were not delayed egress, allowing residents to access other floors unsupervised.
Deficiencies (1)
Based on interviews and observation, the Licensee did not comply with the section cited as R1 and R2 left the memory care floor unsupervised with the elevator which posed a potential health, safety, and personal rights risk to residents in care.
Report Facts
Census: 363
Total Capacity: 436
Deficiency Type B: 1
Plan of Correction Due Date: Jun 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
| Allison Marty | Executive Director | Interviewed during inspection regarding elevator access and supervision |
| Jessica Saks | Director of Nursing | Conducted physical plant tour during inspection |
Inspection Report
Complaint Investigation
Census: 365
Capacity: 436
Deficiencies: 1
Date: Mar 26, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations including staff not ensuring resident's doors are in good repair, medication administration issues, inadequate supervision resulting in resident wandering, and inadequate food service.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure resident's doors were in good repair. Allegations regarding medication administration, supervision of residents to prevent wandering, and adequacy of food service were unsubstantiated.
Findings
The allegation regarding resident doors not being in good repair was substantiated with two out of three doors observed lacking functional door closers, which were repaired during the visit. Allegations related to medication administration, supervision, and food service were unsubstantiated based on record reviews, interviews, and observations.
Deficiencies (1)
Two out of three resident apartment doors did not have functioning door closers, posing potential health, safety, and personal rights risks.
Report Facts
Resident doors observed without functional door closers: 2
Staff interviewed: 7
Residents interviewed: 5
Residents for medication review: 3
Meal points allowance for Independent Living residents: 800
Meal points allowance for Assisted Living residents: 1050
Plan of Correction due date: Apr 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Lourdes Bustamante | Administrator/Director of Hospitality | Facility administrator interviewed during investigation |
| Allison Marty | Executive Director | Facility executive director contacted and interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 355
Capacity: 436
Deficiencies: 0
Date: Feb 3, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff were not ensuring infection control practices and did not notify appropriate agencies of an outbreak.
Complaint Details
The complaint alleged failure to follow infection control practices and failure to notify appropriate agencies of an outbreak. The allegations were deemed unsubstantiated due to insufficient evidence despite some validity of the claims.
Findings
The investigation found that the facility implemented multiple infection control measures including closing common areas, using PPE, and notifying families. Incident reports and notifications to the public health department were timely. There was insufficient evidence to substantiate the allegations, and no deficiencies were cited.
Report Facts
Resident symptom reports: 15
Resident symptom onset: 7
Resident symptom onset: 8
Resident symptom reports: 3
Resident symptom reports: 6
Stool samples collected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joyce Aquino | Administrator | Facility administrator mentioned in the report header |
| Jessica Saks | Director of Nursing | Met with Licensing Program Analyst during investigation |
| Allison Marty | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 355
Capacity: 436
Deficiencies: 0
Date: Feb 3, 2025
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation in response to an allegation that staff were not providing residents with comfortable accommodations due to heavy noises coming from the unit above certain residents' shared unit.
Complaint Details
The complaint was unsubstantiated. The allegation involved noise disturbances affecting residents' comfort. Investigations included interviews, document reviews, and inspections. No evidence was found to corroborate the complaint.
Findings
The investigation found no sufficient evidence to substantiate the allegation. Multiple attempts were made by the facility to address the noise concerns, including plumbing and HVAC inspections and offering to relocate residents. Interviews with residents and staff did not support the allegation, and the unit above was vacant for about three weeks during the alleged noise period.
Report Facts
Capacity: 436
Census: 355
Residents interviewed: 5
Staff interviewed: 3
Residents interviewed on same floor as R1 and R2: 3
Residents interviewed on floor above: 1
Residents interviewed in adjacent building: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joyce Aquino | Administrator | Facility administrator mentioned in the report header |
| Jessica Saks | Director of Nursing | Interviewed during the investigation and involved in addressing the complaint |
| Allison Marty | Executive Director | Interviewed during the investigation and involved in addressing the complaint |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 352
Capacity: 436
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
The visit was conducted as a case management incident investigation following a report of fraudulent activity by a staff member toward a resident involving unauthorized personal checks.
Complaint Details
The complaint involved fraudulent activity by Staff #1 toward Resident #1 involving two personal checks totaling $8,000. The staff member was suspended and terminated. The facility cross-reported to Adult Protective Services, the Long-Term Care Ombudsman, and Law Enforcement. Adult Protective Services conducted a visit. The resident confirmed the facility acted appropriately.
Findings
The facility responded quickly and effectively to the incident, suspending and terminating the staff member involved, cross-reporting to appropriate agencies, and safeguarding resident property. No monies were taken from the resident's account as the bank prevented the fraudulent checks from processing. No citations were issued.
Report Facts
Amount involved in fraudulent checks: 8000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Marty | Executive Director | Met with Licensing Program Analyst during the visit |
| Jessica Saks | Director of Nursing | Interviewed during initial visit related to investigation |
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced case management incident visit |
| Kristin Heffernan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 352
Capacity: 436
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
The visit was conducted as a case management incident investigation following a report of fraudulent activity by a staff member toward a resident involving unauthorized personal checks.
Complaint Details
The complaint involved fraudulent activity by Staff #1 toward Resident #1, with two personal checks totaling $8,000 made out from the resident's account. The staff member was suspended and terminated promptly. Adult Protective Services conducted a visit. No funds were lost due to bank intervention.
