Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. The facility’s most recent report on July 22, 2025, was a complaint investigation with no deficiencies cited and allegations found to be unfounded. Past issues included a serious deficiency in August 2023 when a resident was left unattended, posing an immediate safety risk, and a $1,500 fine in December 2022 for staff fingerprinting noncompliance. Other complaints over time involved concerns about medication management, resident care, and environment, but these were mostly unsubstantiated or resolved without citations. The facility appears to have improved since the serious events, with no deficiencies noted in recent inspections.
The visit was an unannounced Case Management - Incident inspection conducted in response to an Incident Report received on 2025-07-16 alleging staff yelling at a resident.
Findings
The investigation found the allegations to be unfounded based on interviews with staff and the resident, and review of the resident's records. No deficiencies were cited.
Complaint Details
The complaint involved a resident reporting hearing two staff yelling at another resident, but the resident could not identify the staff or residents involved. Interviews with four staff and the resident did not corroborate the allegation. The resident's medical and service records indicated no cognitive impairments affecting reliability. The allegations were determined to be unfounded.
Report Facts
Facility capacity: 240
Employees Mentioned
Name
Title
Context
Brenda Ritter
Interim Executive Director
Met with during the inspection and stated the purpose of the visit
Simranjit Rai
Licensing Program Analyst
Conducted the unannounced Case Management - Incident visit
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-05-06 regarding staff treatment of residents, adequacy of food service, and supervision of fall-risk residents.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Observations and staff interviews indicated that residents were treated with dignity and respect, food service was adequate, and fall-risk residents were supervised appropriately.
Complaint Details
The complaint included allegations that facility staff did not treat residents with dignity and respect, did not provide adequate food service, and failed to supervise residents at fall risk. After interviews, observations, and record reviews, the allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 240
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation and observations
Romeo Manzano
Licensing Program Manager
Oversaw the complaint investigation
Corey Miller
Administrator
Facility administrator during the investigation
Brenda Ritter
Interim Executive Director
Met with Licensing Program Analyst during the visit
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-12-31 regarding facility staff not allowing a resident to make phone calls and withholding a resident's personal check without their knowledge.
Findings
The investigation found the allegations to be unfounded after interviews with staff and the resident, review of records, and observation. The resident was able to make phone calls on their personal cellphone, and the facility did not withhold the resident's personal check.
Complaint Details
The complaint involved allegations that facility staff did not allow resident R1 to make phone calls and withheld R1's personal check without their knowledge. The investigation included interviews with seven staff members and the resident, review of the resident's physician report and financial arrangements, and attempts to contact the resident's responsible party. The allegations were found to be unfounded.
Report Facts
Complaint Control Number: 26Staff interviewed: 7Resident interviewed: 1Date complaint received: Dec 31, 2024
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation
Melissa Lummis
Business Office Director
Met with Licensing Program Analyst during investigation and exit interview
Corey Miller
Administrator
Facility administrator named in report header
Romeo Manzano
Licensing Program Manager
Named as Licensing Program Manager overseeing investigation
The visit was conducted as a complaint investigation following allegations that facility staff were not answering residents' call buttons and were not providing incontinence care at night.
Findings
The investigation found the allegations to be unfounded based on staff interviews, resident refusals to be interviewed, and review of call button reports and incontinence care records. No deficiencies were cited.
Complaint Details
The complaint included allegations that facility staff were not answering residents' call buttons and were not providing incontinence care at night. The allegations were found to be unfounded after investigation.
Report Facts
Census: 165Total Capacity: 240Number of staff interviewed: 5Number of residents interviewed: 5Call button report months reviewed: 2Residents reviewed for incontinence care: 5
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation and interviews
Melissa Lummis
Business Office Director
Met with Licensing Program Analyst during the visit and exit interview
The visit was an unannounced case management follow-up on an Incident Report and Death Report concerning a resident who sustained an unwitnessed fall and subsequently passed away at the hospital.
Findings
The Licensing Program Analyst reviewed the incident and death reports, obtained relevant medical and service documents, and determined that further investigation is needed regarding the case management of the incident.
Report Facts
Capacity: 240Census: 167
Employees Mentioned
Name
Title
Context
Brenda Ritter
Executive Director
Met with Licensing Program Analyst during the visit and discussed the incident
The visit was an unannounced complaint investigation triggered by an allegation that the facility did not maintain the fuel/diesel for the back-up power generator causing power outages.
