Inspection Reports for The Village At Sherman Oaks
5450 Vesper Ave, Sherman Oaks, CA 91411, United States, CA, 91411
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated. The most recent report from October 1, 2025, cited one deficiency for failure to assist a resident with self-administered medication over a period of time, posing a potential health risk. Previous deficiencies included issues with timely written notice of rate increases and incomplete medical assessments for residents with dementia, while other concerns such as medication documentation and environmental repairs were minor and isolated. There was one substantiated complaint in March 2023 involving failure to obtain timely medical attention after a resident’s fall, but no fines, license suspensions, or enforcement actions were noted in the available reports. Overall, the facility’s record shows mostly compliance with some improvement after earlier issues, though medication management and resident rights remain areas to watch.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
84% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 151
Capacity: 179
Deficiencies: 1
Oct 1, 2025
Visit Reason
The visit was an unannounced Case Management follow-up on a self-reported incident involving missed medication administration that occurred on 2025-09-17.
Findings
The facility failed to administer a prescribed medication (Olanzapine) to Resident #1 between 2025-08-04 and 2025-09-16, posing a potential health risk. The facility conducted in-service training and coordinated with the hospice company and family to prevent future delays. A Type B deficiency was cited for this violation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist Resident #1 with self-administered medication Olanzapine between 08/04/2025 and 09/16/2025, posing a potential health risk. | Type B |
Report Facts
Census: 151
Total Capacity: 179
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Hartnett | Executive Director | Met with Licensing Program Analyst during inspection and provided documentation |
| Trevor Byrne | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 179
Deficiencies: 1
Aug 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that facility staff did not ensure residents' responsible parties received written notice of a rate increase.
Findings
The investigation substantiated that the facility failed to provide residents' responsible parties with the required 90-day written notice of a rate increase, instead providing only a 60-day notice, which posed a potential personal rights risk to residents.
Complaint Details
The complaint alleged that facility staff did not ensure residents' responsible parties received written notice of a rate increase. The allegation was substantiated based on interviews and document review showing a 60-day notice was given instead of the required 90-day notice.
Deficiencies (1)
| Description |
|---|
| Failure to provide no less than 90 days' prior written notice of rate increase to residents as required by regulation. |
Report Facts
Rate increase amount: 500
Census: 123
Total capacity: 179
Plan of Correction due date: Sep 8, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erica Mosley | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Grace Hartnett | Executive Director | Facility administrator involved in interviews and findings. |
| Yamilette Caprilla | Director of Assisted Living | Met with Licensing Program Analyst during entrance interview. |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 179
Deficiencies: 0
Jul 15, 2025
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding allegations that staff were not properly addressing a pest infestation in the facility.
Findings
The investigation found that although there was an active cockroach infestation reported on 07/08/2025, facility staff took immediate and appropriate measures including pest control treatment, deep cleaning, repairs, and monitoring. No current signs of infestation were observed during the visit, and the allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff were not properly addressing a cockroach infestation in the dry food storage room. The facility had an inspection by the County of Los Angeles Department of Public Health on 07/08/2025 which confirmed the infestation. Facility staff responded promptly with pest control treatment on 07/09/2025, cleaning, repairs, and follow-up monitoring. The allegation was found unsubstantiated.
Report Facts
Cockroaches observed: 10
Cockroach eggs observed: 5
Pest control treatment date: Jul 9, 2025
Pest control follow-up period: 5
Last pest control service date: Apr 23, 2025
Drains sealed: 2
Total drains in dry storage room: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Hartnett | Executive Director | Interviewed regarding pest infestation and facility response |
| Trevor Byrne | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Jun 4, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following allegations that a resident fell sustaining injuries due to lack of supervision and did not receive timely medical treatment.
Findings
The investigation found that the resident in question was an independent living resident not receiving services or supervision from the licensed facility. Therefore, the allegations were deemed unfounded as the resident did not reside in the licensed facility or receive care from it.
