Inspection Reports for
The Vineyard at Fountaingrove Memory Care
200 Fountaingrove Parkway, Santa Rosa, CA 95403, CA, 95403
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
270% worse than California average
California average: 4 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
36% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 23
Capacity: 64
Deficiencies: 0
Date: Oct 2, 2025
Visit Reason
The inspection was an unannounced Case Management - Legal/Non-compliance visit to evaluate the facility's compliance status following a prior non-compliance placement and management change.
Findings
The facility was found to be in a safe and comfortable condition with proper heating, electrical utilities, and working fire safety systems. No citations were issued during this inspection.
Report Facts
Residents present: 23
Facility capacity: 64
Care staff observed: 6
Fire Department inspection date: Jul 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Downey | Administrator | New Administrator implementing management change |
| Heidi Schultz | Business Officer | Met with Licensing Program Analyst during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 23
Capacity: 64
Deficiencies: 3
Date: Sep 9, 2025
Visit Reason
License Program Analyst Shannan Hansen arrived unannounced to complete an Annual inspection of the facility.
Findings
The inspection found deficiencies related to staff health screenings, medication training, and annual training requirements. Several staff files lacked required health screening or TB results, and some direct care staff did not have documented medication training or annual training.
Deficiencies (3)
Personnel Requirements – All personnel must be in good health, verified by health screening including TB test; staff S1, S2, and S3 missing required health screening or TB results.
Medication training requirements not met; staff S4 missing proof of initial hands-on medication training.
Annual training requirements not met; staff S3 missing proof of required annual training including dementia care and hospice care.
Report Facts
Deficiencies cited: 3
Census: 23
Total Capacity: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Downey | Administrator | Met with Licensing Program Analyst during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and signed the report |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 25
Capacity: 64
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted by the License Program Analyst to evaluate compliance with licensing requirements at the facility.
Findings
The facility was generally found to be clean, safe, and compliant with many regulations including fire safety and medication storage. However, a deficiency was noted regarding hot water temperatures in resident bathrooms, with 6 out of 11 sinks measuring outside the acceptable range of 105 to 120 degrees Fahrenheit.
Deficiencies (1)
Hot water temperature controls were not maintained within the required range of 105 to 120 degrees Fahrenheit in 6 out of 11 resident bathroom sinks, posing a potential health and safety risk.
Report Facts
Residents present: 25
Total licensed capacity: 64
Fire extinguishers inspected: 16
Hot water sinks out of range: 6
Personnel files reviewed: 5
Resident records reviewed: 5
Staff records reviewed: 5
Resident medications reviewed: 2
Disaster drills conducted quarterly: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Downey | Administrator | Met with License Program Analyst during inspection and involved in addressing hot water temperature deficiency |
| Shannan Hansen | License Program Analyst | Conducted the annual inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 64
Deficiencies: 0
Date: Aug 28, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff left medication out accessible to residents.
Complaint Details
The complaint alleged that staff (S1) left medication out accessible to residents, including medications left on handrails in hallways and resident rooms. Multiple visits and interviews were conducted, but no evidence supported the allegation. The complaint was unsubstantiated.
Findings
The investigation found conflicting information from staff and no corroborating evidence to support the allegation. Medication records and staff interviews did not confirm that medications were left accessible to residents. The complaint was determined to be unsubstantiated.
Report Facts
Staff interviewed: 9
Investigation visits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Downey | Administrator | Met with Licensing Program Analyst during investigation |
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 64
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The visit was conducted as case management to address issues revealed during a complaint investigation involving alleged abuse by staff witnessed at the facility.
Complaint Details
Complaint (21-AS-20250521082833) revealed staff witnessed alleged abuse of a resident and failed to notify within the required timeframe. Facility agreed to conduct mandated reporting training for all staff.
Findings
The investigation found that staff failed to notify the appropriate authorities of the alleged abuse within the required timeframe, posing a potential health and safety risk to residents. The facility agreed to conduct staff training on mandated reporting and facility policies.
Deficiencies (1)
Failure to report suspected abuse within two hours as required by Welfare and Institutions Code 15630(b)(1)(A)(i).
Report Facts
Deficiencies cited: 1
Plan of Correction due date: Aug 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Downey | Administrator | Met with during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted case management and complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 64
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations that the licensee did not include the facility license number on advertisements and did not have required information posted prominently for residents and the public.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to display license number on advertisements and failure to post required information for residents and the public. The investigation found evidence to the contrary, including license numbers on website and brochures, and required postings observed in the facility.
Findings
The investigation found that the facility did include the license number on its website and brochures, and required residents' rights postings were observed in multiple locations. Therefore, the allegations were unsubstantiated due to lack of evidence.
Report Facts
Capacity: 64
Census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Denise Downey | Administrator | Facility administrator met during investigation and provided brochures |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 64
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff hit a resident and spoke inappropriately to a resident.
Complaint Details
The complaint involved allegations that staff member S1 hit Resident R1 on the shoulder and face/neck and spoke inappropriately to the resident. After investigation including staff interviews, review of schedules, facility records, police report, and follow-up with the district attorney, the allegations were found unsubstantiated due to lack of evidence.
Findings
Based on interviews, document reviews, and correspondence with the district attorney, there was no evidence to prove or disprove the allegations. The complaint was determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 64
Census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Downey | Administrator | Met with during the complaint investigation and exit interview |
| Shannan Hansen | Licensing Evaluator | Conducted the complaint investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 64
Deficiencies: 1
Date: Jul 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee did not issue a resident’s authorized representative a timely refund.
Complaint Details
Complaint was substantiated. The allegation was that the licensee did not issue a timely refund to the resident’s authorized representative after the resident's death and removal of belongings. Evidence showed the refund was delayed beyond the required 15 days.
Findings
The investigation found that the licensee did not pay the refund to the resident's responsible party within the required 15 days after the removal of the resident's belongings, substantiating the complaint. A refund check was eventually sent on 07/23/2025 and delivered on 07/24/2025.
Deficiencies (1)
Failure to issue refund within 15 days after removal of resident's property as required by Health & Safety Code 1569.652(c).
Report Facts
Capacity: 64
Census: 22
Deficiency count: 1
Plan of Correction Due Date: Jul 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Downey | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Shannan Hansen | Licensing Evaluator | Conducted complaint investigation and signed report |
| Bethany Moellers | Supervisor | Supervisor overseeing complaint investigation |
Inspection Report
Census: 21
Capacity: 64
Deficiencies: 0
Date: Jul 15, 2025
Visit Reason
The inspection was an unannounced Case Management - Legal/Non-compliance visit conducted to follow up on a prior non-compliance status and assess current facility conditions and compliance.
Findings
The facility was found to be in a safe and comfortable condition with proper heating, electrical utilities, and working auditory alarms. The fire panel was repaired and operable, and the recent Fire Department inspection passed. No citations were issued at this inspection.
Report Facts
Care staff observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Downey | Administrator | Met with Licensing Program Analyst during inspection and discussed facility conditions |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection visit |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Census: 22
Capacity: 64
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
The inspection was an unannounced Case Management - Legal/Non-compliance visit to evaluate the facility's compliance status following a prior non-compliance placement and subsequent conference.
Findings
The facility was found to be in a safe and comfortable condition with proper heating, electrical utilities, and working auditory alarms. The fire panel was still being repaired with a fire watch log maintained. No citations were issued during this inspection.
Report Facts
Care staff observed: 5
Capacity: 64
Census: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Downey | Administrator | Administrator present during inspection and discussed reporting requirements and other topics |
| April Postal | Business Office Manager | Greeted Licensing Program Analyst and conducted walk-through with LPA |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 22
Capacity: 64
Deficiencies: 8
Date: Mar 21, 2025
Visit Reason
The visit was an unannounced office inspection conducted to review issues identified by the Community Care Licensing Agency regarding the operation of The Vineyard at Fountaingrove, including concerns about financial solvency, change of management company, fire clearance, insufficient care and supervision, medication errors, and compliance with reporting and plan of correction requirements.
Complaint Details
Since the 4/15/2024 Non-Compliance Conference, the Community Care Licensing has received a total of 19 complaints, with 3 complaints delivered along with citations at the meeting on 03/21/2025.
Findings
The facility was found non-compliant in multiple areas including financial solvency with failed audits, unauthorized change of management company, fire clearance concerns, insufficient care and supervision, medication errors, and failure to clear plans of correction timely. The facility has also been non-compliant with providing records and meeting deadlines, and a non-compliance conference was held to address these issues.