Findings
The investigation found that the allegation was unfounded. The power outage on 4/22/2024 was due to low fuel in the generator maintained by a third-party vendor, not the facility. No deficiencies were cited.
Complaint Details
The complaint alleged failure to maintain fuel for the back-up power generator causing power outages. The allegation was found to be unfounded after interviews and document review.
Report Facts
Capacity: 240Census: 140
Employees Mentioned
Name
Title
Context
Wes McKinley
Maintenance Director
Interviewed during complaint investigation and exit interview
An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements and facility operations.
Findings
The inspection included a tour of the facility, review of resident and staff records, and safety checks. No deficiencies were cited during the visit, and all safety equipment and supplies were found to be in order.
Report Facts
Residents in assisted living: 135Residents in memory care: 31Staff records reviewed: 5Resident records reviewed: 5Resident medications reviewed: 5Staff interviewed: 2Residents interviewed: 4Room temperature: 70Hot water temperature range: 114Hot water temperature range: 116Fire extinguisher service date: Nov 2, 2024Sprinkler system inspection date: 202409Last drill date: Oct 7, 2024
Employees Mentioned
Name
Title
Context
Corey Miller
Administrator
Met with Licensing Program Analyst during the inspection and provided census information
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-06-14 alleging multiple issues including billing for services not rendered, failure to adhere to dietary restrictions, lack of dental hygiene assistance, and failure to follow the resident's Needs and Services Plan.
Findings
The investigation found that the allegations were either unfounded or unsubstantiated. The facility reimbursed a resident for billing errors, staff followed dietary orders as per physician instructions, and residents received appropriate dental hygiene reminders and assistance as documented. No deficiencies were cited.
Complaint Details
The complaint included allegations that the facility billed a resident for services not rendered, staff did not adhere to dietary restrictions, did not assist with dental hygiene, and did not follow the resident's Needs and Services Plan. The investigation concluded the allegations were unsubstantiated or unfounded based on interviews, record reviews, and observations.
Report Facts
Facility capacity: 240
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation visit
Corey Miller
Executive Director
Met with Licensing Program Analyst during the investigation
The visit was an unannounced complaint investigation triggered by allegations received on 2024-06-10 regarding failure to submit death and incident reports and failure to maintain room temperatures within a comfortable range.
Findings
The investigation found all allegations to be unfounded. The facility submitted required death and incident reports timely, and temperatures in resident rooms and common areas were maintained within the required range of 78 to 85 degrees Fahrenheit.
Complaint Details
The complaint alleged the facility did not submit a Death Report for a resident, did not submit Incident Reports for positive COVID-19 cases, and did not maintain room temperatures between 78 and 85 degrees Fahrenheit. The investigation concluded these allegations were unfounded.
Report Facts
Capacity: 240Census: 147
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Corey Miller
Executive Director
Met with Licensing Program Analyst during the investigation
Ronald Ellenich
Administrator
Facility administrator named in the report
Romeo Manzano
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2023-09-07 alleging multiple issues including inadequate incontinence care, missed meal service, resident wearing the same clothing for over 24 hours, lack of snack provision, resident injury due to safety concerns, and inadequate staffing.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff interviews, resident interviews, and record reviews indicated that care and services were generally provided as required. The allegations were determined to be unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint included allegations that facility staff did not check residents for incontinence care, forgot to serve a meal, allowed a resident to wear the same clothing for at least 24 hours, did not provide snacks prior to supplemental fees, failed to ensure resident safety resulting in injury, and did not have adequate staffing. The investigation involved interviews with staff, residents, and review of care plans and records. The complaint was found to be unsubstantiated.
Report Facts
Complaint Control Number: 26-AS-20230907100701Number of residents present (census): 147Total licensed capacity: 240Staffing levels: 2-3 care staff and 1 Medication Technician per shift (morning and afternoon), 1-2 care staff and 1 Medication Technician during nocturnal shift
Employees Mentioned
Name
Title
Context
Corey Miller
Executive Director
Met with Licensing Program Analyst during inspection and exit interview
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation
Ronald Ellenich
Administrator
Interviewed regarding billing and staffing during complaint investigation
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-12-07 regarding resident care and facility conditions at Watermark at Almaden.
Findings
The investigation found all allegations to be unfounded after interviews with staff and residents, and review of incident reports, resident files, work orders, and activity calendars. No evidence supported claims of unexplained skin injuries, multiple falls, unsafe rooms, unattended medications, lack of activities or snacks, missed meals, obstructed passageways, or absent nighttime staff.
