Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
90% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 174
Capacity: 194
Deficiencies: 0
Date: Dec 5, 2025
Visit Reason
The inspection was an unannounced Case Management - Incident visit to follow up on the Death Report for Resident #1 (R1) dated 11/20/2025.
Complaint Details
Investigation was initiated due to a death report for Resident #1 on 11/20/2025. The investigation remains open pending further information.
Findings
The Licensing Program Analyst conducted interviews with staff, R1's family member, and reviewed records. The investigation could not be closed at this time pending additional information.
Report Facts
Capacity: 194
Census: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Okhata | Assisted Living Director | Met with Licensing Program Analyst during inspection |
| Mariana Agban | Licensing Program Analyst | Conducted the inspection and investigation |
| Nichelle Gillyard | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 194
Deficiencies: 1
Date: Sep 26, 2025
Visit Reason
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.
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.
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.
Deficiencies (1)
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.
Report Facts
Capacity: 194
Census: 164
Deficiency count: 1
Plan 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 |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 194
Deficiencies: 1
Date: Sep 26, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-12-13 regarding staff not properly addressing a resident's multiple falls at the facility.
Complaint Details
The complaint was substantiated based on the investigation. Staff failed to properly address multiple falls of Resident #1, who had 18 falls in 2024. The allegation remains substantiated after additional interviews and a physical plan tour.
Findings
The complaint was substantiated. The facility staff did not properly address multiple falls at the facility. Resident #1 was identified as a fall risk with 18 fall incidents from January to December 2024, but the service plan did not address actions to prevent future falls.
Deficiencies (1)
Facility staff did not properly address resident's multiple falls at facility.
Report Facts
Fall incidents: 18
Census: 164
Total capacity: 194
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation visit |
| Mary Okhata | Assisted Living Director | Met with the evaluator during the investigation |
| Thomas Rekowski | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 194
Deficiencies: 1
Date: Sep 26, 2025
Visit Reason
The inspection was an unannounced Case Management - Deficiency visit conducted in connection with Complaint No. 31-AS-20241213122323 to investigate regulatory compliance related to resident care.
Complaint Details
The visit was complaint-related, connected to Complaint No. 31-AS-20241213122323. The deficiency was substantiated as the facility failed to document two fall incidents for Resident 1, posing a potential health and safety risk.
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.
Deficiencies (1)
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, specifically two undocumented fall incidents involving Resident 1.
Report Facts
Deficiencies cited: 1
Capacity: 194
Census: 164
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Okhata | Assisted Living Director | Met during inspection and advised regarding regulatory reporting requirements |
| Mariana Agban | Licensing Program Analyst | Conducted the inspection and issued citation |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 194
Deficiencies: 1
Date: Sep 26, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2024-12-13 regarding staff not properly addressing a resident's multiple falls at the facility.
Complaint Details
The complaint was substantiated based on investigation findings. The allegation that staff did not properly address resident's multiple falls was confirmed.
Findings
The complaint was substantiated. Facility staff did not properly address multiple falls at the facility. Resident #1 was identified as a fall risk but the service plan did not address actions to prevent future falls. Resident #1 had 18 fall incidents from January to December 2024.
Deficiencies (1)
Staff did not properly address resident's multiple falls at facility.
Report Facts
Fall incidents: 18
Census: 164
Total capacity: 194
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation visit |
| Mary Okhata | Assisted Living Director | Met with Licensing Program Analyst during investigation |
| Thomas Rekowski | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 194
Deficiencies: 1
Date: Jul 31, 2025
Visit Reason
The visit was conducted as a case management-deficiencies inspection in conjunction with a complaint (31-AS-20250721161857).
Complaint Details
The visit was conducted in conjunction with complaint number 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.
Deficiencies (1)
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.
Report Facts
Capacity: 194
Census: 167
Plan 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. |
| Mary Okhta | Met with during the inspection visit. |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 194
Deficiencies: 1
Date: Jul 31, 2025
Visit Reason
The inspection was conducted as a case management visit related to complaint 31-AS-20250721161857 to assess deficiencies at the facility.
Complaint Details
The visit was conducted in conjunction with complaint 31-AS-20250721161857. The report does not explicitly state substantiation status.
Findings
The licensing program analyst observed that Resident 1's room was dirty, with stained carpet, unclean bedsheets on the floor, an unclean toilet, and clutter in the kitchen area, posing a potential health and safety risk.
Deficiencies (1)
The facility was not clean, safe, sanitary, and in good repair as evidenced by a dirty resident room with stained carpet, storage boxes, unclean toilet, and unclean bedsheets on the floor.
Report Facts
Census: 167
Total Capacity: 194
Plan of Correction Due Date: Aug 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mariana Agban | Licensing Program Analyst | Conducted the case management deficiencies visit and observed the cited deficiencies |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 166
Capacity: 194
Deficiencies: 0
Date: Jul 21, 2025
Visit Reason
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 |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 166
Capacity: 194
Deficiencies: 0
Date: Jul 16, 2025
Visit Reason
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: 2
Fire drill date: May 17, 2025
Fire extinguisher service date: Jul 12, 2025
Facility temperature: 75
Hot water temperature: 105.1
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 inspection |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 194
Deficiencies: 1
Date: May 21, 2025
Visit Reason
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.
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.
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.
Deficiencies (1)
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.
Report Facts
Capacity: 194
Census: 167
Deficiencies cited: 1
Plan 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 |
| Thomas Rekowski | Administrator/Director | Facility Administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 194
Deficiencies: 1
Date: Apr 4, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that staff did not make resident records available to a resident's authorized representative.
Complaint Details
The complaint alleged that staff did not make Resident#1's records available to the authorized representative despite a written request sent on 02/24/2025. The allegation was substantiated after investigation.