Complaint Details
The complaint alleged that a resident fell and sustained injuries due to lack of supervision and did not receive timely medical treatment. The allegations were investigated and found to be unfounded because the resident was not part of the licensed facility's care component.
Report Facts
Facility capacity: 179
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Trevor Byrne | Licensing Program Analyst | Conducted the complaint investigation visit |
| Grace Hartnett | Executive Director | Interviewed during the investigation |
| Kasandra Lopez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 171
Capacity: 179
Deficiencies: 0
Apr 3, 2025
Visit Reason
The inspection was an unannounced continuation of the required annual visit to evaluate compliance with licensing requirements.
Findings
No deficiencies were observed during the inspection. The facility's infection control practices and emergency disaster plan were found to be adequate and up to date, with recent disaster drills conducted.
Report Facts
Staff files reviewed: 5
Disaster drill date: Mar 17, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Hartnett | Administrator | Facility Administrator met during inspection |
| Trevor Byrne | Licensing Program Analyst | Conducted the inspection |
| Kasandra Lopez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 172
Capacity: 179
Deficiencies: 0
Mar 26, 2025
Visit Reason
The inspection visit was an unannounced continuation of the required annual case management visit to evaluate compliance with licensing requirements.
Findings
No deficiencies were observed during the inspection. Resident records and staff knowledge were reviewed and found to be in compliance with all requirements. Due to time constraints, some reviews will be completed at a later date.
Report Facts
Staff interviewed: 5
Resident files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Hartnett | Administrator | Met with Licensing Program Analyst during inspection. |
| Trevor Byrne | Licensing Program Analyst | Conducted the inspection visit. |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 172
Capacity: 179
Deficiencies: 2
Mar 17, 2025
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 regulations.
Findings
The facility was generally found to be in good repair and clean with appropriate furnishings and safety measures in place. However, deficiencies were cited related to inaccurate medication record documentation for one resident and three window screens/window screen frames in disrepair.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| One resident's centrally stored medication and destruction record sheet contained inaccurate and out of date information. | Type B |
| Three window screens/window screen frames were observed to be in disrepair. | Type B |
Report Facts
Number of bedrooms: 163
Number of resident rooms toured: 17
Number of resident medications reviewed: 7
Number of residents interviewed: 5
Fire extinguisher last service date: Aug 28, 2024
Water temperature range: 107.8-114.6
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Hartnett | Administrator | Facility Administrator met with Licensing Program Analysts during inspection |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
| Trevor Byrne | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Follow-Up
Census: 167
Capacity: 179
Deficiencies: 0
Feb 7, 2025
Visit Reason
The visit was a follow-up on a self-reported incident that occurred on 2025-02-02 involving a resident who self-administered opioid medications and suffered a medical emergency.
Findings
No deficiencies were cited during the inspection. The facility has implemented room sweeps, pauses on deliveries, and additional care checks to prevent recurrence of the incident. Further investigation is pending to determine if citations are warranted.
Report Facts
Facility capacity: 179
Census: 167
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Hartnett | Executive Director | Met during inspection and provided information about the incident and facility measures |
| Yamilette Capilla | Director of Assisted Living | Interviewed during inspection |
| Trevor Byrne | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 179
Deficiencies: 0
Sep 20, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 03/19/2024 alleging neglect and falsification of incident reports related to Resident #1 (R1).
Findings
The investigation found insufficient evidence to substantiate the allegations of neglect/lack of supervision resulting in a fall and head injuries to Resident #1, and staff falsifying incident reports. Interviews, medical records, and incident reports were consistent and did not support the allegations.
Complaint Details
The complaint alleged that staff failed to provide adequate supervision to Resident #1, resulting in a fall and head injuries, and that staff falsified an incident report. The investigation included interviews with staff and resident representatives, review of medical records and incident reports. The allegations were deemed unsubstantiated due to lack of sufficient evidence.