Deficiencies (8)
Financial solvency issues with failed audits and non-compliance with auditor deadlines
Change of management company prior to Community Care Licensing approval
Fire clearance concerns including Fire Department involvement and firewatch
Insufficient care and supervision and medication errors with multiple prior citations
Failure to clear plans of correction (POCs) timely
Non-compliance with reporting requirements
Facility's future compliance concerns
Elopements
Report Facts
Complaints received: 19
Complaints delivered with citations: 3
Facility capacity: 64
Census: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Williams | CEO of One Life Senior Living LLC | Met during inspection and non-compliance conference |
| Joe Diagle | VP Quality Assurance of Frontier Living | Met during inspection and non-compliance conference |
| Denise Downey | Administrator of One Life Senior Living LLC | Met during inspection and non-compliance conference; requested copies of civil penalties |
| Bethany Moellers | Licensing Program Manager | Supervisor and participant in non-compliance conference |
| Shannan Hansen | Licensing Program Analyst | Licensing evaluator and participant in non-compliance conference |
| Carla Nuti-Martinez | Regional Manager | Participant in non-compliance conference |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 64
Deficiencies: 1
Date: Mar 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation received on 12/26/2024 that the licensee did not ensure the facility was adequately staffed to meet residents' needs.
Complaint Details
The complaint was substantiated. The allegation that the licensee did not ensure adequate staffing to meet residents' needs was validated based on interviews, records, and observations. Civil penalties of $250 were imposed for the third repeat citation within the last 12 months.
Findings
The investigation substantiated the complaint, finding insufficient staffing levels, a non-working call system, and delayed staff response times of up to two hours during night shifts, posing immediate health and safety risks to residents.
Deficiencies (1)
Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by licensee as evidenced by records review, observation, and interviews with staff, including a non-working call system and night shift staff taking up to two hours to respond to resident calls for assistance at least 6 times during November 2024.
Report Facts
Civil Penalty Amount: 250
Resident Census: 22
Facility Capacity: 64
Staff Response Delay: 2
Number of Residents: 30
Number of Residents on Hospice: 3
Number of Caregivers: 4
Number of Caregivers: 3
Number of Medication Technicians: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Evaluator | Conducted the complaint investigation and signed the report. |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation. |
| Rajvir Sandhu | Administrator | Facility administrator mentioned in report. |
| Dan Williams | CEO of One Life Senior Living | Met during the investigation. |
| Joe Diagle | VP Quality Assurance of Frontier Living | Met during the investigation. |
| Denise Downey | Administrator, One Life Senior Living LLC | Met during the investigation. |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 64
Deficiencies: 1
Date: Mar 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility's fire system was in disrepair and not functioning for approximately one year.
Complaint Details
The complaint alleging the facility’s fire system was in disrepair was substantiated based on evidence including fire department inspection reports, staff interviews, and fire watch logs. The facility had not fixed the system but was working on it. An immediate civil penalty of $500 was assessed.
Findings
The complaint was substantiated as the fire alarm system was found not functioning properly for about a year, posing an immediate health and safety risk. The facility had not repaired the system but had signed a vendor proposal for replacement parts and was following fire inspectors' guidance. An immediate civil penalty of $500 was assessed due to the fire clearance violation.
Deficiencies (1)
Facility failed to maintain a fire clearance approved by the fire department; fire alarm system not functioning properly for approximately one year, posing immediate health and safety risk.
Report Facts
Immediate Civil Penalty: 500
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Evaluator | Conducted the complaint investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
| Rajvir Sandhu | Administrator | Facility administrator mentioned in relation to findings |
| Dan Williams | CEO of One Life Senior Living | Met during investigation |
| Joe Diagle | VP Quality Assurance of Frontier Living | Met during investigation |
| Denise Downey | Administrator, One Life Senior Living LLC | Met during investigation |
Inspection Report
Plan of Correction
Census: 24
Capacity: 64
Deficiencies: 0
Date: Feb 4, 2025
Visit Reason
This was a Plan of Correction (POC) visit to verify that previously cited deficiencies have been corrected.
Findings
The Licensing Program Analyst verified that the Administrator is now cleared and associated with the facility, the front door is operational, and heat in the resident room was previously cleared. All deficiencies issued on the prior visit date 2024-01-07 have been cleared and a cleared POC letter was issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Evaluator | Conducted the POC visit and verified corrections. |
| Carla Martinez | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 64
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations that staff were not ensuring the facility kitchen was clean, safe, and sanitized, and that staff did not answer residents' calls for assistance.
Complaint Details
The complaint investigation was substantiated for allegations that the kitchen was not clean and safe, and staff did not respond timely to residents' calls for assistance. The call system was not working for an unknown period, and residents experienced delays of up to two hours for assistance during night shifts. The allegation that the facility failed to meet residents' care needs was unsubstantiated due to lack of supporting evidence.
Findings
The investigation substantiated that the facility kitchen was not properly sanitized, leftover food was improperly handled, and the call response system was not working, causing delays of up to two hours in responding to residents' calls for assistance. Another allegation regarding failure to meet residents' care needs was unsubstantiated.
Deficiencies (2)
Procedures which protect the safety, acceptability and nutritive values of food were not observed in food storage, preparation, and service, including serving leftover foods uncovered.
Facility personnel were not sufficient in numbers and competent to provide necessary services, evidenced by a non-working call system and delayed response to residents' calls for assistance.
Report Facts
Residents present: 25
Total licensed capacity: 64
Repeated citation fine amount: 250
Number of times delayed response occurred: 5
Number of residents needing two-person assist: 4
Number of staff working night shift: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Downey | Executive Director | Met with Licensing Program Analysts during investigation |
| Antonette Edwards | Administrator | Named as facility administrator |
| Marisol Cuadra | Licensing Evaluator | Conducted complaint investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing investigation |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 64
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that facility staff were not meeting residents' care needs, specifically concerning neglect by a staff member (S1) during night shifts.
Complaint Details
The complaint alleged that staff member S1 neglected residents by not timely changing incontinence care needs, resulting in fungal infections and sores. The investigation included interviews with residents and staff, review of written communications, and consideration of management turnover. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews and review of documentation did not support claims of neglect, and the staff member in question had resigned prior to the investigation. Therefore, the complaint was determined to be unsubstantiated.
Report Facts
Capacity: 64
Census: 25
Complaint receipt date: Complaint received on 2024-11-20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Evaluator | Conducted the complaint investigation |
| Denise Downey | Executive Director | Met with investigators during the visit |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 64
Deficiencies: 1
Date: Jan 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted due to multiple allegations including failure to provide timely bathing services, medication errors, inaccurate resident records, lack of clean clothing provision, and residents developing pressure injuries.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure residents received bathing services in a timely manner due to lack of staffing. Other allegations including medication errors, inaccurate resident records, lack of clean clothing, and pressure injuries were unsubstantiated due to lack of sufficient evidence.
Findings
The investigation substantiated the allegation that staff did not ensure residents received bathing services in a timely manner due to staffing shortages. Other allegations regarding medication errors, inaccurate resident records, provision of clean clothing, and pressure injuries were found to be unsubstantiated due to insufficient evidence.
Deficiencies (1)
Failure to provide personal assistance and care including bathing as indicated in residents' care plans, posing an immediate risk to health and safety.
Report Facts
Residents not bathed as agreed: 12
Total residents reviewed for bathing: 26
Facility capacity: 64
Census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Evaluator | Conducted the complaint investigation and authored the report. |
| Denise Downey | Executive Director | Met with evaluators during the investigation. |
| Rajvir Sandhu | Administrator | Facility administrator mentioned in the report. |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 64
Deficiencies: 2
Date: Jan 9, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 07/03/2024 regarding mishandling of residents' medications and inadequate staff training, among other care-related concerns.
Complaint Details
The complaint investigation was substantiated for medication mishandling and inadequate staff training. Other allegations including inadequate care and supervision, inadequate supplies, withholding food and drinks, improper room maintenance, broken lights, and sharing residents' personal supplies were found unsubstantiated.
Findings
The investigation substantiated allegations that staff mishandled residents' medications and were not properly trained, including missing insulin doses and lack of required First Aid training for some staff. Other allegations related to care, supplies, food withholding, room maintenance, broken lights, and sharing personal supplies were found to be unsubstantiated.
Deficiencies (2)
Failure to assist residents with self-administered medications as needed, evidenced by multiple self-reported medication errors posing immediate risk to residents.
Facility personnel were not sufficient in numbers and competent to meet resident needs, specifically 4 out of 7 staff lacked First Aid training.