Complaint Details
The complaint included allegations of unexplained skin injuries, multiple falls leading to hospitalization, unsafe resident rooms, failure to safeguard personal clothing, unattended medications, lack of activities and snacks, missed meal service, obstructed passageways, and absence of nighttime staff. The investigation concluded all allegations were unfounded.
Report Facts
Incident Reports reviewed: 20Incident Reports related to hospitalization: 3Activities per week: 13Work orders related to passageways: 0Night shift staff coverage: 2
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation and interviews
Corey Miller
Executive Director
Facility representative met during the investigation
The visit was conducted as an unannounced complaint investigation following allegations received on 2023-01-26 regarding expired medication administration, improper medication dispensing and management, and inadequate feeding of residents.
Findings
After interviews with staff and residents, observations, and records review, the allegations were found to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited.
Complaint Details
The complaint included allegations that facility staff gave residents expired medication, did not properly dispense or manage medications, and failed to ensure residents were adequately fed. Investigations included staff and resident interviews and observations. The complaint was determined to be unsubstantiated.
Report Facts
Complaint Control Number: 26-AS-20230126091157Number of staff interviewed: 3Number of residents interviewed: 3
Employees Mentioned
Name
Title
Context
Corey Miller
Executive Director
Met with Licensing Program Analyst during investigation and exit interview
Simranjit Rai
Licensing Program Analyst
Conducted complaint investigation visit and interviews
The inspection was conducted as an unannounced complaint investigation following allegations of lack of staff supervision resulting in resident injury and understaffing at the facility.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff interviews, resident assessments, and record reviews indicated the allegations were unsubstantiated, and no deficiencies were cited.
Complaint Details
The complaint alleged lack of staff supervision resulting in injury to resident R1 and understaffing. The investigation included interviews with staff and paramedics, review of resident medical reports, and observation. The allegations were determined to be unsubstantiated.
Report Facts
Complaint Control Number: 26-AS-20221018164411Facility Capacity: 240Census: 145
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Corey Miller
Executive Director
Met with Licensing Program Analyst during the investigation
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2024-07-08 regarding an alleged unresolved water leak in a resident's room.
Findings
The investigation found the allegation to be unfounded after interviews and record reviews showed the facility addressed the water leak promptly with maintenance responding the day after the work order was submitted. No deficiencies were cited.
Complaint Details
The complaint alleged the facility did not address a water leak in a resident's room. The allegation was found to be unfounded based on interviews with the Maintenance Director and resident, and review of work orders showing timely response and resolution.
Report Facts
Complaint control number: 26Complaint received date: Jul 8, 2024Work order dates: 3
Employees Mentioned
Name
Title
Context
Simranjit Rai
Licensing Program Analyst
Conducted the complaint investigation and interviews
Corey Miller
Executive Director
Met with Licensing Program Analyst during investigation
Wes McKinley
Maintenance Director
Interviewed regarding work order and maintenance response
Ronald Ellenich
Administrator
Facility administrator present during exit interview
Licensing Program Analyst conducted a case management visit to perform a wellness check after power was restored at the facility.
Findings
The facility passed inspections by PG&E and City of San Jose after power restoration. The maintenance team will conduct regular checks on the generator and power grid. No deficiencies were cited at this time.
Report Facts
Capacity: 240Census: 149
Employees Mentioned
Name
Title
Context
Corey Miller
Executive Director
Met with Licensing Program Analyst during the visit
Wesley McKinley
Maintenance Director
Interviewed regarding power restoration and facility maintenance
The visit was an unannounced Case Management visit conducted to perform a health and wellness check following two power outage incidents reported by the facility on 2024-04-14 and 2024-04-22.
Findings
The facility was able to maintain normal operations during both power outages using a power generator. No issues were observed with water or room temperatures, medication administration, or meal services. Emergency food and water supplies were adequate, and no deficiencies were cited.
Licensing Program Analyst conducted a case management visit to perform a wellness check after power was restored at the facility.
Findings
The facility passed inspections by PG&E and City of San Jose after power restoration. The facility's electrical grid and power generator were inspected, with no deficiencies cited. Resident rooms were observed to have appropriate room temperature and functioning equipment.