Report Facts
Facility capacity: 179
Census: 151
Complaint control number: 29-AS-20240319161408
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation visit and delivered final findings |
| Grace Hartnett | Administrator | Facility administrator met during the investigation |
| Laura Garcia | Investigator | Assigned investigator who conducted interviews and reviewed records |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 179
Deficiencies: 1
Sep 20, 2024
Visit Reason
The visit was an unannounced Case Management - Incident Deficiencies inspection conducted in conjunction with a complaint investigation to issue citations for deficiencies observed that were not related to the complaint.
Findings
The inspection found that the facility did not comply with the requirement for an annual medical assessment for residents with dementia, as evidenced by Resident #1's physician's report being outdated (dated 12/20/2022), posing a potential health and safety risk.
Complaint Details
The visit was conducted in conjunction with a complaint visit (Complaint control # 29-AS-20240319161408). The purpose was to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Each resident with dementia shall have an annual medical assessment and reappraisal including reassessment of dementia care needs; this requirement was not met as Resident #1's physician's report (LIC 602) was dated 12/20/2022. | Type B |
Report Facts
Deficiency Plan of Correction Due Date: Oct 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the unannounced Case Management - Incident Deficiencies visit and complaint investigation |
| Grace Hartnett | Executive Director | Met with Licensing Program Analyst during the inspection and provided information about attempts to obtain updated physician's report |
| Desaree Perera | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 179
Deficiencies: 1
Aug 13, 2024
Visit Reason
An unannounced case management visit was conducted in response to a self-reported incident on 08/06/2024 involving the administration of incorrect medication to a resident.
Findings
The investigation found that staff followed appropriate reporting procedures and complied with the resident’s physician’s monitoring recommendations. An in-service training on resident rights and medication error prevention was conducted. One staff member involved had terminated employment prior to the visit. A deficiency was cited related to the facility's plan for incidental medical and dental care.
Complaint Details
The visit was complaint-related due to a medication error incident. The complaint was substantiated as a deficiency was cited.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a plan for incidental medical and dental care that encourages routine care and assists residents with self-administered medications as needed. | Type A |
Report Facts
Residents present: 152
Total licensed capacity: 179
Staff attending in-service training: 3
Resident rights covered in training: 6
Date of incident: Aug 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Hartnett | Administrator | Facility administrator met during inspection |
| Trevor Byrne | Licensing Program Analyst | Conducted the inspection and signed the report |
| Kasandra Lopez | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 179
Deficiencies: 0
May 28, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations received on 2023-11-01 regarding staff leaving residents soiled, speaking inappropriately about residents, improper disposal of diapers, unclean furniture, residents left unsupervised, exclusion from activities, improper hand washing, and failure to wear protective masks when sick.
Findings
After interviews with staff, private caregivers, family members, and case workers, and physical plant observations on multiple dates, the Department found insufficient evidence to substantiate any of the allegations. All allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff leaving residents soiled for extended periods, inappropriate staff speech about residents, improper disposal of diapers, unclean furniture, residents left unsupervised, exclusion from activities, improper hand washing, and failure to wear masks when sick. Interviews and observations did not corroborate these allegations.
Report Facts
Capacity: 179
Census: 155
Number of private caregivers interviewed: 6
Number of staff interviewed: 6
Number of family members/responsible parties interviewed: 7
Number of dining room staff interviewed: 6
Number of parties interviewed regarding inappropriate speech allegation: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
| Grace Hartnett | Executive Director | Met with Licensing Program Analyst during investigation |
| Keith Payne | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 179
Deficiencies: 1
Apr 17, 2024
Visit Reason
An unannounced case management visit was conducted in response to a self-reported incident on 2024-04-01 involving Resident #1 eloping from the facility without supervision.
Findings
Resident #1, diagnosed with dementia and unable to leave unassisted, was found outside the facility without supervision, posing an immediate health and safety risk. Staff completed a new needs assessment and identified the need for a wander guard following the incident.