Report Facts
Civil penalty: 250
Staff without First Aid training: 4
Resident census during investigation: 26
Facility capacity: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Evaluator | Conducted the complaint investigation and authored the report. |
| Robert Frank | Licensing Program Analyst | Assisted in conducting the unannounced complaint investigation visit. |
| Denise Downey | Executive Director | Facility representative met during investigation. |
| Serina Barreda | Business Office Manager | Facility representative met during investigation. |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Census: 26
Capacity: 64
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
Licensing Program Analyst Leibert arrived unannounced to amend a citation issued on 12/31/24 and to address a civil penalty for failure to correct a deficiency.
Findings
The front door does not lock and has not been repaired as of the inspection date. A civil penalty of $400 was issued for failure to correct, with an additional daily penalty of $100 to be assessed until the deficiency is corrected.
Deficiencies (1)
Front door does not lock and has not been repaired.
Report Facts
Civil penalty amount: 400
Daily penalty amount: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Arrived unannounced for the purpose of amending a citation and issuing penalties. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 64
Deficiencies: 2
Date: Dec 31, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that the facility did not have an adequate supply of food for residents, the administrator was not on site for sufficient hours, and the facility was in disrepair.
Complaint Details
The complaint investigation was triggered by allegations that the facility lacked adequate food supply, the administrator was not present on site for sufficient hours, and the facility was in disrepair. The food supply allegation was unsubstantiated, while the other two were substantiated.
Findings
The complaint regarding inadequate food supply was unsubstantiated after multiple site visits confirmed sufficient food. However, allegations that the administrator was absent for an extended period and that the facility was in disrepair were substantiated, including issues with electrical problems, lack of heat in one apartment, and a front door that does not lock.
Deficiencies (2)
The facility front door does not lock and one apartment lacks heat, posing an immediate threat to resident safety and health.
Facility has been without an Administrator on site since 11/27/2024, posing a potential threat to resident welfare.
Report Facts
Capacity: 64
Census: 28
Civil Penalty: 250
Plan of Correction Due Date: Jan 3, 2025
Plan of Correction Due Date: Jan 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Antonette Edwards | Administrator | Named in findings related to absence from facility |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 64
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
An unannounced complaint investigation was conducted following an allegation that facility staff did not dispense medication accurately, resulting in a resident's death.
Complaint Details
The complaint alleged that Resident R1 was administered morphine prescribed for another resident, resulting in death. The allegation was unsubstantiated based on statements, documents, and the death certificate.
Findings
The investigation found that Resident R1 was prescribed morphine and died on 11/9/2024. The facility denied medication errors, and the death certificate listed Alzheimer's Disease as the cause of death with no evidence of medication toxicity. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 64
Census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Evaluator | Conducted the complaint investigation and delivered findings |
| Antonette Edwards | Administrator | Facility administrator mentioned in the report |
Inspection Report
Plan of Correction
Census: 28
Capacity: 64
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
This was a proof of correction visit regarding a previously cited deficiency related to electrical problems in four residents' rooms.
Findings
The licensing analyst toured the facility and noted that the electrical problems had been resolved and the deficiency was cleared.
Report Facts
Residents affected by electrical problems: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Evaluator | Conducted the proof of correction visit |
| Carla Martinez | Supervisor | Supervisor overseeing the evaluation |
Inspection Report
Follow-Up
Census: 28
Capacity: 64
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
The inspection visit was conducted as a Case Management follow-up on an elopement incident involving a resident.
Complaint Details
The visit was related to a complaint or incident of a resident elopement, which was found to be unsubstantiated as the resident was located within the facility.
Findings
The investigation found that the resident did not elope but was found in another resident's closet after an item fell and hit them on the head. The resident was admitted to the hospital and is still there. No deficiencies were cited during this visit.
Report Facts
Census: 28
Total Capacity: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Serina Barreda | Business Office Manager | Interviewed during the inspection regarding the elopement incident |
| Anthony Loera | Licensing Program Analyst | Conducted the inspection visit |
| Kimberley Mota | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 64
Deficiencies: 0
Date: Dec 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was overcharging a resident and that staff did not communicate timely with the resident's responsible party.
Complaint Details
The complaint alleged overcharging of a resident and failure of staff to communicate timely with the responsible party. The investigation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. The facility requires a 30-day written notice for termination, which was not confirmed as received prior to the resident's personal items being removed. Staff denied prior notification, and the complaint was deemed unsubstantiated.
Report Facts
Capacity: 64
Census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Evaluator | Conducted the complaint investigation |
| Serina Barreda | Business Office Manager | Met with investigators during the inspection |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 64
Deficiencies: 1
Date: Dec 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-07-22 regarding unsafe client transport, medication mismanagement, inadequate staff training, facility disrepair, and other concerns at the facility.
Complaint Details
The complaint investigation was triggered by multiple allegations including unsafe client transport, medication mismanagement, inadequate staff training, facility telephone issues, facility disrepair, temperature control problems, inadequate nutrition, insufficient supplies, poor cleanliness, and failure to follow reporting requirements. The financial distress allegation was substantiated based on a solvency audit showing negative income, unpaid utility bills totaling $64,983, late fees, and a water disconnection notice. All other allegations were unsubstantiated due to insufficient evidence.
Findings
The investigation found the facility to be in financial distress with substantiated findings related to inadequate financial planning posing an immediate risk to resident health and safety. All other allegations including unsafe transport, medication mismanagement, inadequate training, facility disrepair, temperature control, nutrition, supplies, cleanliness, and reporting were unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
87213 Finances - The licensee shall have a financial plan that assures sufficient resources to meet operating costs for care of residents. This requirement had not been met, posing an immediate risk to health and safety of residents.
Report Facts
Unpaid utility bills: 64983
Late fees: 1301
Capacity: 64
Census: 29
Number of utility bills past due: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ethel Contreras | Support Staff | Assisted in complaint investigation |
| Serina Barreda | Business Office Manager | Met with investigators during complaint investigation |
| Antonette Edwards | Administrator | Facility administrator named in report |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Plan of Correction
Census: 33
Capacity: 64
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection to verify correction of previously cited electrical problems in 4 resident apartments.
Findings
The electrical repairs required to correct deficiencies were not completed. Additional civil penalties were assessed due to the facility's failure to correct the deficiency.
Deficiencies (1)
Electrical problems in 4 resident apartments not corrected as required.
Report Facts
Civil penalty amount: 1400
Daily civil penalty rate: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the Plan of Correction visit and confirmed deficiencies |
| Ramona Sandoval | Sales Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Plan of Correction
Census: 33
Capacity: 64
Deficiencies: 1
Date: Nov 21, 2024
Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection to verify correction of previously cited electrical problems in 4 resident apartments, originally identified on 10/08/2024.
Findings
The electrical repairs required to correct deficiencies were not completed by the deadline. Additional civil penalties were assessed for the continued non-compliance, including a $900 penalty for the period from 11/13 to 11/21/2024, with further penalties accruing daily until correction.
Deficiencies (1)
Failure to complete electrical repairs in 4 resident apartments as required by the Plan of Correction.
Report Facts
Civil penalty amount: 900
Daily civil penalty rate: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Evaluator | Conducted the Plan of Correction visit and confirmed deficiencies |
| Carla Martinez | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 64
Deficiencies: 0
Date: Nov 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an anonymous complaint alleging inadequate staffing, inadequate hydration for residents, and harmful products accessible to memory care residents.
Complaint Details
The complaint was unsubstantiated based on observations, document reviews, and multiple unannounced site visits. The complainant was anonymous and alleged inadequate staffing, hydration, and harmful products accessible to residents.
Findings
The investigation found that staffing was sufficient to meet residents' needs, hydration stations were available, and no harmful products were accessible. There was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding with no citations issued.
Report Facts
Capacity: 64
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Evaluator | Conducted the complaint investigation and delivered findings |
| Antonette Edwards | Administrator | Facility administrator named in the report |
Inspection Report
Census: 33
Capacity: 64
Deficiencies: 3
Date: Nov 13, 2024
Visit Reason
The inspection visit was an unannounced Case Management - Other visit conducted to evaluate the facility's compliance with reporting requirements and record accessibility.
Findings
The facility failed to submit required incident and death reports to the licensing agency since July 2024, was unable to provide timely access to certain resident medication records, and did not destroy expired narcotic medications timely, posing immediate health and safety risks to residents.
Deficiencies (3)
Facility failed to submit incident and death reports to Community Care Licensing since July 2024 as required by CCR 87211(a)(1).
Facility was unable to provide Electronic Medication Authorization Records for discharged residents and Centrally Stored Medications/Destruction Log due to lack of access, violating CCR 87506(d).
Expired narcotic medications (Lorazepam and Morphine) were not destroyed timely as required by CCR 87465(i).