Findings
The facility responded quickly and effectively to the incident, suspending and terminating the implicated staff member, cross-reporting to appropriate agencies, and safeguarding the resident's cash resources. No monies were taken as the resident's bank prevented the fraudulent checks from processing.
Report Facts
Personal checks amount: 8000
Census: 352
Total capacity: 436
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Marty | Executive Director | Met with Licensing Program Analyst during inspection |
| Jessica Saks | Director of Nursing | Interviewed during initial visit related to investigation |
| Angela Barutyan | Licensing Program Analyst | Conducted the case management incident visit and investigation |
Inspection Report
Complaint Investigation
Census: 352
Capacity: 436
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not evacuate a resident during a fire and that staff were not properly trained for fire evacuation.
Complaint Details
The complaint involved two allegations: 1) Staff did not evacuate resident during a fire, and 2) Staff not properly trained for fire evacuation. Both allegations were found to be unsubstantiated after investigation including interviews, document reviews, and observations.
Findings
The investigation found insufficient evidence to support the allegations. The facility had a small kitchen fire on 8/8/23, residents were instructed to stay in place per the Resident Guide, and evacuation protocols were not activated. Staff training records showed regular fire drills and training, supporting that staff were properly trained.
Report Facts
Facility capacity: 436
Census: 352
Fire drill frequency: 12
Evacuation drill frequency: 1
Facility floors: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Yee | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jessica Saks | Director of Nursing | Interviewed during investigation and provided information about staff training and evacuation procedures |
| Joyce Aquino | Administrator | Named as facility administrator |
| Kristin Heffernan | Licensing Program Manager | Oversaw licensing program related to the investigation |
Inspection Report
Complaint Investigation
Census: 352
Capacity: 436
Deficiencies: 0
Date: Nov 26, 2024
Visit Reason
The visit was an unannounced case management - incident inspection conducted due to a reported incident of fraudulent activity by a staff member toward a resident.
Complaint Details
The complaint involved fraudulent activity by a staff member who cashed two personal checks from a resident's account for $3,000 and $5,000. The staff member was terminated and the incident was cross-reported to relevant authorities.
Findings
The investigation revealed that two personal checks totaling $8,000 were made from Resident #1's account to a staff member who has since been terminated. The facility reported the incident to Adult Protective Services, the Long-Term Care Ombudsman, and Law Enforcement. Further investigation is needed before issuing a final licensing report.
Report Facts
Amount of fraudulent checks: 3000
Amount of fraudulent checks: 5000
Census: 352
Total Capacity: 436
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Interviewed during the investigation |
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced case management - incident visit |
Inspection Report
Complaint Investigation
Census: 352
Capacity: 436
Deficiencies: 0
Date: Nov 26, 2024
Visit Reason
The visit was an unannounced case management incident inspection triggered by a reported incident of fraudulent activity by a staff member toward a resident involving unauthorized personal checks.
Complaint Details
The complaint involved fraudulent activity by Staff #1 toward Resident #1, with two personal checks totaling $8,000 made out from the resident's account. Staff #1 was terminated and the facility reported the incident to Adult Protective Services, the Long-Term Care Ombudsman, and Law Enforcement.
Findings
The Licensing Program Analyst conducted interviews, a physical plant tour, and document reviews related to the incident. Further investigation was determined necessary before issuing a final licensing report.
Report Facts
Amount of fraudulent checks: 8000
Number of staff interviewed: 2
Number of residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with during the inspection and interviewed regarding the incident |
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced case management incident visit |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 354
Capacity: 436
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations that resident records were falsified and that the facility charged residents for insurance paperwork services they did not receive.
Complaint Details
The complaint alleged that the facility referred potential residents to a physician who provided false medical reports to secure insurance payments and that residents were improperly charged fees for insurance paperwork. The investigation included document review and interviews with staff and residents. The allegation was found unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegations. Residents and staff interviews indicated that the facility charges $150 only when insurance paperwork completion is necessary, and residents receive appropriate medical services. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 436
Census: 354
Charge amount: 150
Residents seen by medical director: 12
Residents seen by medical director: 15
Time to complete paperwork: 3
Time to complete paperwork: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation visit and delivered final findings |
| Joyce Aquino | Administrator | Facility administrator interviewed during the investigation |
| Lourdes Bustamante | Director of Hospitality | Facility staff member interviewed during the investigation |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 356
Capacity: 436
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
The inspection was an unannounced Case Management - Annual Continuation visit to evaluate compliance with licensing requirements.
Findings
The inspection included record reviews, medication reviews, staff interviews, and a physical plant tour. No deficiencies were cited during this visit.
Report Facts
Staff files reviewed: 10
Medications reviewed: 5
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with Licensing Program Analysts during the inspection |
| Angel Ascencio | Director of Compliance | Met with Licensing Program Analysts during the inspection |
Inspection Report
Annual Inspection
Census: 356
Capacity: 436
Deficiencies: 0
Date: Aug 6, 2024
Visit Reason
The visit was an unannounced Case Management - Annual Continuation inspection to review compliance with licensing requirements.
Findings
The inspection included record reviews, medication reviews, staff interviews, and a physical plant tour. No deficiencies were cited, and all reviewed areas were found to be in compliance.