Complaint Details
The visit was complaint-related due to a self-reported incident of elopement by Resident #1 on 2024-04-01. The complaint was substantiated by findings of the resident outside the facility without supervision.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Based on interviews and records review, Resident #1 was not permitted to leave the facility unassisted and was found outside without supervision, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 179
Census: 155
Deficiencies cited: 1
Plan of Correction Due Date: Apr 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Grace Hartnett | Executive Director | Met with Licensing Program Analyst during the inspection |
| Desaree Perera | Licensing Program Manager / Supervisor | Supervisor and Licensing Program Manager named in the report |
Inspection Report
Annual Inspection
Census: 150
Capacity: 179
Deficiencies: 0
Mar 13, 2024
Visit Reason
The visit was a required one-year unannounced inspection to evaluate the facility's compliance with health and safety regulations.
Findings
The inspection found the facility to be well-maintained with no health or safety hazards observed. Resident rooms, common areas, kitchen, memory care rooms, and outdoor areas were clean, properly furnished, and in good condition. Safety equipment such as fire extinguishers, fire suppression system, and detectors were up to date and functional. Interviews with residents and staff revealed no concerns.
Report Facts
Number of resident rooms inspected: 10
Number of memory care rooms inspected: 3
Number of residents interviewed: 7
Number of staff interviewed: 6
Facility capacity: 179
Facility census: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Hartnett | Executive Director | Met with Licensing Program Analysts during inspection |
| Valeria Conway | Licensing Program Analyst | Conducted the inspection and signed the report |
| Teresa Camara | Licensing Program Analyst | Conducted the inspection |
| Mariana Pelayo | Regional Nurse | Joined the inspection visit |
| Desaree Perera | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 179
Deficiencies: 0
Aug 22, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate multiple allegations including staff not following COVID protocol, not distributing medications as prescribed, not assisting residents with bathing, and not providing residents with linen.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Interviews with residents, staff, and caregivers, as well as records reviews, indicated that COVID protocols were followed, medications were administered as prescribed, residents received assistance with bathing, and linens were provided as required.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not following COVID protocol, medication distribution issues, lack of assistance with bathing, and failure to provide linens. The department found no sufficient evidence to support these allegations after interviews and record reviews.
Report Facts
Residents interviewed: 10
Staff interviewed: 7
Private caregivers interviewed: 3
Medication Administration Records reviewed: 5
Residents scheduled for showers on Saturdays: 24
Residents interviewed about showers: 8
Towels distributed on 10/22/2022: 155
Towels distributed on 10/29/2022: 150
Residents in community during towel distribution: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
| Ada Navarette | Director of Assisted Living | Met with Licensing Program Analyst during investigation |
| Dana Anderson | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 179
Deficiencies: 0
May 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility lacks adequate staffing to meet residents' care needs and that facility staff speak inappropriately to a resident.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with residents, staff, and caregivers indicated adequate staffing and no inappropriate staff behavior towards residents. The allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate staffing and inappropriate staff communication. Interviews and records review did not support these claims.
Report Facts
Residents interviewed: 10
Staff interviewed: 6
Private caregivers interviewed: 3
Caregivers scheduled on night shift: 2
Residents expressing dissatisfaction: 2
Residents not expressing concerns: 8
Staff interviewed on 01/27/2023: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Keith Payne | Executive Director | Met with Licensing Program Analyst during the investigation |
| Ada Navarette | Director of Assisted Living | Interviewed regarding staffing coverage and call outs |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 179
Deficiencies: 0
May 2, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility did not notify residents of rate increases prior to admission.
Findings
The investigation found that the facility provides a Rate Increase Disclosure Form and Admission Agreement to prospective residents prior to admission, which includes information about rate adjustments and a 60-day written notice prior to any rate changes. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that the facility did not properly notify the resident’s representative about possible rate increases prior to admission. The allegation was unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 179
Census: 141
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Keith Payne | Administrator | Interviewed during the investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 179
Deficiencies: 1
Mar 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff neglected Resident #1 by failing to obtain timely medical attention after a fall.