Report Facts
Deficiencies cited: 3
Plan of Correction due date: Nov 14, 2024
Plan of Correction training submission due date: Nov 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajvir Sandhu | Executive Director | Involved in discussions regarding reporting failures and management change |
| Serina Barerra | Business Office Manager | Met with Licensing Program Analysts during visit and informed about record access issues |
| Cheyenne Flores | Health and Wellness Director | Responsible for access to medication records and involved in discussions during inspection |
Inspection Report
Plan of Correction
Census: 34
Capacity: 64
Deficiencies: 1
Date: Nov 12, 2024
Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection to follow up on unresolved electrical problems in 4 resident apartments that were supposed to be repaired by 10/22/2024.
Findings
The inspection found that the required electrical repairs had not been completed. A civil penalty of $1800 was issued for the period from 10/26/2024 through 11/12/2024 at a rate of $100 per day, with additional penalties accruing daily until the deficiency is corrected.
Deficiencies (1)
Failure to correct electrical problems in 4 resident apartments as required by the Plan of Correction.
Report Facts
Civil penalty amount: 1800
Previous civil penalty amount: 300
Penalty daily rate: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the Plan of Correction visit and inspection |
| Carla Martinez | Supervisor | Supervisor named in the report |
Inspection Report
Plan of Correction
Census: 34
Capacity: 64
Deficiencies: 1
Date: Oct 25, 2024
Visit Reason
The visit was an unannounced Plan of Correction inspection to follow up on unresolved electrical problems in 4 resident apartments identified during a previous case management inspection on 2024-10-08.
Findings
The inspection found that the required electrical repairs had not been completed by the deadline of 2024-10-22. The facility had just approved hiring an electrician to address the issues. A civil penalty of $300 was issued for the period 10/23 through 10/25, with additional penalties accruing daily until correction.
Deficiencies (1)
Failure to complete electrical repairs in 4 resident apartments by the required deadline.
Report Facts
Civil penalty amount: 300
Daily civil penalty rate: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Evaluator | Conducted the Plan of Correction visit and documented findings |
| Carla Martinez | Supervisor | Supervisor overseeing the inspection |
| Rajvir Sandhu | Facility representative met during the inspection | |
| Antonette Edwards | Administrator/Director | Facility Administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 64
Deficiencies: 1
Date: Oct 8, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation due to reported electrical problems in 4 resident apartments where ceiling lighting fixtures were not operating.
Complaint Details
Complaint investigation visit triggered by electrical problems in resident apartments. Substantiation status not explicitly stated.
Findings
The inspection found that 4 resident apartments had inoperable ceiling lights posing an immediate risk to residents' personal rights and safety. Management had requested authorization for repairs but had not yet received approval.
Deficiencies (1)
Maintenance and Operations. The facility shall be clean, safe, sanitary and in good repair at all times. Four resident apartments had inoperable ceiling lights posing an immediate risk to residents.
Report Facts
Resident apartments with electrical issues: 4
Deficiency count: 1
Plan of Correction due date: Oct 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted complaint investigation and cited deficiencies |
| Carla Martinez | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Census: 36
Capacity: 64
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
The visit was an unannounced Case Management - Other inspection conducted to perform a Non-Compliance (NCC) inspection and review employee training and compliance issues.
Findings
No deficiencies were cited during the visit. The inspection included review of employee training, financial solvency, fire clearance concerns, medication errors, and licensing fees. The facility is currently under investigation for previous citations.
Report Facts
Employees hired: 30
Licensing fee notices: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheyenne Flores | Health Services Director | Met with Licensing Program Analyst during inspection |
| Rajvir Sandhu | Executive Director | Will be overseeing the community as the new Administrator |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 64
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not provide a resident with water for an extended period of time.
Complaint Details
The complaint alleged that on June 27, 2024, a resident was sitting outside for 4-6 hours without being offered water. The investigation found multiple hydration opportunities were provided, corroborated by staff interviews and law enforcement findings, resulting in the allegation being unsubstantiated.
Findings
The investigation included four unannounced visits, observations, interviews, and review of a law enforcement report. The allegation that staff failed to provide water to the resident was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Number of unannounced visits: 4
Facility capacity: 64
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Nancy Steers-Crist | Interim Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 38
Capacity: 64
Deficiencies: 3
Date: Aug 21, 2024
Visit Reason
The inspection visit was an unannounced continuation of an annual inspection to evaluate compliance with licensing requirements at the facility.
Findings
The inspection found deficiencies related to incomplete staff training, including first aid, dementia care, and medication training for certain staff members. The facility was requested to update several documents and submit plans of correction by specified due dates.
Deficiencies (3)
Required First aid for staff (S1) was not current.
Required staff dementia training for S1, S2 & S3 was not complete.
Required medication training for S2 was not complete.
Report Facts
Staff records reviewed: 6
Resident records reviewed: 5
Deficiencies cited: 3
Plan of Correction due date: Sep 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Nancy Steers-Crist | Interim Administrator | Met with Licensing Program Analyst during inspection |
| Antonette Edwards | Administrator/Director | Facility Administrator with certificate expiring 9/26/2024 |
| Bethany Moellers | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 38
Capacity: 64
Deficiencies: 2
Date: Aug 13, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with regulations at the full memory care facility.
Findings
The inspection found several deficiencies including accessible dangerous items to residents with dementia, maintenance issues such as a large hole in the kitchen pantry ceiling, faulty stove pilot light, and inoperable electrical lighting and air temperature control in a resident room. The facility was cited for these violations and required to submit plans of correction.
Deficiencies (2)
Items that could constitute a danger to residents with dementia, such as scissors, razors, hydrogen peroxide, and other personal hygiene products, were accessible in multiple resident rooms.
Facility was not clean, safe, sanitary, and in good repair due to a large hole in the kitchen pantry ceiling, faulty stove pilot light, missing window screen in room 20, and no electrical lighting or air temperature control in resident room 23.
Report Facts
Residents on Hospice: 7
Fire extinguishers inspected: 12
Resident bathrooms checked for hot water temperature: 8
Resident files reviewed: 5
Personnel files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | License Program Analyst | Conducted the annual inspection and cited deficiencies |
| Nancy Steers-Crist | Interim Administrator | Met with LPA during inspection and involved in observations |
| Bethany Moellers | Supervisor | Supervisor overseeing the inspection process |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 2
Date: Jun 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of inadequate staffing and untimely answering of the facility telephone.
Complaint Details
The complaint investigation was substantiated. Allegations included inadequate staffing and failure to timely answer the facility telephone. Evidence showed staffing shortages and telephone outages from May 20, 2024, until repaired on May 23, 2024.
Findings
The investigation substantiated that the facility was short staffed, lacking a full-time receptionist since late April, and that the telephone system was not functioning properly until repaired during the investigation. These deficiencies posed potential health, safety, or personal rights risks to residents.
Deficiencies (2)
Facility personnel were not sufficient in numbers and competent to meet resident needs, with only 2 caregivers on each side during AM and PM shifts and 1 Med Tech on each side, despite having 43 residents including 8 two-person assists.
Telephone service was not functioning adequately, with phones disconnected or not in service from May 20, 2024, until repaired during the investigation.
Report Facts
Residents: 43
Two-person assists: 8
Caregivers on AM & PM shifts: 4
Med Techs on AM & PM shifts: 2
Caregivers on night shift: 2
Capacity: 64
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Irene Hernandez | Regional Vice President | Met with Licensing Program Analyst during investigation as Administrator was not available |
| Antonette Edwards | Administrator | Facility Administrator named but not available during investigation |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 64
Deficiencies: 1
Date: May 23, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were not current on required trainings including CPR, First Aid, dementia, and medication training.
Complaint Details
The complaint alleging staff were not current on required trainings was substantiated based on review of staff training records and interviews.
Findings
The investigation found the allegation substantiated; staff training records for dementia care, medication, CPR, and First Aid were insufficient or not current for most staff, posing a potential risk to resident health and safety.
Deficiencies (1)
Failure to meet training requirements for licensees, administrators, and staff including dementia care, medication training, and CPR & First Aid certification.
Report Facts
Census: 43
Total Capacity: 64
Deficiency Count: 1
Plan of Correction Due Date: Jun 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Serina Barreda | Business Office Manager | Met with evaluator during investigation and involved in training record review |
| Jennifer Rice | Nurse Consultant | Met with evaluator during investigation and involved in training record review |
| Antonette Edwards | Administrator | Facility administrator; not available during investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Follow-Up
Census: 43
Capacity: 64
Deficiencies: 1
Date: May 23, 2024
Visit Reason
The visit was an unannounced case management follow-up to a self-reported incident of resident elopement submitted on 2024-05-21.