Report Facts
Staff files reviewed: 10
Medications reviewed: 5
Staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with LPAs during the inspection |
| Angel Ascencio | Director of Compliance | Met with LPAs during the inspection |
| Angela Barutyan | Licensing Program Analyst | Conducted the inspection |
| Trevor Byrne Barutyan | Licensing Program Analyst | Conducted the inspection |
| Kristin Heffernan | Licensing Program Manager | Named in the report |
Inspection Report
Annual Inspection
Census: 356
Capacity: 436
Deficiencies: 0
Date: Jul 11, 2024
Visit Reason
The inspection was a required unannounced annual visit conducted by Licensing Program Analysts to evaluate compliance with Title 22 Regulations and ensure health and safety standards at the facility.
Findings
The facility was found to be in compliance with regulations during the inspection. Observations included adequate facility layout, safety features, amenities, infection control practices, emergency disaster planning, and record reviews. No citations were issued.
Report Facts
Resident rooms toured: 30
Resident records reviewed: 10
Residents interviewed: 5
Emergency disaster drills frequency: 4
Delayed egress doors tested: 1
Signal cord tests: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analysts during inspection and participated in facility tour |
| Angel Ascencio | Director of Compliance | Participated in facility tour with Licensing Program Analysts |
| Jessica Saks | Director of Nursing | Participated in facility tour with Licensing Program Analysts |
| Mark Lagasca | Maintenance Technician | Participated in facility tour with Licensing Program Analysts |
| Angela Barutyan | Licensing Evaluator | Conducted inspection and signed report |
Inspection Report
Annual Inspection
Census: 356
Capacity: 436
Deficiencies: 0
Date: Jul 11, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure health and safety standards at the facility.
Findings
The facility was found to be in compliance with regulations, with no citations issued. Observations included adequate facility layout, safety features, amenities, infection control practices, and emergency preparedness. Resident records reviewed were compliant, and staff and resident interviews were conducted.
Report Facts
Resident rooms toured: 30
Resident records reviewed: 10
Residents interviewed: 5
Water temperature range: 107.6
Water temperature range: 119.3
Fire extinguisher service date: Apr 9, 2024
Emergency disaster drill date: May 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analysts during inspection and participated in facility tour |
| Angel Ascencio | Director of Compliance | Participated in facility tour with Licensing Program Analysts |
| Jessica Saks | Director of Nursing | Participated in facility tour with Licensing Program Analysts |
| Mark Lagasca | Maintenance Technician | Participated in facility tour with Licensing Program Analysts |
| Angela Barutyan | Licensing Program Analyst | Conducted inspection and signed report |
| Kelly Dulek | Licensing Program Analyst | Conducted inspection |
| Trevor Byrne | Licensing Program Analyst | Conducted inspection |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 350
Capacity: 436
Deficiencies: 0
Date: May 4, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility does not ensure an adequate quantity of food to provide to residents in care.
Complaint Details
The complaint alleged inadequate quantity of food for residents, with concerns that certain food items run out on some days. The investigation found this unsubstantiated based on observations and interviews.
Findings
The investigation included observations of dining areas, interviews with residents, staff, and administrators, and review of relevant records. The allegation was found to be unsubstantiated as residents reported sufficient food quantity with alternatives available, and staff confirmed adequate meal preparation based on census and resident preferences.
Report Facts
Residents interviewed: 14
Facility capacity: 436
Facility census: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Interviewed regarding food quantity and complaint |
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 356
Capacity: 436
Deficiencies: 1
Date: Mar 8, 2024
Visit Reason
The visit was an unannounced Case Management Deficiency inspection conducted in conjunction with an initial 10-day complaint investigation to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.
Complaint Details
The visit was conducted as part of an initial 10-day complaint investigation (CC #29-AS-20240305121059). The deficiencies cited were not related to the original complaint but were observed during the investigation.
Findings
The facility failed to have personnel records for two staff members readily available for Licensing review, which is a violation of Title 22, California Code of Regulations, and poses a potential risk to residents in care. Citations were issued and a plan of correction was agreed upon.
Deficiencies (1)
Personnel records for two staff members (S1, S2) were not readily available for Licensing review as required by CCR 87412(g)(1).
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Mar 15, 2024
Personnel files missing: 2
Total personnel files: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst during inspection and acknowledged issues with personnel files |
| Valeria Conway | Licensing Program Analyst | Conducted the unannounced Case Management Deficiency visit |
| Desaree Perera | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 356
Capacity: 436
Deficiencies: 1
Date: Mar 8, 2024
Visit Reason
The visit was an unannounced Case Management Deficiency inspection conducted in conjunction with an initial 10-day complaint investigation to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.
Complaint Details
The visit was triggered by an initial 10-day complaint investigation (CC #29-AS-20240305121059). The deficiency cited was not related to the complaint but was identified during the complaint investigation.
Findings
The facility failed to have personnel records for 2 out of 14 staff members readily available for review by the licensing agency, which is a violation of Title 22 regulations and poses a potential risk to residents in care.
Deficiencies (1)
Failure to maintain and make available personnel records for 2 out of 14 staff members (S1, S2) for licensing review.
Report Facts
Personnel files not available: 2
Facility census: 356
Facility capacity: 436
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst during inspection; discussed personnel file accessibility |
| Valeria Conway | Licensing Program Analyst | Conducted the inspection and issued citations |
| Desaree Perera | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 356
Capacity: 436
Deficiencies: 1
Date: Mar 8, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations including that the facility administrator was not certified, staff were not TB tested, and staff did not have fingerprint clearance and association to the facility.
Complaint Details
The complaint investigation was initiated based on allegations received on 2024-03-05. The allegations included that the facility administrator was not certified, staff were not TB tested, and staff did not have fingerprint clearance and association to the facility. The first two allegations were unsubstantiated, while the third was substantiated.