Findings
The allegation was substantiated as staff delayed providing requested resident records to the authorized representative due to technical issues, with records eventually provided on 04/03/2025. A citation was issued and appeal rights were given.
Deficiencies (1)
Failure to provide prompt access to review all resident records and to purchase photocopies within two business days as required.
Report Facts
Census: 160
Total Capacity: 194
Deficiencies cited: 1
Plan of Correction Due Date: Apr 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation |
| Thomas Rekowski | Executive Director | Facility administrator met during investigation |
| Eva Miller | Supervisor | Supervisor overseeing the investigation |
| Staff 1 | Staff member involved in delay of providing records |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 194
Deficiencies: 1
Date: Dec 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not properly address a resident's multiple falls and failed to provide proper medical attention to a resident.
Complaint Details
The complaint investigation was substantiated for failure to properly address resident's multiple falls. The allegation that staff did not properly provide medical attention was unsubstantiated.
Findings
The investigation substantiated that staff failed to properly address Resident #1's multiple falls, with the facility's care plan insufficiently addressing the fall risk. The allegation regarding failure to provide medical attention was unsubstantiated as records showed medical attention was provided and the resident was transferred to the hospital when needed.
Deficiencies (1)
Basic Services: Facility's care plan was not sufficient in addressing Resident #1 as a fall risk, posing a potential threat to the resident in care.
Report Facts
Capacity: 194
Census: 158
Plan of Correction Due Date: Jan 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mariana Agban | Licensing Evaluator | Conducted the complaint investigation |
| Thomas Rekowski | Administrator | Facility administrator named in the report |
| Mary Okhata | Met with during the inspection | |
| Eva Miller | Supervisor | Supervisor overseeing the investigation |
| Michael Cava | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 194
Deficiencies: 2
Date: Oct 3, 2024
Visit Reason
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.
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.
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.
Deficiencies (2)
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 |
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 194
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
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.
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.
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.
Report Facts
Capacity: 194
Census: 153
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
| Thomas Rekowski | Administrator | Facility Administrator |
| Mary Okahata | Met with during the inspection |
Inspection Report
Annual Inspection
Census: 154
Capacity: 194
Deficiencies: 0
Date: Aug 30, 2024
Visit Reason
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. |
Inspection Report
Annual Inspection
Census: 154
Capacity: 194
Deficiencies: 0
Date: Aug 28, 2024
Visit Reason
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: 194
Resident census: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Rose Okahata | Director of Assisted Living | Met with Licensing Program Analyst during inspection |
| Mariana Agban | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 194
Deficiencies: 1
Date: Aug 15, 2024
Visit Reason
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.
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.
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.
Deficiencies (1)
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.
Report Facts
Capacity: 194
Census: 150
Staff confirmation count: 6
Staff interviewed: 10
Plan of Correction Due Date: Aug 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Rekowski | Executive Director | Met with during the investigation |
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 222
Capacity: 194
Deficiencies: 0
Date: May 23, 2024
Visit Reason
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.
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.
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.
Report Facts
Capacity: 194
Census: 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 |
| Eva Miller | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 122
Capacity: 194
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
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. |
| Mariana Agban | Licensing Program Analyst | Conducted the unannounced annual inspection. |
| Eva Miller | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 194
Deficiencies: 0
Date: May 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that staff did not address a resident's change in medical condition.
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.
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.
Report Facts
Facility capacity: 194
Census: 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 |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 194
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
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.
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.
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.
Report Facts
Capacity: 194
Census: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maryrose Okahata | Director of Assisted Living | Met during investigation and advised of the allegation |
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation |
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 125
Deficiencies: 0
Date: Jul 11, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that facility staff administered medication without reason.
Complaint Details
The allegation that facility staff administered medication without reason was investigated and found to be unsubstantiated based on record reviews and interviews.
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.
Report Facts
Capacity: 125
Census: 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 |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 125
Deficiencies: 0
Date: Jul 11, 2022
Visit Reason
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.
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.
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.
Report Facts
Capacity: 125
Census: 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 |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 125
Deficiencies: 0
Date: Jun 20, 2022
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation of illegal eviction of a 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.
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.
Report Facts
Facility capacity: 125
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bradlee Ann Foerschner | Executive Director | Facility representative met during investigation |
| Cassandra Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 92
Capacity: 125
Deficiencies: 0
Date: Jun 2, 2022
Visit Reason
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: 194
Fee 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. |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 125
Deficiencies: 0
Date: Dec 15, 2021
Visit Reason
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.
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.
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.
Report Facts
Complaint Control Number: 31
Facility Capacity: 125
Census: 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 |
| Kevan Sidney | Administrator | Facility Administrator named in the report |
Inspection Report
Census: 91
Capacity: 125
Deficiencies: 0
Date: Dec 11, 2021
Visit Reason
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: 3
Residents in isolation: 6
Residents interviewed: 9
Apartments 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 |
| Gary Tan | Licensing Program Analyst | Conducted the unannounced case management visit |
| Naira Margaryan | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 90
Capacity: 125
Deficiencies: 0
Date: Jun 15, 2021
Visit Reason
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.
Report Facts
Vaccination rate - residents: 99.1
Vaccination rate - staff: 73
Staff surveillance testing rate: 25
Sick leave policy hours - full time: 80
Sick leave policy hours - part time: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradlee Ann Foerschner | Executive Director | Facility administrator and primary contact during inspection |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the infection control inspection |
| Cassandra Harris | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 125
Deficiencies: 4
Date: Jun 15, 2021
Visit Reason
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.
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.
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.
Deficiencies (4)
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: 125
Census: 90
Plan 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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