Findings
The facility failed to comply with safety measures to prevent wandering of a resident with dementia, resulting in a third repeat violation of regulation 87705(b)(2) within 12 months. Civil penalties of $1,000 were assessed.
Deficiencies (1)
Failure to implement safety measures to address wandering behaviors of a resident with dementia, allowing elopement without staff knowledge.
Report Facts
Civil Penalties: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Serina Barreda | Business Office Manager | Met during inspection and interviewed regarding incident |
| Jennifer Rice | Nurse Consultant | Met during inspection and interviewed regarding incident |
| Bethany Moellers | Supervisor | Named in report as supervisor |
| Shannan Hansen | Licensing Evaluator | Conducted inspection and signed report |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 64
Deficiencies: 1
Date: May 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff were not managing residents' medication properly, including missing medications and non-compliance in the medication room.
Complaint Details
The complaint was substantiated. Staff failed to administer scheduled insulin to resident R1 on 5/9/2024 and medication room conditions were not compliant. Civil penalties of $250 were assessed for a second repeat violation within 12 months.
Findings
The complaint was substantiated with evidence that a resident did not receive a scheduled insulin dose on 5/9/2024, and observations found opened pudding in the medication cart posing a health and safety risk. A citation and civil penalty were issued for medication errors and a repeat violation.
Deficiencies (1)
Failure to assist residents with self-administered medications as needed, including not administering 4:30pm insulin on 5/9/2024 as prescribed and unsafe medication storage practices.
Report Facts
Civil Penalty Amount: 250
Deficiency Citation: 1
Plan of Correction Due Date: May 21, 2024
Plan of Correction Due Date: May 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted complaint investigation and issued findings. |
| Serina Barreda | Business Office Manager | Met with investigator during complaint investigation. |
| Jennifer Rice | Nurse Consultant | Met with investigator during complaint investigation. |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation. |
| Antonette Edwards | Administrator | Facility administrator referenced in investigation but not present at meeting. |
Inspection Report
Capacity: 64
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
The visit was an unannounced office Non-Compliance Conference conducted to review concerns identified by the Community Care Licensing Agency regarding the operation of The Vineyard at Fountaingrove.
Findings
The conference discussed issues including financial solvency, fire clearance concerns with unresolved plan of correction, insufficient care and supervision with medication errors from previous citations, administrator duties and qualifications, licensing fees with late payments, and the facility's future compliance. No new deficiencies were cited during this conference.
Report Facts
Facility capacity: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Moellers | Licensing Program Manager | Supervisor present at the Non-Compliance Conference |
| Shannan Hansen | Licensing Program Analyst | Licensing evaluator who met with the facility during the Non-Compliance Conference |
| Joseph Hansen | Administrator/Director | Facility administrator named in the report |
Inspection Report
Plan of Correction
Census: 48
Capacity: 64
Deficiencies: 1
Date: Mar 27, 2024
Visit Reason
The visit was an unannounced Plan of Correction (POC) follow-up to verify correction of previously cited deficiencies related to malfunctioning hallway fire doors.
Findings
The facility had not corrected the previously cited deficiency regarding hallway fire doors that could not shut on their own due to broken magnetic devices. Multiple internal fire doors were observed wedged open with door stops, and the facility had not provided a scheduled repair appointment.
Deficiencies (1)
Hallway fire doors malfunctioning due to broken magnetic devices, preventing them from closing properly.
Report Facts
Civil penalties assessed: 700
Daily penalty amount: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Hansen | Administrator | Named in relation to previous case management visit and facility tour |
| Christina Cruz | Marketing Director/Assistant Executive Director | Met with Licensing Program Analysts during the POC visit |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 64
Deficiencies: 1
Date: Mar 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility is in financial distress.
Complaint Details
The complaint was substantiated. The facility did not provide requested financial documentation despite multiple requests, and evidence supported that the facility is in financial distress.
Findings
The investigation found that the facility failed to provide requested financial documentation and is experiencing financial distress, posing an immediate health, safety, and personal rights risk to residents. The allegation was substantiated based on interviews, observations, and audit findings.
Deficiencies (1)
Licensee failed to have a financial plan assuring sufficient resources to meet operating costs for care of residents, as required by CCR 87213.
Report Facts
Capacity: 64
Census: 48
Plan of Correction Due Date: Apr 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Cruz | Marketing Director/Assistant Executive Director | Met during investigation and agreed to provide corporate and management company reports |
| Eric Perry | Administrator | Administrator who deferred to corporate members regarding financial documentation |
| Shannan Hansen | Licensing Evaluator | Conducted the complaint investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Follow-Up
Census: 47
Capacity: 64
Deficiencies: 3
Date: Feb 20, 2024
Visit Reason
The visit was an unannounced case management follow-up to a self-reported incident of resident elopement submitted on 2024-02-01, to assess compliance and safety measures.
Complaint Details
The visit was triggered by a self-reported incident of resident elopement on 2024-01-29. The resident was found uninjured after leaving the facility unassisted. The complaint was substantiated with findings of safety deficiencies and repeated violations.
Findings
The facility was cited for not having an updated Physician’s Report for a dementia resident within the required 12-month period and for malfunctioning hallway fire doors. Civil penalties of $1,000 were issued due to a repeated violation related to resident safety and elopement.
Deficiencies (3)
Failure to ensure safety measures for residents with dementia, resulting in resident elopement without staff knowledge.
Failure to have an updated Physician’s Report for a dementia resident within the required 12-month period.
Hallway fire doors malfunctioning due to broken magnetic devices, posing a potential health and safety risk.
Report Facts
Civil penalties: 1000
Capacity: 64
Census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Hansen | Administrator | Met with Licensing Program Analyst during the inspection and involved in discussion of findings. |
| Shannan Hansen | Licensing Evaluator | Conducted the inspection and signed the report. |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 64
Deficiencies: 1
Date: Jan 23, 2024
Visit Reason
The visit occurred as a case management follow-up to deliver complaint findings related to a medication error self-reported by the facility that occurred on 11/17/2023.
Complaint Details
The visit was complaint-related based on a self-reported medication error incident. The report documents the error, corrective actions taken, and no adverse effects to the resident. Substantiation status is not explicitly stated.
Findings
A medication error was identified where a resident (R1) was given a second dose of PRN medication within hours, contrary to physician orders. The error was caught the same day, reported to health services and the responsible party, and the staff involved was disciplined and relieved of medication duties.
Deficiencies (1)
Failure to administer PRN medication to resident as prescribed by physician, posing an immediate health and safety risk.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Hansen | Administrator | Met with Licensing Program Analyst during case management visit |
| Shannan Hansen | Licensing Evaluator | Conducted inspection and signed report |
| Bethany Moellers | Supervisor | Named as supervisor in report |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 64
Deficiencies: 1
Date: Jan 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-08-24 regarding cleanliness, care, supervision, and safeguarding of residents' personal belongings at the facility.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility did not ensure residents' rooms were clean, safe, and sanitary. The complaint was unsubstantiated for allegations of lack of care and supervision resulting in severe malnutrition and dehydration, failure to meet care needs, and failure to safeguard residents' personal belongings.
Findings
The investigation substantiated the allegation that the facility did not ensure residents' rooms were clean, safe, and sanitary due to insufficient housekeeping staff. However, allegations related to lack of care and supervision resulting in severe malnutrition and dehydration, failure to meet care needs, and failure to safeguard residents' personal belongings were unsubstantiated based on evidence and interviews.
Deficiencies (1)
87303 (a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Report Facts
Capacity: 64
Census: 46
Weight loss: 35
Plan of Correction Due Date: Jan 26, 2024
Additional staff hired: 7
Total caregivers: 22
Full-time housekeepers hired: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Hansen | Executive Director | Met with Licensing Program Analyst during investigation |
| Shannan Hansen | Licensing Program Analyst | Conducted complaint investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing investigation |
| Eric Perry | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 64
Deficiencies: 1
Date: Oct 2, 2023
Visit Reason
An unannounced complaint investigation was conducted following allegations that a resident's room was not locked as requested, resulting in another resident entering and assaulting the resident.
Complaint Details
The complaint was substantiated based on evidence including staff statements, resident interviews, and observations. The facility was previously cited for the same issue and failed to correct it, resulting in a repeat violation and civil penalty.
Findings
The investigation substantiated the allegation that the facility failed to keep the resident's room locked as required, leading to an assault. This was a repeat violation resulting in a $250 civil penalty.
Deficiencies (1)
Failure to ensure residents' rights to safe, healthful, and comfortable accommodations by not securing resident's room doors as required.