Findings
The investigation found the allegation that the administrator was not certified to be unsubstantiated as the administrator held a valid certificate. The allegation that staff were not TB tested was also unsubstantiated as all sampled staff had appropriate TB clearances. However, the allegation that staff did not have fingerprint clearance and association to the facility was substantiated, with three staff not having fingerprint association transferred to the facility prior to working, posing an immediate health and safety risk.
Deficiencies (1)
Criminal Record Clearance. Licensee did not ensure 3 out of 3 staff had fingerprint association transferred to the facility prior to working, posing an immediate health and safety risk to residents.
Report Facts
Capacity: 436
Census: 356
Staff with TB clearance: 14
Staff fingerprint clearance deficiency: 3
Plan of Correction Due Date: Mar 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator/Director of Resident Care | Named in findings related to certification and TB clearance |
| Valeria Conway | Licensing Program Analyst | Conducted the complaint investigation |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 347
Capacity: 436
Deficiencies: 1
Date: Mar 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that the facility dishwasher was in disrepair and that facility staff were not following general food service requirements.
Complaint Details
The complaint investigation was triggered by allegations received on 02/29/2024. The dishwasher allegation was unsubstantiated. The allegation that staff were not following general food service requirements was substantiated. Citations were issued and a plan of correction was required by 03/11/2024.
Findings
The allegation regarding the dishwasher being in disrepair was found to be unsubstantiated as the dishwasher was observed functioning properly and no evidence of dirty dishes was found. However, the allegation that staff were not following general food service requirements was substantiated due to uncovered and unlabeled tubs of ice cream in the freezer, posing a potential health and safety risk.
Deficiencies (1)
Staff did not cover and label multiple ice cream tubs in the freezer, violating general food service requirements.
Report Facts
Capacity: 436
Census: 347
Plan of Correction Due Date: Mar 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Conway | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joyce Aquino | Administrator | Facility administrator met during the investigation |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 353
Capacity: 436
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff failed to act appropriately during an incident between two residents and failed to comply with reporting requirements.
Complaint Details
The complaint alleged that Resident #1 slapped Resident #2 in the memory care unit and staff did not intervene or report the incident. The complaint was unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff, residents, and family members, as well as observations, did not corroborate the claims of staff inaction or failure to report the incident.
Report Facts
Capacity: 436
Census: 353
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Interviewed during the investigation regarding the incident and staff reporting |
| Joyce Aquino | Administrator | Met with during the investigation |
| Valeria Conway | Licensing Program Analyst | Conducted the complaint investigation |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 329
Capacity: 436
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff do not ensure hot water is available to residents.
Complaint Details
The complaint alleged that staff did not ensure hot water was available to residents. The allegation was unsubstantiated based on interviews and investigation findings.
Findings
The investigation found that on 12/29/2023, the facility was without hot water due to a scheduled shutoff to install a pressure release valve, with residents informed and provided with alternative water supplies. Interviews with nine residents revealed no immediate or potential concerns regarding hot water availability. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 436
Census: 329
Complaint Control Number: 29-AS-20231229150057
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joyce Aquino | Administrator | Facility administrator met during the investigation |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 327
Capacity: 436
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
The visit was an unannounced Case Management – Incident inspection to follow up on a self-reported incident and suspected abuse involving a staff member reportedly pinching a resident to wake them up.
Complaint Details
The visit was triggered by a complaint of suspected abuse where Staff #1 was reported to have pinched Resident #1's nipples to wake them. The complaint was substantiated based on interviews, witness statements, and photographic evidence of bruising.
Findings
The investigation found that Staff #1 reportedly pinched Resident #1's nipples to awaken them, causing bilateral bruising consistent with pinching. Staff #1 was suspended pending investigation, and remaining staff were retrained on resident personal rights and proper care.
Deficiencies (1)
Failure to ensure residents are free from punishment, humiliation, intimidation, abuse, or other actions interfering with daily living functions such as eating, sleeping, or elimination, evidenced by Staff #1 pinching Resident #1's nipples to awaken them.
Report Facts
Capacity: 436
Census: 327
Plan of Correction Due Date: Jan 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met during inspection and involved in reporting the incident |
| Kelly Dulek | Licensing Program Analyst | Conducted the inspection |
| Kristin Heffernan | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 327
Capacity: 436
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
The visit was an unannounced Case Management – Incident follow-up to a self-reported incident and suspected abuse involving a staff member reportedly pinching a resident to awaken them.
Findings
The investigation confirmed that Staff #1 pinched Resident #1's nipples to awaken them, causing bilateral bruising consistent with pinching. The facility cited a deficiency for violating personal rights by subjecting the resident to punishment and abuse.
Deficiencies (1)
Based on interview, review of witness statements and bruising observed on Resident #1, Staff #1 reportedly pinched Resident #1's nipples to awaken them, posing an immediate health, safety, and personal rights risk.
Report Facts
Capacity: 436
Census: 327
Plan of Correction Due Date: Jan 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst during the visit and involved in incident reporting |
| Kelly Dulek | Licensing Program Analyst | Conducted the unannounced Case Management – Incident visit and authored the report |
| Kristin Heffernan | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 300
Capacity: 436
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate an allegation that the facility is in disrepair due to water issues.
Complaint Details
The complaint alleged that the facility was in disrepair due to water issues. The allegation was found to be unsubstantiated after investigation.
