Most inspections found no deficiencies, with several complaint investigations deemed unsubstantiated, reflecting generally good compliance over time. However, some complaint investigations substantiated issues related to resident dignity, cleanliness, and safety, including staff yelling at a resident in August and October 2024 and failure to monitor a resident at risk for elopement in May 2025. The facility also received citations for not documenting resident falls and for unsanitary conditions in a resident’s room as recently as July and September 2025. The most recent report from September 26, 2025, identified a deficiency for failure to report two undocumented fall incidents but did not note any immediate jeopardy or fines. While some issues have persisted, the facility has shown periods of compliance, with no clear pattern of worsening or improvement.
Deficiencies (last 5 years)
Deficiencies (over 5 years)2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than California average
California average: 4 deficiencies/year
Deficiencies per year
43210
2021
2022
2023
2024
2025
Census
Latest occupancy rate85% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
The visit was an unannounced Case Management – Deficiency inspection conducted in connection with Complaint No. 31-AS-20241213122323 to investigate alleged deficiencies at the facility.
Findings
The Licensing Program Analyst observed that Resident 1 had multiple falls, including two incidents with no documentation or unusual incident reports, indicating a failure to meet regulatory reporting requirements. A citation was issued to the facility.
Complaint Details
The visit was conducted in response to Complaint No. 31-AS-20241213122323. The complaint was substantiated by the finding of undocumented fall incidents for Resident 1.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to submit a written report to the licensing agency and responsible person within seven days of any incident threatening the welfare, safety, or health of any resident, evidenced by two undocumented fall incidents for Resident 1.
Type B
Report Facts
Capacity: 194Census: 164Deficiency count: 1Plan of Correction Due Date: Oct 3, 2025
Employees Mentioned
Name
Title
Context
Mariana Agban
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Mary Okhata
Assisted Living Director
Facility representative met during the inspection and advised regarding regulatory requirements
Thomas Rekowski
Administrator/Director
Named as facility administrator/director
Troy Agard
Licensing Program Manager
Named as Licensing Program Manager overseeing the inspection
The visit was conducted as a case management-deficiencies inspection in conjunction with a complaint (31-AS-20250721161857).
Findings
The licensing program analyst observed R1's room to be dirty, including stained carpet, unclean bedsheets on the floor, an unclean toilet, and clutter in the kitchen area. A citation was issued due to these deficiencies posing a potential health and safety risk to residents.
Complaint Details
The visit was conducted in conjunction with complaint number 31-AS-20250721161857.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
The facility was not clean, safe, sanitary, and in good repair as evidenced by R1's dirty room with stained carpet, storage boxes, unclean toilet, and unclean bedsheets on the floor.
Type B
Report Facts
Capacity: 194Census: 167Plan of Correction Due Date: Aug 5, 2025
Employees Mentioned
Name
Title
Context
Mariana Agban
Licensing Program Analyst
Conducted the case management-deficiencies visit and signed the report.
Eva Miller
Licensing Program Manager
Named in the report as Licensing Program Manager.
Thomas Rekowski
Administrator/Director
Facility Administrator/Director named in the report.
An unannounced continuation of the annual inspection was conducted to review compliance with Title 22 regulations and assess the facility's operations.
Findings
During the visit, the facility was found to be in compliance with Title 22 regulations with no immediate health and safety risks observed. The annual inspection was not completed due to time constraints, and a follow-up visit was planned.
Employees Mentioned
Name
Title
Context
Mary Rose Okahata
Assisted Living Director
Met with Licensing Program Analyst during inspection
Mariana Agban
Licensing Program Analyst
Conducted the unannounced continuation of the annual inspection
The visit was an unannounced annual inspection conducted to evaluate compliance with licensing requirements for the assisted living facility.
Findings
The facility was observed to be clean, properly furnished, and compliant with Title 22 regulations. No immediate health and safety risks were noted, but the annual inspection was not completed due to time constraints, and a follow-up visit was planned.
Report Facts
Residents reviewed: 2Fire drill date: May 17, 2025Fire extinguisher service date: Jul 12, 2025Facility temperature: 75Hot water temperature: 105.1
Employees Mentioned
Name
Title
Context
Mary Rose Okahata
Assisted Living Director
Met with Licensing Program Analyst during inspection
The inspection was conducted as an unannounced case management visit following a Special Incident Report regarding a resident (R1) being AWOL and concerns about resident safety and supervision.