Report Facts
Civil penalty amount: 250
Deficiency type count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Hansen | Executive Director | Interviewed during investigation and named in findings regarding failure to secure resident's room |
| Kimiyo Jones | Health Services Director | Interviewed during investigation |
| Christina Cruz | Business Office Director | Interviewed during investigation |
| Shannan Hansen | Licensing Program Analyst | Conducted complaint investigation and authored report |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 64
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-07-06 regarding resident care issues including unexplained injuries, delayed medical attention, delayed insulin administration, and unmet care needs.
Complaint Details
The complaint investigation addressed multiple allegations: 1) Resident sustained unexplained injuries while in care; 2) Staff did not seek timely medical attention for resident; 3) Staff did not administer resident’s insulin in a timely manner; 4) Facility staff did not meet residents care needs. All allegations were found to be unsubstantiated after review of documentation and interviews.
Findings
The investigation found insufficient evidence to prove or disprove the allegations. All allegations including unexplained injuries, untimely medical attention, delayed insulin administration, and unmet care needs were determined to be unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Capacity: 64
Census: 42
Complaint Control Number: 21-AS-20230706090520
Dates of medical contacts: 6
Delay in insulin administration: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Evaluator | Conducted complaint investigation and authored report |
| Joseph Hansen | Executive Director | Met with Licensing Evaluator during investigation |
| Christina Cruz | Business Office Director | Met with Licensing Evaluator during investigation |
| Kimiyo Jones | Health Services Director | Met with Licensing Evaluator during investigation |
| Eric Perry | Administrator | Facility Administrator named in report header |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation |
| S1 | Staff member involved in insulin administration and medical attention findings |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 64
Deficiencies: 5
Date: Sep 21, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including insufficient staffing, mismanagement of medication, lack of activities, and transportation issues at the facility.
Complaint Details
The complaint investigation was substantiated for allegations of insufficient staffing, inability to supply appropriate incontinent care products, staff not following residents' care needs, mismanagement of medication, lack of activities, and transportation issues. Allegations of residents wandering due to staff neglect, inadequate food service, and dishwasher disrepair were unsubstantiated.
Findings
The investigation substantiated multiple allegations including insufficient staffing to meet resident needs, inability to supply appropriate incontinent care products, staff not following residents' care needs, mismanagement of residents' medication, lack of activities for residents, and non-operational transportation. Other allegations such as residents wandering due to staff neglect, inadequate food service, and dishwasher disrepair were unsubstantiated.
Deficiencies (5)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
Care of Persons with Dementia. There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor disposed of according to the hospice’s established procedures shall be destroyed in the facility by the facility administrator and one other adult who is not a resident.
Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.
Motor Vehicles Used in Transporting Residents. Only drivers licensed for the type of vehicle operated shall be permitted to transport residents. The rated seating capacity of the vehicles shall not be exceeded. Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition.
Report Facts
Capacity: 64
Census: 45
Deficiencies cited: 5
Expired medication counts: 11
Expired medication counts: 2
POC Due Dates: Sep 21, 2023
POC Due Dates: Sep 22, 2023
POC Due Dates: Sep 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Interviewed regarding transportation issues |
| Christina Cruz | Assistant Executive Director | Met with Licensing Program Analyst during investigation |
| Kimiyo Jones | Health Services Director | Met with Licensing Program Analyst during investigation |
| Betty Kennedy | Executive Chef | Interviewed regarding food service and dishwasher |
| James Brady | Environmental Services Director | Interviewed regarding dishwasher repairs |
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 64
Deficiencies: 1
Date: Sep 12, 2023
Visit Reason
The inspection visit was conducted as a case management incident investigation continuing from a complaint, specifically related to two reported insulin medication errors at the facility.
Complaint Details
The visit was complaint-related, investigating two insulin medication errors. The complaint was substantiated as the facility self-reported the incidents. Immediate civil penalties were issued due to repeated citation within 12 months.
Findings
Two insulin medication errors were self-reported by the facility involving failure to administer prescribed insulin doses to two residents, posing an immediate health and safety risk. Immediate civil penalties of $250 were issued due to repeated citation within 12 months, and the responsible staff member was suspended for 7 days.
Deficiencies (1)
Failure to assist residents with self-administered medications as needed, specifically two insulin medication errors where staff did not administer insulin as prescribed.
Report Facts
Civil penalty amount: 250
Suspension duration (days): 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the investigation and authored the report. |
| Rickay Hidalgo | VP of Operations West Region | Met with Licensing Program Analyst during investigation. |
| Edie Cano | Regional Director of Operations/West Region | Provided information about staff suspension and facility actions. |
| Joe Hansen | Interim Administrator | Met with Licensing Program Analyst during investigation. |
| Christina Cruz | Assistant ED/Marketing Director | Met with Licensing Program Analyst during investigation. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 1
Date: Aug 31, 2023
Visit Reason
The visit was conducted as a case management follow-up on issues found during a complaint investigation regarding delayed staff response times to resident call cords.
Complaint Details
The visit was a complaint investigation follow-up. The complaint was substantiated based on observed deficiencies in staff response times and equipment functionality.
Findings
The facility had multiple delayed response times to resident call cords, with seven responses between 10-30 minutes and at least 68 responses between 30-60 minutes. Staff were observed leaving pagers at the desk and some pagers were inoperable, posing an immediate risk to resident health, safety, and personal rights.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to meet resident needs, evidenced by delayed response times to call cords and inoperable pagers.
Report Facts
Response times between 10-30 minutes: 7
Response times between 30-60 minutes: 68
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Cruz | Interim Administrator | Met with Licensing Program Analyst during complaint investigation and case management |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 1
Date: Aug 31, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that the facility did not provide residents with safe, healthful, and comfortable accommodations, failed to respond timely to communication requests about residents, and did not safeguard residents' personal belongings.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility did not provide safe, healthful, and comfortable accommodations, based on evidence of repeated aggressive incidents by a resident and failure to implement safety measures. The allegations regarding untimely communication and safeguarding of personal belongings were unsubstantiated.
Findings
The complaint that the facility failed to provide safe, healthful, and comfortable accommodations was substantiated due to prior knowledge of a resident's violent tendencies and failure to update care plans or install requested safety measures. The allegation that staff did not respond timely to communication requests and did not safeguard residents' personal belongings were both found to be unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
Facility did not ensure the health and safety of clients by failing to have proper protocols or requested locks despite prior knowledge of a resident's aggressive behavior and repeat assaults.
Report Facts
Capacity: 64
Census: 41
Plan of Correction Due Date: Sep 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation |
| Eric Perry | Administrator | Named in findings related to failure to implement safety measures |
| Christina Cruz | Interim Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 45
Capacity: 64
Deficiencies: 2
Date: Jun 22, 2023
Visit Reason
The inspection visit was a case management continuation of an annual inspection to evaluate compliance with licensing regulations at the facility.
Findings
The inspection found deficiencies related to unsafe storage of disinfectants and sharp objects accessible to residents, posing immediate health and safety risks. Staff records showed some required first aid certifications were not current, though resident records were current.
Deficiencies (2)
Disinfectants and cleaning solutions were stored in a lower cabinet accessible to residents, posing an immediate health and safety risk.
Sharp objects including scissors, razors, and push pins were found unlocked and accessible to residents with dementia, posing an immediate health and safety risk.
Report Facts
Staff records reviewed: 6
Resident records reviewed: 5
Deficiency due date: Jun 23, 2023
Deficiency due date: Jun 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with Licensing Program Analyst during inspection; named in relation to removal of hazardous items and certification |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 45
Capacity: 64
Deficiencies: 1
Date: Jun 22, 2023
Visit Reason
The inspection visit was conducted as an annual inspection with case management to follow up on two self-reported incident reports involving resident elopements and an incident between residents.
Findings
The facility had multiple incidents of resident elopement and an altercation between residents, resulting in civil penalties for repeated violations related to safety measures for residents with dementia. The facility was cited for failure to implement adequate safety measures to prevent wandering and elopement.
Deficiencies (1)
Failure to implement safety measures to address behaviors such as wandering and exit seeking in residents with dementia, resulting in elopements.
Report Facts
Civil Penalties: 1000
Repeat Violations: 3
Incident Dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with Licensing Program Analyst during inspection and provided information about incidents. |
| Shannan Hansen | Licensing Evaluator | Conducted the inspection and authored the report. |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Annual Inspection
Census: 45
Capacity: 64
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
The inspection was an unannounced Annual Required - 1 Year inspection of the facility conducted by the License Program Analyst.