Findings
The investigation found that a water main burst on facility property causing flooding and water damage. The facility responded promptly by arranging repairs, providing water and food to residents, relocating affected residents temporarily, and keeping residents and families informed. The allegation was unsubstantiated as the water main burst was not conclusively due to facility neglect and the facility took timely corrective actions.
Report Facts
Facility capacity: 436
Resident census: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Yee | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joyce Aquino | Administrator | Facility administrator met during the investigation |
| Cassandra Moan | Director of Memory Care | Primary contact during the investigation and interviewed |
| Ray Rosales | Director of Engineering | Contacted private contractor for repairs |
| Kristin Heffernan | Licensing Program Manager | Named in report signature |
Inspection Report
Follow-Up
Census: 294
Capacity: 436
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The inspection was conducted as a follow-up on a self-reported incident from 10/11/2023, where the facility reported that the main water line had burst and the facility water was shut off.
Findings
The Licensing Program Analyst observed gallons of water throughout the facility and resident rooms, as well as catered food. The facility had a sufficient amount of bottled water for resident and staff use, and no immediate health and safety concerns were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with the Licensing Program Analyst during the inspection and toured the facility. |
| Jim Biggs | Executive Director | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Census: 294
Capacity: 436
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The inspection was an unannounced Case Management visit to follow up on a self-reported incident from 10/11/2023, where the facility reported that the main water line had burst and the facility water was shut off.
Findings
The Licensing Program Analyst observed gallons of water throughout the facility and resident rooms, as well as catered food. The facility had a sufficient amount of bottled water for resident and staff use. No immediate health and safety concerns were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Saks | Director of Nursing | Met with the Licensing Program Analyst during the inspection and toured the facility. |
| Joyce Aquino | Administrator | Named as the facility administrator. |
| Jim Biggs | Executive Director | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Census: 287
Capacity: 436
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The visit was an unannounced Case Management - Incident inspection to address a self-reported Unusual Incident/Injury Report (LIC 624) concerning an incident involving Resident #1 and two staff members on 2023-09-17.
Complaint Details
The visit was complaint-related, triggered by a self-reported Unusual Incident/Injury Report involving Resident #1 and staff members S1 and S2. The complaint was substantiated by observations and staff interviews.
Findings
The inspection found that staff member S1 was observed forcefully gripping and sitting Resident #1, which posed an immediate personal rights risk. Resident #1 exhibited unusual behavior and redness/bruises were noted on their arm. The facility was cited for failure to protect residents from abuse and intimidation.
Deficiencies (1)
S1 was observed forcefully gripping and forcefully sitting Resident #1, posing an immediate personal rights risk to residents in care.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst during the visit and provided information about the incident |
| Esther Cortez | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Kasandra Lopez | Licensing Program Manager | Supervisor for the inspection and cited the deficiency |
Inspection Report
Complaint Investigation
Census: 287
Capacity: 436
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The visit was an unannounced Case Management - Incident inspection to address a self-reported Unusual Incident/Injury Report (LIC 624) concerning an incident on 2023-09-17 involving Resident #1 and two staff members.
Complaint Details
The visit was complaint-related, triggered by a self-reported Unusual Incident/Injury Report concerning alleged abuse by staff member S1 against Resident #1. The complaint was substantiated by staff interviews and observations.
Findings
The inspection found that staff member S1 was observed forcefully gripping and sitting Resident #1, causing redness/bruises on the resident's arm. This was determined to be a violation of personal rights regulations, posing an immediate risk to residents. A deficiency was cited accordingly.
Deficiencies (1)
Failure to comply with CCR 87468.1(a)(3) Personal Rights of Residents to be free from punishment, humiliation, intimidation, abuse, or other actions interfering with daily living functions, evidenced by staff S1 forcefully gripping and sitting Resident #1.
Report Facts
Capacity: 436
Census: 287
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Facility administrator interviewed during the visit |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection visit |
| Kasandra Lopez | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 283
Capacity: 436
Deficiencies: 0
Date: Sep 8, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not allowing a resident to leave the facility.
Complaint Details
The complaint alleged that staff were not allowing Resident #1 to leave the facility. The allegation was unsubstantiated after investigation, with no preponderance of evidence to prove the violation occurred.
Findings
The investigation found that Resident #1 was allowed to leave the facility unassisted per physician report, and staff did not restrict residents from leaving. Interviews and record reviews confirmed the resident had left the facility on multiple occasions. There was insufficient evidence to substantiate the allegation, and it was deemed unsubstantiated.
Report Facts
Capacity: 436
Census: 283
Complaint control number: 29-AS-20230901154555
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joyce Aquino | Administrator | Facility administrator interviewed during the investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 280
Capacity: 436
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff mishandled residents' medication and did not administer medication as prescribed.
Complaint Details
The complaint involved allegations that staff mishandled residents’ medication and did not administer medication as prescribed. The allegations were deemed unsubstantiated after investigation. The complaint did not provide names of residents or reporting parties, limiting interviews.
Findings
The investigation found the allegations to be unsubstantiated based on interviews and record reviews. A similar incident had been self-reported and resolved earlier in the year. No evidence supported the current allegations at the time of the investigation.
Report Facts
Facility capacity: 436
Census: 280
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst during investigation and provided information |
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Kasandra Lopez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 274
Capacity: 436
Deficiencies: 0
Date: Aug 9, 2023
Visit Reason
An unannounced case management visit was conducted due to a fire incident in the facility kitchen on 08/08/2023.