Report Facts
Capacity: 240Census: 107
Employees Mentioned
Name
Title
Context
Brenda Ritter
Interim Executive Director
Met with Licensing Program Analyst during the visit
Wesley McKinley
Maintenance Director
Interviewed regarding power restoration and facility maintenance
Unannounced case management visit to follow up on the Type A and Type B deficiencies cited on 1/11/2024.
Findings
No deficiencies were cited at this time as per California Code of Regulations Title 22. Observations included unlocked bathrooms and resident rooms, in-service trainings, weight logs, updated physician reports, and ongoing electrical system repairs.
Report Facts
Room temperature range: 68Room temperature range: 74Water temperature range: 109Water temperature range: 116
Unannounced case management visit to follow up on the recent power outage and assess the facility's ability to maintain essential services.
Findings
The facility was operating at full capacity without interruption to services. Temperatures in refrigerators and freezers were maintained appropriately, and water and room temperatures were within acceptable ranges. No deficiencies were noted during the visit.
Report Facts
Water temperature range (F): 109-116Room temperature range (F): 68-74Refrigerator temperature (F): 40Freezer temperature (F): 0
Employees Mentioned
Name
Title
Context
Cheryl Grace
Interim Program Director
Met during visit and participated in exit interview
Wesley McKinley
Maintenance Director
Provided information about the temporary generator and power status
The visit was an unannounced continuation of the annual inspection to evaluate compliance with licensing regulations and facility operations.
Findings
The inspection found multiple deficiencies including inaccurate medication records, lack of weight monitoring for Assisted Living residents, hot water temperatures exceeding regulatory limits, locked bathrooms and bedrooms in the Memory Care unit, and missing annual medical assessments for residents with dementia.
Severity Breakdown
Type A: 2Type B: 3
Deficiencies (5)
Description
Severity
Inaccurate records of centrally stored prescription medications for residents R1 and R2.
Type B
Lack of weight logs and monitoring of Assisted Living residents' weight.
Type B
Hot water temperatures in resident bathroom sinks ranged from 120.9F to 130.3F, exceeding the allowed maximum of 120F.
Type A
Bedrooms and bathrooms in the Memory Care Department were locked, restricting resident access and posing safety risks.
Type A
Resident R2 with dementia did not have an updated annual medical assessment on file.
Type B
Report Facts
Resident bathroom sinks with hot water temperature out of range: 9Medications reviewed for resident R1: 4Medications reviewed for resident R2: 8
Employees Mentioned
Name
Title
Context
Angel Bustos
Resident Service Director
Participated in inspection and interview regarding medication records and facility operations
Patty Cuzia
Regional Director of Health Services
Participated in inspection and interview regarding facility operations and findings
Leann Marquez
Memory Care Director
Agreed and understood the requirement to not lock common bathrooms and resident rooms in Memory Care unit
The visit was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The Licensing Program Analyst toured the facility, observed the use of a back-up generator due to repairs, checked common areas and resident rooms for safety and hygiene, and noted that the facility will submit daily updates while using the back-up generator. The inspection was not completed on this day and will continue on another day.
Employees Mentioned
Name
Title
Context
Brenda Ritter
Interim Executive Director
Met with Licensing Program Analyst during the inspection and reviewed the report.
The visit was an unannounced Case Management visit conducted to perform a health and wellness check after the facility reported being without electrical power since 2024-01-06.
Findings
During the visit, the facility was observed to have emergency food and water supplies, continued access to medication systems, and residents were provided with necessary items such as flashlights and blankets. No deficiencies were cited at this time.
Report Facts
Residents electing to stay with family: 36Residents on hospice: 2
Employees Mentioned
Name
Title
Context
Brenda Ritter
Executive Director
Met with Licensing Program Analysts during the visit and provided information about the facility's response to the power outage
David Marrufo
Licensing Program Analyst
Conducted the unannounced Case Management visit and requested a Plan of Action
The visit was an unannounced case management follow-up on an incident that occurred on 2023-06-26, where a resident (R1) was left unattended outside a doctor's clinic during transportation.
Findings
The facility admitted fault for leaving R1 unattended, which posed an immediate health, safety, and personal rights risk. Deficiencies were cited related to failure to provide adequate care and supervision to meet the resident's needs.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Licensee did not provide care and supervision to meet R1's needs wherein R1 was left unattended in front of the doctor's office which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
Type A
Report Facts
Capacity: 240Census: 110
Employees Mentioned
Name
Title
Context
Ron Ellenich
Executive Director
Met with Licensing Program Analyst during visit and admitted fault for incident
Angel Bustos
Resident Care Director
Interviewed during visit regarding supervision of Memory Care residents
Simranjit Rai
Licensing Program Analyst
Conducted the unannounced case management visit and authored the report
The inspection was an unannounced complaint investigation triggered by allegations of lack of supervision resulting in a resident suffering a fall while in care.