Findings
The investigation substantiated neglect/lack of supervision related to failure to obtain timely medical attention for Resident #1 after a fall resulting in a fractured hip and subsequent surgery. Other allegations including staff pushing the resident, neglect resulting in pressure injury, untimely toilet repairs, hygiene neglect, pest control issues, and delayed assistance were unsubstantiated.
Complaint Details
The complaint was received on 11/08/2022 alleging neglect/lack of supervision when staff failed to obtain timely medical attention for Resident #1 after a fall. The allegation was substantiated. Other allegations related to physical abuse, pressure injury neglect, maintenance, hygiene, pest control, and assistance response times were investigated and found unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain timely medical attention for Resident #1 after a fall, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 179
Census: 78
Civil penalty: 500
Maintenance requests: 10
Work orders: 5
Resident interviews: 12
Average response time: 3.88
Longest observed wait time: 46
Facility pest control visits: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted complaint investigation visits and authored report |
| Desaree Perera | Licensing Program Manager | Oversaw complaint investigation and signed report |
| Ada Navarette | Assisted Living Director | Facility staff member interviewed during investigation |
| Christine Ferris | Investigator | Assigned to complaint investigation branch for this case |
Inspection Report
Annual Inspection
Census: 87
Capacity: 179
Deficiencies: 0
Feb 7, 2023
Visit Reason
The inspection was a required one-year unannounced visit focusing on infection control practices and procedures at the facility.
Findings
The facility was found to be generally clean and properly furnished with adequate infection control signage and supplies. Resident bedrooms and bathrooms were well maintained with functional fixtures and safety features. The kitchen and common areas were clean and well stocked. The facility's infection control policies and procedures were deemed adequate at the time of the visit.
Report Facts
Bedrooms inspected: 10
Memory care rooms inspected: 3
Hot water temperature range: 107
Hot water temperature range: 115.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ada S. Navarrete | Director of Assisted Living | Met with Licensing Program Analyst during inspection and discussed infection control practices |
| Brian Balisi | Licensing Program Analyst | Conducted the inspection |
| Desaree Perera | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Annual Inspection
Census: 61
Capacity: 100
Deficiencies: 0
Mar 29, 2022
Visit Reason
The inspection was a required one-year unannounced visit with emphasis on infection control practices and procedures.
Findings
The facility was found to have properly furnished and clean resident bedrooms and common areas, adequate infection control signage and supplies, a clean and functional kitchen with sufficient food supply, and appropriate infection control policies including COVID-19 testing and PPE availability. No deficiencies were noted in the report.
Report Facts
Bedrooms inspected: 13
Memory care rooms inspected: 3
Hot water temperature range: 107.4
Hot water temperature range: 115.7
Hot water temperature range in memory care: 107
Hot water temperature range in memory care: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Sahar Mosalla | Operations Specialist | Met with the Licensing Program Analyst during the inspection. |
| Mariana Pelayo | Regional Nurse | Met with the Licensing Program Analyst during the inspection. |
| Pamela Munday | Administrator | Facility administrator named in the report. |
| Desaree Perera | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 100
Deficiencies: 0
Jan 13, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations of physical abuse and neglect/lack of supervision resulting in injuries to a resident.
Findings
The investigation found no sufficient evidence to substantiate the allegations of physical abuse or neglect. Interviews with caregivers, hospice employees, facility staff, residents, and family members revealed no knowledge or suspicion of abuse or neglect. The injuries were likely accidental and possibly related to transfers or care activities.
Complaint Details
The complaint alleged physical abuse resulting in injuries and neglect/lack of supervision causing a resident to sustain a skin tear, scrape on forehead, and injury to lip. The investigation included interviews and review of hospice and facility records. The allegations were deemed unsubstantiated due to lack of supporting evidence.