Findings
The fire was localized to the kitchen area causing damage to ceiling panels and food, with water damage from sprinklers. There was no structural damage and kitchen equipment remained operational. The kitchen was closed pending clearance from the Department of Public Health. Residents were evacuated safely and provided meals from local restaurants during the kitchen shutdown.
Report Facts
Residents impacted by electricity disruption: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Director of Resident Care Services | Met with Licensing Program Analyst during the visit and provided information about the fire incident and facility response. |
| Christine Yee | Licensing Program Analyst | Conducted the unannounced case management visit and kitchen tour. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 239
Capacity: 436
Deficiencies: 6
Date: Jul 18, 2023
Visit Reason
Licensing Program Analysts conducted an Annual Continuation inspection to evaluate compliance with state regulations following the initial annual inspection conducted on 06/12/2023.
Findings
The inspection found deficiencies related to medication management, including discrepancies in medication pill counts and unsecured medications, as well as food safety issues such as uncovered food items, expired food, unclean kitchen areas, and improper storage of cleaning substances and disinfectant wipes.
Deficiencies (6)
3 out of 5 resident medication pill counts did not concur with documentation, posing an immediate health, safety, or personal rights risk.
Medications were accessible in an unlocked office, posing an immediate health, safety, or personal rights risk.
3 out of 5 centrally stored medication and destruction records were not up to date, posing a potential health, safety, or personal rights risk.
Pies, bread, and vegetables were not properly covered, posing a potential health, safety, or personal rights risk.
Disinfectant wipes were observed in the kitchen area, posing a potential health, safety, or personal rights risk.
Kitchen area was observed unclean and not sanitary, posing a potential health, safety, or personal rights risk.
Report Facts
Resident files reviewed: 10
Staff files reviewed: 10
Staff interviewed: 5
Residents medication reviewed: 5
Medication pill count discrepancies: 3
Medication administration errors: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Facility administrator named in medication audit and plan of correction |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
| Angel Ascencio | Licensing Program Analyst | Licensing evaluator conducting the inspection |
| Ashley Morgan | Licensing Program Analyst | Licensing evaluator conducting the inspection |
Inspection Report
Complaint Investigation
Census: 254
Capacity: 436
Deficiencies: 1
Date: Jul 7, 2023
Visit Reason
The visit was a Case Management - Incident investigation triggered by an incident reported on 07/05/2023 involving a Memory Care resident and staff members, concerning potential resident abuse.
Complaint Details
The visit was complaint-related due to an incident reported involving potential elder abuse. Staff members involved were temporarily suspended pending investigation. The resident was unable to recall the incident. One citation was issued.
Findings
The investigation found that Staff #1 waved a soiled adult brief in close proximity to the resident's face and laughed, which was confirmed by written statements from staff. The resident could not recall the incident. One citation was issued for violation of personal rights regulations.
Deficiencies (1)
Staff member humiliated a resident by waving a soiled adult brief in the resident's face, violating personal rights.
Report Facts
Deficiencies cited: 1
Plan of Correction due date: Jul 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator/Director of Resident Care Services | Met with Licensing Program Analyst during visit and reported the incident |
| Angel Ascencio | Licensing Program Analyst | Conducted the Case Management - Incident visit and authored the report |
| Kristin Heffernan | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 254
Capacity: 436
Deficiencies: 1
Date: Jul 7, 2023
Visit Reason
The visit was a Case Management - Incident investigation triggered by an incident reported on 07/05/2023 involving a Memory Care resident and staff members, concerning potential resident abuse.
Complaint Details
The visit was complaint-related, investigating an incident reported by the Director of Resident Care Services involving alleged abuse. The complaint was substantiated by written statements from staff confirming the incident.
Findings
The investigation found that staff member S1 waved a soiled adult brief in the resident's face, humiliating the resident, which violated the resident's personal rights. Staff members involved were temporarily suspended pending internal investigation. One citation was issued related to this deficiency.
Deficiencies (1)
S1 humiliated Resident #1 by waving a soiled adult brief in the resident's face, violating personal rights.
Report Facts
Citation count: 1
Plan of Correction Due Date: Jul 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator / Director of Resident Care Services | Reported the incident and met with Licensing Program Analyst during the visit. |
| Angel Ascencio | Licensing Program Analyst | Conducted the Case Management - Incident visit and authored the report. |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Annual Inspection
Census: 239
Capacity: 436
Deficiencies: 2
Date: Jun 12, 2023
Visit Reason
The inspection was a required annual unannounced visit to evaluate the facility's compliance with Title 22 regulations.
Findings
The facility was toured inside and out, including resident rooms and common areas, to assess compliance. Deficiencies were found related to water temperature exceeding regulatory limits and cleaning supplies accessible to residents, posing safety risks.
Deficiencies (2)
Water temperature in 5 Memory Care unit rooms and 7 resident rooms in Buildings A, B, and C was observed to be between 121 - 130 degrees Fahrenheit, exceeding the maximum allowed temperature.
Windex and other cleaning supplies were accessible to persons in care, violating storage safety requirements.
Report Facts
Rooms with elevated water temperature: 12
Facility capacity: 436
Current census: 239
Vehicles for transportation: 3
Parking spots: 275
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Director of Resident Care Services | Met with Licensing Program Analysts during entrance interview and involved in deficiency correction |
| Ray Rosales | Maintenance Director | Participated in facility tour with Licensing Program Analysts |
| Angel Ascencio | Licensing Evaluator | Conducted inspection and signed report |
| Ashley Morgan | Licensing Program Analyst | Conducted inspection |
Inspection Report
Annual Inspection
Census: 239
Capacity: 436
Deficiencies: 2
Date: Jun 12, 2023
Visit Reason
The inspection was a required unannounced annual visit to evaluate the facility's compliance with Title 22 regulations.