Findings
The inspection found that all exits were unobstructed, fire extinguishers were properly serviced, fire department inspection showed no violations, smoke alarms and carbon monoxide detectors were in place, bathrooms had required safety features, food supply was sufficient, hot water temperatures were within acceptable range, and medications were securely stored. However, the License Program Analyst was unable to complete the review of resident and personnel files and medication review, and will return at a later date to complete the inspection.
Report Facts
Residents on Hospice: 9
Fire extinguishers: 12
Resident bathrooms checked for hot water temperature: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with License Program Analyst during inspection and toured facility |
| Shannan Hansen | License Program Analyst | Conducted the Annual Required - 1 Year inspection |
| Ramona Sandoval | Office Manager | Welcomed License Program Analyst upon arrival |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 64
Deficiencies: 1
Date: May 19, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff mismanaged a resident's medication.
Complaint Details
The complaint was substantiated. Staff mismanaged Resident 1's medication by failing to administer Coumadin (Warfarin) on multiple dates in March 2023 and incorrectly entering medication orders in the electronic MAR, leading to missed doses on 5/15/23. Immediate civil penalties of $250 were issued due to repeated citation within 12 months.
Findings
The investigation substantiated that staff failed to administer Warfarin medication as prescribed to Resident 1, including missed doses and incorrect medication entries in the electronic MAR, resulting in an immediate health and safety risk. The facility implemented corrective actions including an alert charting system and interim service to prevent recurrence.
Deficiencies (1)
The Administrator failed to assist residents with self-administered medications as needed, resulting in medication errors and missed doses of Warfarin.
Report Facts
Capacity: 64
Census: 44
Fine amount: 250
Plan of Correction Due Date: May 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Executive Director/Administrator | Met with Licensing Program Analyst during investigation and acknowledged medication error |
| Marisol Cuadra | Licensing Evaluator | Conducted the complaint investigation |
| Bethany Moellers | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Follow-Up
Census: 38
Capacity: 64
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
The inspection was an unannounced case management visit to follow up on a self-reported SOC 341 form submitted by the facility regarding an alleged staff-to-resident abuse incident.
Complaint Details
The visit was triggered by a self-reported incident where staff allegedly hit a resident three times. The facility is conducting an internal investigation and has notified appropriate authorities.
Findings
No deficiencies were cited during the inspection. The facility reported the incident to the police and Ombudsman, notified the responsible party, and is conducting staff training on reporting requirements and disciplinary actions.
Report Facts
Incident report date: Feb 26, 2023
Report submission date: Mar 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Cruz | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Darien Gostas | Administrator | Facility Administrator named in report header |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Supervisor | Supervisor named in report |
Inspection Report
Follow-Up
Census: 41
Capacity: 64
Deficiencies: 1
Date: Jan 17, 2023
Visit Reason
The inspection was an unannounced case management follow-up visit to review three self-reported incident reports and two SOC 341 forms submitted to Community Care Licensing.
Findings
The facility was cited for repeated deficiencies related to resident elopement and safety measures for residents with dementia, resulting in civil penalties. Incidents included residents eloping without staff knowledge and aggressive behavior between residents.
Deficiencies (1)
Failure to ensure safety measures to address behaviors such as wandering, aggressive behavior, and ingestion of toxic materials for residents with dementia.
Report Facts
Civil Penalty Amount: 250
Civil Penalty Amount: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Cruz | Assistant Executive Director | Met with Licensing Program Analyst during the inspection. |
| Darien Gostas | Administrator | Administrator was out during inspection; involved in incident reporting and follow-up. |
| Shannan Hansen | Licensing Evaluator | Conducted the inspection and signed the report. |
| Bethany Moellers | Supervisor | Supervisor overseeing the inspection. |
Inspection Report
Census: 40
Capacity: 64
Deficiencies: 0
Date: Dec 29, 2022
Visit Reason
The inspection was an unannounced case management visit to follow up on a self-reported incident and SOC 341 form submitted to Community Care Licensing regarding resident incidents.
Findings
The facility reported two incidents involving residents, increased supervision, and updated medications to ensure safety. No deficiencies were cited during this inspection.
Report Facts
Capacity: 64
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darien Gostas | Administrator | Met with Licensing Program Analyst during inspection and involved in incident follow-up |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 64
Deficiencies: 1
Date: Dec 6, 2022
Visit Reason
The inspection was conducted as a Case Management-Deficiency inspection following a Special Incident Report that a resident with dementia eloped from the facility unassisted on two occasions.
Complaint Details
The visit was complaint-related due to a Special Incident Report of a resident eloping unassisted on 11/25/2022 and again on 12/5/2022. The facility was contacted by law enforcement to return the resident. The complaint was substantiated by the findings.
Findings
The facility failed to implement adequate safety measures to address wandering behavior of a resident with dementia, resulting in two elopements that posed an immediate health and safety risk. Deficiencies were cited related to care of persons with dementia and elopement prevention.
Deficiencies (1)
Failure to address behaviors such as wandering in residents with dementia, resulting in elopement incidents.
Report Facts
Capacity: 64
Census: 43
Plan of Correction Due Date: Dec 7, 2022
Plan of Correction Training Submission Due Date: Dec 14, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darien Gostas | Administrator | Met with Licensing Program Analyst during inspection and provided information about resident elopements |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Follow-Up
Census: 41
Capacity: 64
Deficiencies: 0
Date: Nov 15, 2022
Visit Reason
The inspection was an unannounced case management visit to follow up on two SOC 341 incident reports and a self-reported incident submitted to Community Care Licensing.
Findings
The inspection found multiple aggressive incidents involving residents, with no injuries reported. The facility is monitoring affected residents and coordinating with families and authorities. No deficiencies were cited during this inspection.
Report Facts
Aggressive incidents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darien Gostas | Administrator | Met with Licensing Program Analyst during inspection and provided information on incidents |
| Shannan Hansen | Licensing Evaluator | Conducted the unannounced case management inspection |
| Bethany Moellers | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 1
Date: Nov 4, 2022
Visit Reason
The visit was an unannounced case management inspection to follow up on an incident report received regarding a medication error involving three residents who did not receive their scheduled morning insulin.
Complaint Details
The visit was triggered by a complaint incident report received on 11/02/2022 regarding a medication error on 11/01/2022 involving three residents missing their scheduled morning insulin. The deficiency was substantiated and cited under CCR 87465(a)(5).
Findings
The inspection found a medication error where three residents missed their morning insulin due to miscommunication among nursing staff. The facility took corrective actions including monitoring residents and contacting physicians. A deficiency was cited for failure to assist residents with self-administered medications as required.
Deficiencies (1)
Medication error due to failure to assist residents with self-administered medications as needed, resulting in missed morning insulin for three residents.
Report Facts
Residents affected: 3
Deficiency citation: 1
Plan of Correction due date: Nov 7, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darien Gostas | Administrator | Met during inspection and named in medication error finding |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and evaluation |
| Bethany Moellers | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 64
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
The visit was an unannounced case management inspection regarding a recently reported self-incident involving suspected verbal abuse of a resident.
Complaint Details
The complaint involved a suspected verbal abuse incident reported on 7/25/22, occurring on 7/21/22, involving a caregiver raising their voice and swearing at a resident, with a possible slap heard. The police were contacted but did not generate a report due to lack of injuries. The facility conducted an internal investigation with no report generated yet. The allegation was probably not substantiated.
Findings
The investigation found no apparent injury or physical signs of abuse to the resident. The allegation was probably not substantiated based on interviews and assessments. No deficiencies were cited during the visit.
Report Facts
Incident date: Jul 21, 2022
Report submission date: Jul 25, 2022
Report date: Jul 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Annet Nakiyuka | Administrator | Met with Licensing Program Analyst during the visit and involved in the internal investigation |
| Marisol Cuadra | Licensing Evaluator | Conducted the unannounced case management visit |
| Bethany Moellers | Supervisor | Supervisor of the Licensing Program Analyst |
Inspection Report
Annual Inspection
Census: 42
Capacity: 64
Deficiencies: 1
Date: Jun 9, 2022
Visit Reason
An unannounced Annual Required 1-year Infection Control inspection was conducted to evaluate compliance with health and safety regulations at the facility.
Findings
The facility was generally clean and well-maintained with proper infection control measures in place, but a deficiency was found with hot water temperatures in 9 of 11 resident bathrooms exceeding the regulatory limit of 120 degrees F, posing an immediate health and safety risk.
Deficiencies (1)
Hot water temperature in 9 of 11 resident bathrooms ranged between 120.3 and 124.3 degrees F, exceeding the required range of 105 to 120 degrees F.