Report Facts
Facility capacity: 100
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation visits and authored the report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Michele Johnson | Executive Director | Met with during the inspection visit |
| Elizabeth Ham | Director of Assisted Living | Met with during the initial complaint visit |
| Douglas Real | Investigator | Conducted interviews and investigation related to the complaint |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 100
Deficiencies: 0
Dec 14, 2021
Visit Reason
The inspection was an unannounced Case Management - Incident inspection pertaining to a self-reported Unusual Incident/Injury Report (LIC 624) received on 12/13/2021 regarding an incident that occurred on 11/29/2021 involving Resident #1.
Findings
No immediate health and safety concerns were observed during the inspection. The Licensing Program Analyst determined that further investigation is needed.
Complaint Details
The visit was triggered by a self-reported unusual incident/injury involving Resident #1. The Licensing Program Analyst conducted interviews with staff and residents, reviewed facility records, and reviewed video footage. No immediate concerns were found, but further investigation was deemed necessary.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yasmin Hernandez | Memory Care Director | Interviewed during the inspection related to the unusual incident/injury report. |
| Michele Johnson | Executive Director | Met with Licensing Program Analyst and reviewed video footage during the inspection. |
| Kasandra Lopez | Licensing Program Analyst | Conducted the unannounced Case Management - Incident inspection. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 100
Deficiencies: 0
Nov 4, 2021
Visit Reason
An unannounced case management visit was conducted in response to a self-reported incident on October 26, 2021, involving a staff member yelling at a resident.
Findings
The Licensing Program Analyst did not observe any immediate health and safety concerns during the visit. Further review is required before concluding the investigation.
Complaint Details
The visit was triggered by a complaint regarding an incident where Staff (S1) screamed at Resident 1 to 'Shut up' while the resident was sitting and yelling in the dining room. Investigation is ongoing.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Balisi | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Pamela Munday | Administrator | Facility Administrator mentioned in the report header. |
| Yazmin Hernandez | Enliven Director | Met with during the visit. |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 100
Deficiencies: 1
Aug 9, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility had not promptly provided a resident's records as requested.
Findings
The investigation found that the facility personnel failed to provide copies of resident #1's records within the required two business days, resulting in a substantiated finding and issuance of a citation.
Complaint Details
The complaint was substantiated. The facility failed to provide requested resident records within the required timeframe despite multiple requests via voicemail and fax. The initial finding of unsubstantiated was amended to substantiated after discovering the facility did not comply with the request by the agreed date.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to promptly provide requested resident records within two business days as required by Health and Safety Code Section 1569.269(a)(21). | Type B |
Report Facts
Capacity: 100
Census: 70
Deficiency Type Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff LaBelle | Administrator | Named in relation to failure to provide requested records |
| Michele Johnson | Executive Director | Met with Licensing Program Analyst during investigation |
| Salia Walker | Licensing Program Analyst | Conducted complaint investigation and issued report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw complaint investigation |
| Eva Miller | Licensing Program Analyst | Conducted initial complaint visit and amended finding |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 100
Deficiencies: 0
Jun 18, 2021
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including staff failing to follow doctor's orders and other related complaints.
Findings
The investigation found that staff complied with doctor's orders regarding resident care, including not providing alcohol to Resident #1. Interviews and record reviews indicated that the allegations were unsubstantiated at this time.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff failing to follow doctor's orders, failure to appraise the Responsible Party of resident services, and failure to answer resident calls timely. Interviews and record reviews showed compliance and reasonable response times.
Report Facts
Resident interview sample: 6
Census: 62
Total capacity: 100
Complaint received date: Dec 4, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Elizabeth Ham | Director of Assisted Living | Met with Licensing Program Analyst during investigation |
| Greg Becker | Administrator | Facility administrator named in report header |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
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