Findings
The facility was toured inside and out, including resident rooms and common areas, with observations of compliance in most areas. However, deficiencies were cited related to water temperature exceeding safe limits in several resident rooms and accessible cleaning supplies posing a safety risk.
Deficiencies (2)
Water temperature in 5 rooms in the Memory Care unit and 7 resident rooms in Buildings A, B, and C was observed to be between 121 - 130 degrees Fahrenheit, exceeding the maximum allowed temperature.
Windex and other cleaning supplies were accessible to persons in care, violating storage safety requirements.
Report Facts
Rooms with water temperature 121-130°F: 12
Resident water temperature measured low: 1
Vehicles for transportation: 3
Parking spots available: 275
Facility capacity: 436
Census: 239
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Director of Resident Care Services | Met with Licensing Program Analysts during inspection and involved in locking away hazardous items after deficiency cited |
| Ray Rosales | Maintenance Director | Participated in facility tour to ensure compliance |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
| Angel Ascencio | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Complaint Investigation
Census: 236
Capacity: 436
Deficiencies: 1
Date: May 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-03-15 alleging that staff did not ensure the correct medication was dispensed properly to a resident in care.
Complaint Details
Complaint was substantiated. The complaint alleged staff did not ensure correct medication was dispensed properly. Investigation confirmed the medication error and related harm to the resident.
Findings
The investigation found that on 2023-02-13, a resident was administered the wrong medication (nasal spray instead of eye drops) by a new Wellness Nurse who was still in training, causing irritation and burning to the resident's eye and requiring hospital treatment. The facility staff was reactive but failed to ensure proper medication administration. The complaint was substantiated.
Deficiencies (1)
Failure to comply with CCR 87465(c)(2) requiring medication to be given according to physician's directions, evidenced by a medication error where a resident was administered nasal spray solution to the eye causing immediate health and safety risk.
Report Facts
Capacity: 436
Census: 236
Plan of Correction Due Date: May 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Joyce Aquino | Director of Resident Care Services | Interviewed regarding medication error and facility practices |
| Keith Payne | Administrator | Facility administrator involved in exit interview and discussions |
| S1 | Wellness Nurse | Staff member who administered incorrect medication and underwent additional training |
| Kristin Heffernan | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Census: 214
Capacity: 436
Deficiencies: 0
Date: Apr 25, 2023
Visit Reason
An unannounced Case Management visit was conducted to discuss COVID-19 policies and procedures, review infection control areas of concern, and assist with outbreak line list for March/April.
Findings
Two residents were observed in isolation due to COVID-19, with no staff testing positive. The facility's COVID-19 policies and procedures were reviewed, and no citations were issued during the visit.
Report Facts
Residents in isolation: 2
COVID positive residents: 2
Isolation end date: Apr 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst and participated in the visit |
| Angel Ascencio | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Chelsea De Lara | Public Health Nurse | Participated in the meeting regarding COVID-19 policies |
| Camellia Babaie | Physician Specialist | Participated in the meeting regarding COVID-19 policies |
| Jessica Saks | Variel Representative participating in the meeting |
Inspection Report
Census: 214
Capacity: 436
Deficiencies: 0
Date: Apr 25, 2023
Visit Reason
An unannounced Case Management visit was conducted to discuss COVID-19 policies and procedures, review infection control areas of concern, and assist with outbreak line lists for March and April.
Findings
Two residents were observed in isolation due to COVID-19, with no staff testing positive. The facility's COVID-19 policies and procedures were reviewed, and no citations were issued during the visit.
Report Facts
Residents in isolation: 2
COVID positive residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Aquino | Administrator | Met with Licensing Program Analyst during the visit |
| Angel Ascencio | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Chelsea De Lara | Public Health Nurse | Participated in the meeting regarding COVID-19 policies |
| Camellia Babaie | Physician Specialist | Participated in the meeting regarding COVID-19 policies |
| Jessica Saks | Variel Representative participating in the meeting |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 436
Deficiencies: 2
Date: Sep 12, 2022
Visit Reason
The inspection was an unannounced Case Management-Deficiencies visit conducted due to deficiencies observed during the investigation of complaint control #29-AS-20220826125755.
Complaint Details
The visit was triggered by complaint control #29-AS-20220826125755. The complaint involved concerns about Resident #2's care needs not being communicated or discovered until admission. The complaint was substantiated as deficiencies were cited.
Findings
The facility did not accurately reflect Resident #2's extensive care needs in the medical assessment and care plan, which poses a potential health and safety risk. Specifically, R2 requires more assistance than documented, and there were inconsistencies regarding R2's ability to feed themselves.
Deficiencies (2)
The pre-admission appraisal was not updated as frequently as necessary to note significant changes and keep the appraisal accurate, resulting in R2's care needs not being accurately reflected.
The licensee did not obtain an updated medical assessment reflecting R2's capacity for activities of daily living care.
Report Facts
Capacity: 436
Census: 89
Plan of Correction Due Date: Sep 16, 2022
Plan of Correction Due Date: Sep 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Keith Payne | Administrator | Facility administrator involved in the inspection and agreed to corrective actions |
| Jeralyn Ann Pfannenstiel | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 436
Deficiencies: 2
Date: Sep 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints alleging inappropriate handling of a resident resulting in bruising, failure to fulfill reporting requirements, and staff not being up to date regarding resident care needs.