Report Facts
Residents bedridden: 2
Residents on Hospice: 7
Deficiencies cited: 1
Hot water temperature range: 120.3
Hot water temperature range: 124.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Annet Nakiyuka | Administrator | Named as facility administrator during inspection |
| Michelle Larrew | Health Services Director | Acting administrator during inspection and accompanied LPA on tour |
| Hercules Cuevas | Environmental Services Director | Provided information about hot water temperature adjustment |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 64
Deficiencies: 1
Date: May 17, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation regarding the lack of documentation of a resident's personal property inventory at the facility.
Complaint Details
The visit was triggered by a complaint investigation concerning missing documentation of a resident's personal property inventory. The deficiency was substantiated and corrected during the visit.
Findings
The investigation found that no documentation existed for the initial personal property inventory of resident R1, constituting a potential violation of the resident's personal rights. The deficiency was corrected at the time of the visit by the facility administration.
Deficiencies (1)
No documentation exists at the facility of the initial inventory of R1's personal property, violating personal rights.
Report Facts
Capacity: 64
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and noted the deficiency |
| Annet Nakiyuka | Administrator | Facility administrator who corrected the deficiency |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 64
Deficiencies: 0
Date: May 17, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that the facility failed to safeguard residents' belongings and violated personal rights.
Complaint Details
The allegations were unsubstantiated after investigation. No evidence was found to prove that residents stole property or entered the resident's room uninvited and acted inappropriately.
Findings
The investigation found no evidence to substantiate the allegations of theft or inappropriate entry into a resident's room. The resident involved has dementia and a pattern of making inaccurate theft allegations. No citations were issued.
Report Facts
Capacity: 64
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Evaluator | Conducted the complaint investigation and delivered findings |
| Shawn Mooney | Administrator | Facility administrator met during the investigation |
Inspection Report
Follow-Up
Census: 43
Capacity: 64
Deficiencies: 0
Date: May 3, 2022
Visit Reason
The visit was an unannounced follow-up to an incident that occurred on April 22, 2022, involving the discovery of a bullet remnant inside a resident's room after a broken window was found.
Findings
The facility administration took appropriate action by securing the window, relocating the resident at the family's request, and involving the police. No citations were issued, and no further action was required pending the police report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Annet Nakiyuka | Administrator | Interviewed during the visit and involved in incident response |
| David Leibert | Licensing Program Analyst | Conducted the unannounced follow-up visit |
| Carla Martinez | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 1
Date: Jan 20, 2022
Visit Reason
This was an unannounced complaint investigation visit conducted in response to allegations including staff not responding to resident call bells in a timely manner, lack of supervision resulting in resident injury, insufficient staffing, failure to answer the facility main telephone line, and failure to provide managed incontinence care.
Complaint Details
The complaint investigation was substantiated regarding staff not responding timely to resident call bells. Other allegations were unsubstantiated. The investigation was conducted by Licensing Program Analyst Shannan Hansen following a complaint received on 07/12/2021.
Findings
The investigation substantiated the allegation that staff failed to respond timely to resident call bells, with documented instances of calls unanswered for over 15 and 30 minutes. Other allegations including lack of supervision, insufficient staffing, failure to answer the main telephone, and failure to provide managed incontinence care were found unsubstantiated.
Deficiencies (1)
Facility personnel failed to respond to emergency call bell alarms in a timely manner.
Report Facts
Call bell response delays: 68
Call bell response delays: 36
Deficiency citation count: 1
Staff on night duty: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Annet Nakiyuka | Executive Director | Met with Licensing Program Analyst during investigation. |
| Michelle Larrew | Health Services Director | Met with Licensing Program Analyst during investigation. |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 0
Date: Sep 23, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 06/22/2021 regarding allegations of resident neglect and improper care.
Complaint Details
The complaint involved allegations that a resident had a fall and sustained multiple injuries due to staff negligence and lack of care, staff were not assisting the resident timely, did not transfer the resident properly, and did not follow the resident care plan. The allegations were found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the allegations of resident fall due to staff negligence, untimely assistance, improper transfer, and failure to follow the care plan were unsubstantiated. No deficiencies or citations were issued during the visit.
Report Facts
Facility capacity: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Mooney | Administrator | Met with during inspection and mentioned in findings |
| Dina Alviso | Licensing Evaluator | Conducted the complaint investigation |
| Hope DeBenedetti | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 2
Date: Sep 23, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff do not safeguard residents' personal belongings and that the facility entrance automatic door openers were not working properly.
Complaint Details
The complaint investigation was substantiated based on interviews and observations. The allegations included staff not safeguarding residents' personal belongings and malfunctioning automatic door openers. The preponderance of evidence standard was met, and citations were issued accordingly.
Findings
The investigation substantiated the allegations that staff did not adequately safeguard residents' personal belongings and that the facility's automatic door openers were not functioning properly. The facility had ongoing issues with the door openers and lacked official repair documentation, and new procedures were instituted to better safeguard resident belongings.
Deficiencies (2)
Failure to safeguard resident personal belongings, violating residents' personal rights as per CCR 87468.1(a)(12).
Facility entrance automatic door openers not working properly, violating maintenance and operation requirements per CCR 87303(a).
Report Facts
Facility capacity: 64
Plan of Correction due date: Sep 24, 2021
Plan of Correction due date: Sep 30, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Mooney | Administrator | Named in findings related to door repairs and safeguarding resident belongings |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Annette | Administrator Assistant | Discussed safeguarding procedures and resident belongings issues |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 0
Date: Sep 23, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 06/16/2021 alleging that a resident was not adequately supervised.
Complaint Details
The complaint alleged that a resident was not adequately supervised. The investigation included interviews with staff, residents, and review of facility and hospital records. The allegation was found to be unsubstantiated.
Findings
The investigation found that the resident (R1) was a full need resident requiring hourly checks, and staff conducted hourly checks and routine care as documented. Although the resident had a fall resulting in multiple injuries, the allegation of inadequate supervision was unsubstantiated due to lack of preponderance of evidence. No deficiencies or citations were issued.
Report Facts
Facility capacity: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dina Alviso | Licensing Evaluator | Conducted the complaint investigation |
| Shawn Mooney | Administrator | Facility administrator met during inspection |
| Shannan Hansen | Licensing Program Analyst who conducted complaint inspection | |
| Hope DeBenedetti | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 64
Deficiencies: 2
Date: Jul 23, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations that staff failed to administer resident's medication as prescribed and failed to safeguard resident's personal belongings.
Complaint Details
The complaint investigation was substantiated for allegations that staff failed to administer medication as prescribed and failed to safeguard resident's personal belongings. The allegations regarding resident falls and incontinent care were unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated that staff continued to administer a discontinued medication to a resident and failed to safeguard resident's personal belongings, which went missing. Another complaint regarding resident falls and incontinent care was unsubstantiated due to insufficient evidence.
Deficiencies (2)
Staff failed to administer medication according to physician's orders, continuing a discontinued medication for several days.
Staff failed to safeguard resident's personal belongings, resulting in missing medical care supplies and personal items.
Report Facts
Capacity: 64
Census: 51
Plan of Correction Due Date: Jul 24, 2021
Plan of Correction Due Date: Aug 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Mooney | Administrator | Named in relation to findings and responsible for ensuring staff training and submitting plans of correction |
| Dina Alviso | Licensing Evaluator | Conducted the complaint investigation |
| Karen Lopez | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Annual Inspection
Census: 51
Capacity: 64
Deficiencies: 0
Date: Jul 23, 2021
Visit Reason
An unannounced required annual inspection was conducted focusing on the facility's infection control procedures.
Findings
The facility was found to be clean and compliant with infection control and safety regulations, including proper food storage, secured medications, and staff wearing masks. No deficiencies were cited during the inspection.
Report Facts
Hot water temperature: 110
Inspection start time: 1005
Inspection end time: 1340
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Mooney | Administrator | Met with Licensing Program Analysts during the inspection. |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 1
Date: Apr 9, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted due to a complaint that staff were not answering the facility's main phone line.
Complaint Details
The complaint was substantiated. The allegation that staff were not answering the facility's main phone line was confirmed. A citation (87411(a)(e)) was issued related to personnel requirements.
Findings
The investigation substantiated the allegation that staff failed to answer the main phone line for approximately four hours due to a new receptionist not switching the night mobile phone line back to the main line. The issue was corrected promptly and in-service training was provided to the staff.
Deficiencies (1)
Failure to ensure staff answered the facility's main phone line due to a receptionist not switching the phone line back, causing calls to go unanswered for approximately four hours.
Report Facts
Total licensed capacity: 64
Citation number: 87411
Plan of Correction due date: Apr 13, 2021
Duration of phone line issue: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Mason | Executive Director | Named in relation to the phone line issue and corrective actions |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
Report
March 21, 2025
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January 9, 2025
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May 9, 2024
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