Findings
The facility failed to ensure that Resident #1 had an auditory device or staff alert feature to monitor exits on exterior doors and perimeter fence gates, posing an immediate risk to resident safety. The resident was found outside unsupervised, despite physician orders restricting unsupervised exits due to dementia.
Complaint Details
The visit was triggered by a complaint and Special Incident Report received on May 15, 2025, regarding Resident #1 being AWOL. The resident was found outside the facility unsupervised, which violated physician orders due to dementia or cognitive decline.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to ensure that Resident #1 has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to residents at risk for elopement.
Type A
Report Facts
Capacity: 194Census: 167Deficiencies cited: 1Plan of Correction Due Date: May 22, 2025
Employees Mentioned
Name
Title
Context
Mariana Agban
Licensing Program Analyst
Conducted the unannounced case management visit and authored the report
Mary Okhata
Assisted Living Director
Met with Licensing Program Analyst during the visit and involved in resident care and findings
Unannounced visit/investigation of a complaint received on 2024-08-09 regarding allegations that facility staff yelled at a resident and did not treat residents with dignity and respect.
Findings
The complaint was substantiated after interviews with 15 residents and a physical tour to ensure health and safety compliance with Title 22 Regulations. The plan of correction was cleared as of 2024-08-19.
Complaint Details
The complaint was substantiated. The investigation included interviews and a physical plan tour. The plan of correction was cleared as of 2024-08-19.
Deficiencies (2)
Description
Facility staff yelled at resident in care
Facility staff did not treat residents with dignity and respect
Report Facts
Residents interviewed: 15
Employees Mentioned
Name
Title
Context
Thomas Rekowski
Executive Director
Met with during the investigation and named in the report
An unannounced complaint investigation was conducted in response to an allegation that the facility was not clean, safe, sanitary, and in good repair, specifically citing mold and leak issues in various areas.
Findings
The Licensing Program Analyst conducted a physical tour and interviews with staff and residents, finding no evidence of mold or leaks in the alleged areas. The allegation was deemed unsubstantiated based on observations and interviews.
Complaint Details
The complaint was unsubstantiated after investigation. Interviews with the Assisted Living Director, staff, and residents denied the allegations. Maintenance work orders are placed promptly when disrepair is noticed.
An unannounced continuation of the annual inspection was conducted to review resident and personnel files and conduct interviews.
Findings
No deficiencies were observed during the visit pursuant to Title 22 Division 6 of the CA Code of Regulations. An exit interview was conducted and a copy of the report was issued.
Employees Mentioned
Name
Title
Context
Mariana Agban
Licensing Program Analyst
Conducted the unannounced continuation of the annual inspection.
Thomas Rekowski
Administrator/Director
Met with Licensing Program Analyst during the inspection.
The inspection was an unannounced annual inspection conducted to evaluate compliance with Title 22 regulations at the facility.
Findings
The facility was found to be in compliance with Title 22 regulations with no immediate health and safety risks observed. Various areas including common areas, bathrooms, laundry, medication room, fire safety equipment, kitchen, bedrooms, and outside areas were toured and found to be properly maintained and equipped.
Report Facts
Facility capacity: 194Resident census: 154
Employees Mentioned
Name
Title
Context
Mary Rose Okahata
Director of Assisted Living
Met with Licensing Program Analyst during inspection
An unannounced complaint investigation visit was conducted in response to allegations that facility staff yelled at a resident and did not treat residents with dignity and respect.
Findings
The investigation substantiated that staff yelled at a resident regarding the resident's pet and humiliated the resident in front of others, posing a potential health and safety risk.
Complaint Details
The complaint investigation was substantiated based on interviews with staff and observations that facility staff yelled at resident R1 about R1's pet and humiliated R1 in front of others.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
80072(a)(1) Personal Rights (a)...each client shall have personal rights which include...(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by: Based on interviews R1 was subjected to infliction of humiliation by facility staff. This poses a potential health and safety risk to the resident.
Type B
Report Facts
Capacity: 194Census: 150Staff confirmation count: 6Staff interviewed: 10Plan of Correction Due Date: Aug 22, 2024
The inspection was an unannounced complaint investigation visit triggered by allegations that staff made financial decisions on behalf of a resident without proper authorization, and that staff turned off the resident's telephone and Wi-Fi services.