Complaint Details
The complaint investigation was substantiated for allegations that staff handled a resident inappropriately causing bruising and that the facility did not fulfill reporting requirements. The allegation that staff were not up to date regarding resident care needs was unsubstantiated.
Findings
The investigation substantiated that staff handled a resident inappropriately causing bruising and that the facility failed to submit an unusual incident report regarding the bruising. The allegation that staff were not up to date regarding resident care needs was unsubstantiated. Deficiencies were cited related to resident rights and reporting requirements.
Deficiencies (2)
Staff handled Resident #1 in a manner which resulted in bruises, posing an immediate health and safety risk to residents in care.
Facility failed to submit an unusual incident report regarding the bruises observed on Resident #1, posing a potential health and safety risk.
Report Facts
Capacity: 436
Census: 89
Staff interviewed: 12
Plan of Correction Due Date: Sep 14, 2022
Plan of Correction Due Date: Sep 16, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Keith Payne | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 436
Deficiencies: 2
Date: Sep 12, 2022
Visit Reason
The inspection visit was conducted due to deficiencies observed during the investigation of complaint control #29-AS-20220826125755.
Complaint Details
The visit was triggered by a complaint investigation under control #29-AS-20220826125755. The complaint involved concerns about Resident #2's care needs not being properly communicated or documented.
Findings
The facility did not accurately reflect Resident #2's extensive care needs in the medical assessment and care plan, posing a potential health and safety risk. Specifically, R2's care plan underestimated the assistance required for activities of daily living and transfers.
Deficiencies (2)
Pre-admission appraisal was not updated in writing as frequently as necessary to note significant changes and keep the appraisal accurate, resulting in R2's care needs not being accurately reflected.
Medical assessment was not updated to reflect R2's capacity for activities of daily living care, posing a potential health and safety risk.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection. |
| Keith Payne | Administrator | Facility administrator met during the inspection. |
Inspection Report
Original Licensing
Capacity: 436
Deficiencies: 0
Date: Jun 29, 2022
Visit Reason
This is a pre-licensing visit for a new facility, Variel of Woodland Hills, to evaluate compliance and readiness for licensing including a dementia program and hospice waiver.
Findings
The facility was found to be in compliance with Title 22 regulations at the time of the visit. The physical plant, safety systems, amenities, infection control measures, and medication storage were all inspected and found adequate. The facility is not yet operational and has a census of zero.
Report Facts
Capacity: 436
Census: 0
Maximum bedridden residents: 20
Hospice waiver capacity: 50
Number of units: 336
Number of vehicles: 3
Parking spots: 275
Water temperature range: 106
Water temperature range: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Payne | Executive Director | Met with Licensing Program Analysts during pre-licensing visit |
| Elsie Campos | Licensing Evaluator | Conducted the facility evaluation and signed the report |
| Jeralyn Ann Pfannenstiel | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Original Licensing
Capacity: 436
Deficiencies: 0
Date: Jun 29, 2022
Visit Reason
This is a pre-licensing visit for a new facility, Variel of Woodland Hills, to evaluate compliance and readiness for licensing including a dementia program and hospice waiver.
Findings
The facility was found to be in compliance with Title 22 regulations at the time of the visit. The physical plant, safety systems, amenities, infection control measures, and medication storage were all observed to meet regulatory requirements.
Report Facts
Capacity: 436
Census: 0
Maximum bedridden residents: 20
Hospice waiver capacity: 50
Units: 336
Water temperature range: 106-114
Passenger capacity: 17
Passenger capacity: 6
Parking spots: 275
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Payne | Executive Director | Met with Licensing Program Analysts during pre-licensing visit |
| Elsie Campos | Licensing Program Analyst | Conducted the pre-licensing visit and signed the report |
| Ashley Smith | Licensing Program Analyst | Participated in the pre-licensing visit |
| Emily Peraldi | Licensing Program Analyst | Participated in the pre-licensing visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Original Licensing
Capacity: 436
Deficiencies: 0
Date: Feb 17, 2022
Visit Reason
Initial licensing evaluation conducted via telephone call with the Community Care Licensing analyst to verify applicant and administrator understanding of Title 22 and facility operation requirements.
Findings
The applicant and administrator successfully completed the COMP II component, confirming understanding of licensing requirements including staff qualifications, training, medication management, and grievance procedures. No clients were in care at the time of the evaluation.
Report Facts
Capacity: 436
Census: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Payne | Administrator | Named as applicant and administrator participating in COMP II |
| Shannon Betker | Licensing Evaluator | Analyst conducting the COMP II evaluation |
| Jude De La Concepcion | Supervisor | Supervisor named in the report |
Inspection Report
Original Licensing
Capacity: 436
Deficiencies: 0
Date: Feb 17, 2022
Visit Reason
The visit was an initial licensing evaluation conducted via telephone call to assess the applicant and administrator's understanding of Title 22 and facility operation requirements.
Findings
The applicant and administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, staff qualifications, training, grievances, medication management, and application document review.
Report Facts
Capacity: 436
Census: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Payne | Administrator | Participant in COMP II licensing evaluation |
| Shannon Betker | Analyst | CAB analyst conducting licensing evaluation |
| Jude De La Concepcion | Licensing Program Manager | Named in report as Licensing Program Manager |
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