Findings
The investigation found the allegations to be unfounded after reviewing medical records, incident reports, staff interviews, and law enforcement findings. No deficiencies were cited.
Complaint Details
The complaint alleged that a resident (R1) in the Memory Care unit suffered a fall caused by their spouse (R2) residing in the Assisted Living unit due to lack of supervision. The investigation included review of medical and incident reports, staff interviews, and law enforcement welfare check. The allegations of elder abuse and neglect were determined to be unfounded.
Report Facts
Complaint Control Number: 26-AS-20210630114224Facility Capacity: 240Census: 95
Employees Mentioned
Name
Title
Context
Chihhsien Chang
Licensing Program Analyst
Conducted the complaint investigation visit
Ronn Ellenich
Executive Director
Met with Licensing Program Analyst during investigation
Charmaine Verador
Resident Services Director
Interviewed during initial investigation
Steve Chang
Licensing Program Analyst
Conducted unannounced complaint visit to deliver investigation findings
An unannounced annual required inspection was conducted to evaluate compliance with licensing regulations and infection control measures.
Findings
The facility was found to have proper infection control practices and clear fire exit routes; however, a deficiency was cited for failing to ensure 3 out of 3 staff members were properly associated with the facility, posing an immediate safety risk. A civil penalty totaling $1500 was assessed.
Deficiencies (1)
Description
Facility failed to ensure 3 out of 3 staff members were fingerprint cleared and associated with the facility, posing an immediate safety risk.
The visit was an unannounced complaint investigation triggered by allegations received on 11/30/2021 regarding accessibility of public restrooms, insufficient hallway lighting, and resident apartment door fitting issues.
Findings
The investigation found the allegations to be unfounded. Public restrooms were accessible and ADA supported after renovations completed in June 2022. Hallway lighting was sufficient with motion detectors and emergency lights. The resident apartment door was properly fitted, though a threshold bar initially made it difficult for a resident using a walker, which was subsequently removed.
Complaint Details
The complaint included allegations that public restrooms were not accessible to residents, hallways had insufficient lighting, and a resident apartment door was not properly fitted. The investigation concluded these allegations were unfounded with no citations issued.
Report Facts
Facility capacity: 240Resident census: 122
Employees Mentioned
Name
Title
Context
Chihhsien Chang
Licensing Program Analyst
Conducted the complaint investigation visit and authored the report
Hunter Obrero
Administrator
Met with Licensing Program Analyst during inspection
Shay Arias
Community Business Director
Interviewed regarding restroom construction completion
Romeo Manzano
Licensing Program Manager
Named as Licensing Program Manager on report
Wesley Whittemore
Administrator
Named as facility administrator in report header
Assistant Executive Director
Assistant Executive Director
Interviewed regarding restroom accessibility and apartment door threshold
The visit was an unannounced complaint investigation triggered by a complaint received on 2021-05-14 alleging that facility staff did not allow resident's family to attend care meetings and did not inform family of resident's condition, among other concerns.
Findings
The investigation found the allegations to be unsubstantiated or unfounded after reviewing records, conducting interviews, and examining incident reports. No deficiencies were cited under California Code of Regulations Title 22.
Complaint Details
The complaint involved allegations that facility staff did not allow resident's family to attend care meetings and did not inform family of resident's condition. The investigation included interviews with staff and family, review of resident records and incident reports, and found the allegations to be unsubstantiated or unfounded.
Report Facts
Capacity: 240Census: 73Complaint received date: May 14, 2021
The visit was an unannounced complaint investigation triggered by an allegation that the facility violated a resident's personal rights related to the execution of a Power of Attorney (POA).
Findings
The investigation found that the facility had a validly executed POA signed and notarized by the resident's spouse, who was involved in the resident's care and finances. The resident's child/family member was unaware of the POA and not involved in care or finances. The allegation of violation of personal rights was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged violation of resident's personal rights regarding the execution of a Power of Attorney. The investigation determined the allegation was unsubstantiated as the facility had a valid POA from the resident's spouse, and the resident's child/family member was not involved or aware of the POA until after the resident's death.