Findings
The investigation found the complaint to be unfounded, meaning the allegations were false, could not have happened, or were without a reasonable basis. The resident involved lives in the independent living section, which is not under the department's jurisdiction.
Complaint Details
The complaint was investigated and found to be unfounded. The allegations included unauthorized financial decisions by staff and disconnection of resident's telephone and Wi-Fi services. The complaint was dismissed after review.
Report Facts
Capacity: 194Census: 222
Employees Mentioned
Name
Title
Context
Mariana Agban
Licensing Program Analyst
Conducted the complaint investigation
Thomas Rekowski
Executive Director
Facility representative met during the investigation
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with regulatory standards.
Findings
The inspection found all common areas, bathrooms, laundry, medication room, fire and carbon monoxide alarms, kitchen, bedrooms, and outside areas to be in compliance with no deficiencies issued. The facility was clean, properly furnished, and maintained appropriate safety measures.
Employees Mentioned
Name
Title
Context
Mary Rose Okahata
Director of Assisted Living
Met with Licensing Program Analyst during the inspection.
The inspection was conducted as a complaint investigation regarding an allegation that staff did not address a resident's change in medical condition.
Findings
The investigation found insufficient evidence to corroborate the allegation. The resident had been out of the facility for surgery and rehabilitation, and the infection occurred at the rehabilitation center, not the facility. Therefore, the complaint was deemed unfounded.
Complaint Details
The complaint alleged that staff did not address a resident's change in medical condition. After investigation including interviews and record review, the allegation was found to be unfounded.
Report Facts
Facility capacity: 194Census: 98
Employees Mentioned
Name
Title
Context
Michael Cava
Licensing Program Analyst
Conducted the complaint investigation
Eva Miller
Licensing Program Manager
Named in report as Licensing Program Manager
Maryrose Okahata
Director of Assisted Living
Interviewed during investigation regarding the allegation
The visit was an unannounced complaint investigation to determine if staff failed to address a resident's change in medical condition, specifically regarding a wound care issue.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff failed to address the resident's medical condition. The resident had been transferred out of the facility prior to the alleged neglect, and the infection occurred at a rehabilitation center, not at the facility.
Complaint Details
The complaint alleged that staff did not address a resident's change in medical condition related to wound care. The allegation was deemed unsubstantiated after interviews and record review.
Report Facts
Capacity: 194Census: 114
Employees Mentioned
Name
Title
Context
Maryrose Okahata
Director of Assisted Living
Met during investigation and advised of the allegation
An unannounced complaint investigation was conducted regarding an allegation that facility staff administered medication without reason.
Findings
The investigation found that the medication Ativan was prescribed under hospice care for a resident with terminal illness and chronic conditions, and was administered and documented according to physician and hospice orders. There was no supporting information or corroborating evidence for the allegation, which was deemed unsubstantiated.
Complaint Details
The allegation that facility staff administered medication without reason was investigated and found to be unsubstantiated based on record reviews and interviews.
Report Facts
Capacity: 125Census: 78
Employees Mentioned
Name
Title
Context
Tuesday Cabiness
Licensing Program Analyst
Conducted the complaint investigation and delivered final findings
Bradlee Ann Foerschner
Administrator / Executive Director
Facility administrator mentioned in relation to the investigation
Tyler Barnes
Operation Specialist
Met with Licensing Program Analyst during the investigation
The visit was an unannounced complaint investigation conducted in response to an allegation that a resident sustained a pressure injury while in care at the facility.
Findings
The investigation found that the resident developed a skin tear while in the facility and received treatment from hospice nurses and facility staff. There was no supporting evidence that the skin condition was due to neglect or inadequate care by the facility staff. Therefore, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that resident #1 sustained a pressure injury while in care. The investigation included review of medical and hospice records and interviews with complainant, facility staff, and witnesses. The allegation was found unsubstantiated.
Report Facts
Capacity: 125Census: 78
Employees Mentioned
Name
Title
Context
Tuesday Cabiness
Licensing Program Analyst
Conducted the complaint investigation and delivered final findings
Bradlee Ann Foerschner
Administrator / Executive Director
Facility administrator mentioned in the report
Tyler Barnes
Operation Specialist
Met with Licensing Program Analyst during the investigation
The visit was an unannounced complaint investigation regarding an allegation of illegal eviction of a resident.
Findings
The investigation found that the allegation of illegal eviction was unsubstantiated. Documentation and interviews showed that the resident and facility agreed on move-out dates, with a final move-out on 12/02/2021, and the facility settled with the resident.