Report Facts
Facility capacity: 240Census: 73Complaint received date: Jan 27, 2022POA provided date: Jul 14, 2021Resident death date: 202111
Employees Mentioned
Name
Title
Context
David Marrufo
Licensing Program Analyst
Conducted the complaint investigation visit
San Sor
Assistant Executive Director
Met with Licensing Program Analyst during investigation
Steve Chang
Licensing Program Analyst
Interviewed Community Business Director during investigation
An unannounced required 1-year visit was conducted to evaluate the facility's compliance with regulations.
Findings
The Licensing Program Analyst toured the facility and observed compliance with COVID-19 protocols, adequate food and PPE supplies, and clear exits. No deficiencies were cited according to California Code of Regulations Title 22.
The visit was an unannounced Case Management follow-up on a report received regarding alleged verbal abuse by a staff member towards a resident.
Findings
A care staff member was witnessed verbally abusing a resident by scolding and ordering them in an unprofessional manner during assistance with activities of daily living. The staff member involved was suspended and a deficiency was cited.
Complaint Details
The complaint was substantiated based on interviews and review of documentation. The verbal abuse incident occurred on 06/06/21 and was witnessed by a family member and captured via virtual video chat.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Care staff verbally abused a resident by scolding and ordering them in an unacceptable and unprofessional manner while assisting with activities of daily living, posing a potential health and safety risk.
Type B
Report Facts
Deficiency Type B: 1Plan of Correction Due Date: Jun 16, 2021
Employees Mentioned
Name
Title
Context
Charmaine Verador
Resident Services Director
Interviewed during investigation
Antoine Rabbat
Memory Care Director
Interviewed during investigation and received copy of reports
The visit was a case management tele-visit conducted to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.
Findings
The facility was observed to have COVID-19 related postings, screening stations, hand sanitizers, and staff following infection control practices including mask wearing and social distancing. No deficiencies were cited during the tele-visit, but recommendations were made to improve infection control measures.
Report Facts
Capacity: 240Census: 18
Employees Mentioned
Name
Title
Context
Paul Shepodd
Executive Director
Met with licensing staff during the tele-visit
Joanne Roadilla
Licensing Program Analyst
Conducted the tele-visit and provided technical assistance
Barbie Henson
Health Facilities Evaluator Nurse
Conducted the tele-visit and provided technical assistance
Inspection Report Original LicensingCapacity: 240Deficiencies: 0Dec 17, 2020
Visit Reason
The inspection was a pre-licensing tele-inspection visit conducted via Zoom due to COVID-19 restrictions, to evaluate the facility prior to licensing approval.
Findings
The facility was inspected virtually and found to have no issues during the pre-licensing tele-inspection. The physical plant was approved pending completion of the Centralized Application Bureau review. Various areas including resident rooms, common areas, and safety features were observed to be in good condition and compliant with requirements.
Report Facts
Water temperature: 113.3Water temperature: 115.4Water temperature: 113.2Water temperature: 113Fire extinguisher last serviced: Oct 22, 2020Nonperishable food supply: 7
Employees Mentioned
Name
Title
Context
Paul Shepodd
Executive Director
Met with Licensing Program Analyst during inspection
Joanne Roadilla
Licensing Program Analyst
Conducted the pre-licensing tele-inspection
Jason Walthour
Regional Vice President
Met with Licensing Program Analyst during inspection
Jordan Pope
Project Director Operations Management
Met with Licensing Program Analyst during inspection
Alisa Salluce
Divisional Director of Care
Met with Licensing Program Analyst during inspection and observed during pull cord alarm test
Inspection Report Original LicensingCapacity: 240Deficiencies: 0Nov 20, 2020
Visit Reason
Initial licensing evaluation and new construction application for the facility, including verification of applicant and administrator qualifications and understanding of regulatory requirements.
Findings
The applicant and administrator successfully completed the Component II evaluation, demonstrating understanding of facility operation, staff qualifications, program policies, and application requirements. Technical assistance was provided regarding licensing documentation and compliance.
Report Facts
Capacity: 240Census: 0
Employees Mentioned
Name
Title
Context
Paul Shepodd
Administrator
Facility administrator met during the visit and participated in the licensing evaluation
Jude De La Concepcion
Licensing Program Manager
Named as Licensing Program Manager on the report
Bethany Hunter
Licensing Program Analyst
Named as Licensing Program Analyst who signed the report
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