Complaint Details
The complaint alleged an illegal eviction of resident #1. The investigation included virtual and in-person visits, interviews, and document review. The allegation was found unsubstantiated based on agreements and documentation.
Report Facts
Facility capacity: 125Census: 95
Employees Mentioned
Name
Title
Context
Tuesday Cabiness
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
The visit was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements and infection control practices.
Findings
The inspection found the facility to be in compliance with infection control measures, proper maintenance of common and outdoor areas, and adequate food supplies. No deficiencies were issued during the visit.
Report Facts
Requested capacity change: 194Fee amount: 25
Employees Mentioned
Name
Title
Context
Bradlee Ann Foerschner
Administrator
Met with Licensing Program Analyst during inspection and involved in capacity change request.
Melissa Ruiz
Licensing Program Analyst
Conducted the inspection visit and authored the report.
The visit was an unannounced complaint investigation conducted in response to allegations received on 10/29/2019 concerning resident care, medication administration, observation of condition changes, and reporting to responsible parties.
Findings
All allegations were investigated and deemed unsubstantiated based on staff interviews, resident documentation, medication records, and progress notes indicating appropriate care, medication administration, observation, and reporting.
Complaint Details
The complaint involved four allegations: 1) Resident sustained multiple falls and injury due to lack of care and supervision; 2) Facility failed to administer medication as prescribed; 3) Facility failed to observe resident's change in condition; 4) Facility failed to report resident's change in condition to responsible party. All allegations were found unsubstantiated.
Report Facts
Complaint Control Number: 31Facility Capacity: 125Census: 95
Employees Mentioned
Name
Title
Context
Patrick Shanahan
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Nichelle Gillyard
Licensing Program Manager
Named in report as Licensing Program Manager
Helen Lee
Assistant Executive Director
Met with the Licensing Program Analyst during the investigation
An unannounced case management visit was conducted to tour the facility, interview staff and residents, and assess the situation related to a NORO virus outbreak.
Findings
The facility was found to be generally clean and orderly with residents feeling safe and satisfied. Three residents were hospitalized due to the outbreak, six were isolated in their apartments with proper PPE and signage. No health and safety hazards were observed during the visit.
Report Facts
Residents hospitalized due to outbreak: 3Residents in isolation: 6Residents interviewed: 9Apartments visited: 7
Employees Mentioned
Name
Title
Context
Tristan Garcia
Zest Director
Met during visit and provided information about outbreak and facility conditions
Bradlee Ann Foerschner
Administrator / Executive Director
Reported outbreak to public health and communicated with Licensing Program Analyst
The inspection was an unannounced infection control inspection conducted as part of the required 1-year visit to evaluate compliance with COVID-19 protocols and general infection control measures.
Findings
The facility was found to have effective infection control procedures in place, including vaccination documentation, mask usage, cleaning protocols, and COVID-19 screening and testing policies. No active or past COVID-19 cases were reported, and PPE supplies were adequate and properly stored.
The inspection was an unannounced complaint investigation visit triggered by allegations received on 01/25/2021 regarding facility conditions including presence of cockroaches, dirty resident room, mold, and improper chemical storage.
Findings
All four allegations were substantiated based on interviews, virtual tours, photographs, and document reviews. The facility was found to have cockroaches, dirty resident rooms, mold, and improperly stored chemicals, posing potential health and safety risks to residents.
Complaint Details
The complaint investigation was substantiated. Allegations included presence of cockroaches, dirty resident room, mold, and improper chemical storage. The findings confirmed these issues, posing health and safety risks.
Deficiencies (4)
Description
Facility had cockroaches in resident #1's room including alive and dead roaches on bedroom and bathroom floors and in wall cracks.
Resident #1's room was dirty with dirty floors, soiled carpet, stained walls, drippings of unknown dried substance, dirt and mold under shower chair, and spider webs in windows.
Facility had mold in resident #1's bathroom cracks, floor, and underneath shower chair.
Resident #1 had improperly stored chemicals (can of RAID and bug repellant) in room.
Report Facts
Facility capacity: 125Census: 90Plan of Correction due date: 6
Employees Mentioned
Name
Title
Context
Tuesday Cabiness
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Bradlee Ann Foerschner
Executive Director
Facility administrator met during inspection and named in findings
Cassandra Harris
Licensing Program Manager
Oversaw licensing program and named in report
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