Inspection Report Summary
Most inspections found no deficiencies, including the most recent report on August 3, 2025, which was a complaint investigation that found the allegations unsubstantiated. Earlier reports with deficiencies primarily involved issues related to safeguarding residents’ personal belongings and compliance with the facility’s theft and loss program, as well as some concerns about employee documentation and privacy violations with audio-enabled cameras. The facility also had substantiated findings in 2024 regarding disabled resident pendants during a management transition and failure to report positive COVID-19 cases along with facility disrepair. Several complaint investigations were unsubstantiated, and there were no fines, license suspensions, or immediate jeopardy findings listed in the available reports. Overall, the recent inspections suggest improvement, with no deficiencies cited in the latest visits despite some isolated past issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
30% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 70
Capacity: 237
Deficiencies: 0
Aug 3, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff did not ensure residents' personal belongings were safely secured and that the facility was not in good repair.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with residents, staff, and a witness, as well as review of records and facility inspection, did not corroborate claims of missing personal belongings or non-operational elevators. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint included two main allegations: (1) staff does not ensure residents’ personal belongings are safely secured, with reports of missing items from Resident #1's room over the past three years; (2) staff does not ensure the facility is in good repair, specifically that two out of three elevators were out of order since November 2024. Both allegations were investigated and found unsubstantiated.
Report Facts
Residents interviewed: 10
Staff interviewed: 7
Medications reviewed: 14
Elevators reported out of order: 2
Elevators functional: 2
Facility capacity: 237
Facility census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sahar Masarati | Director of Enrichment | Met with Licensing Program Analyst during investigation and exit interview |
| Stephanie Koffman | Administrator | Named as facility administrator |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 237
Deficiencies: 0
Jul 9, 2025
Visit Reason
The visit was an unannounced Case Management investigation triggered by an Unusual Incident Report received on 2025-05-28 regarding missing items from residents' rooms, including cash, credit cards, unauthorized charges, and a wedding band.
Findings
The Licensing Program Analyst conducted interviews with residents and witnesses and reviewed documentation. No deficiencies were observed and no citations were issued at this time.
Complaint Details
The complaint involved missing items from residents' rooms, including a $2,900 check, six unauthorized credit card charges, two missing credit cards, $300 in cash, and a wedding band. The complaint was investigated and found to have no deficiencies.
Report Facts
Missing check amount: 2900
Missing cash amount: 300
Census: 137
Total capacity: 237
Unauthorized credit card charges: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farid Tommy Taheri | Assistant Executive Director | Met with Licensing Program Analyst during visit |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the investigation and inspection |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 237
Deficiencies: 0
Jun 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-02-09 regarding questionable death and failure of facility staff to meet a resident's oxygen needs.
Findings
The investigation found no evidence to support the allegations. The department reviewed records, interviewed staff, residents, and the administrator, and concluded the allegations were unsubstantiated. No deficiencies were cited.
Complaint Details
The complaint alleged that a resident (R1) died due to failure of staff to provide lifesaving oxygen and that staff did not meet the resident's oxygen needs, resulting in oxygen saturation dropping below 60%. The investigation included interviews with staff, residents, and review of medical and emergency reports. The department found no preponderance of evidence to prove the alleged violations and classified the allegations as unsubstantiated.
Report Facts
Capacity: 237
Census: 137
Doses of epinephrine administered: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Koffman | Senior Executive Director | Met with during investigation and named in findings |
| Lilit Mnatsakanyan | Administrator | Interviewed during investigation |
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 237
Deficiencies: 0
May 15, 2025
Visit Reason
The visit was conducted as a Case Management visit following a complaint received on 2025-05-14 regarding two facility employees allegedly joking around and possibly tapping a dementia resident inappropriately.
Findings
No deficiencies were observed during the visit, and no citations were issued. The Licensing Program Analyst met with the Assistant Executive Director and explained the purpose of the visit.
Complaint Details
Complaint involved two facility employees observed joking around with a dementia resident and possibly tapping the resident's inner thigh. The complaint was investigated but no deficiencies were found.
Report Facts
Capacity: 237
Census: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farid Taheri | Assistant Executive Director | Met with Licensing Program Analyst during the visit |
| Stephanie Koffman | Administrator/Director | Named as facility administrator |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the Case Management visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 237
Deficiencies: 2
May 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to allegations that the licensee did not comply with facility theft and loss program requirements and that staff did not safeguard a resident's personal belongings.
Findings
The investigation substantiated that the facility failed to comply with theft and loss program requirements, including failure to provide required forms to the resident and failure to train staff on the theft and loss program. Additionally, the facility staff did not safeguard a resident's personal belongings, resulting in stolen items. Another allegation that staff did not ensure a safe environment for residents was found to be unsubstantiated.
Complaint Details
The complaint was substantiated regarding failure to comply with theft and loss program requirements and failure to safeguard resident's personal belongings. The allegation that staff did not ensure a safe environment was unsubstantiated. The investigation included interviews with the resident, staff, executive director, and witnesses, review of police reports, video footage, and facility records.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee failed to comply with theft and loss program requirements, including failure to provide LIC 621 form to resident upon admission and failure to train staff on theft and loss policies within 90 days of employment. | Type B |
| Facility staff did not safeguard resident's personal belongings, resulting in stolen jewelry and designer bags. | Type B |
Report Facts
Capacity: 237
Census: 136
Staff hired in 2024: 5
Residents interviewed: 12
Staff interviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Koffman | Senior Executive Director | Met during inspection and named in findings related to complaint investigation |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 237
Deficiencies: 0
May 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 02/09/2024 regarding questionable death and failure of facility staff to meet a resident's oxygen needs.
Findings
The investigation found no evidence to support the allegations. Interviews, record reviews, and evidence showed that staff provided appropriate care, including medication administration and oxygen equipment maintenance. The resident was pronounced deceased due to cardiac arrest from hypoxia and other medical conditions, but no violations were substantiated.
Complaint Details
The complaint involved two allegations: 1) questionable death due to failure to provide lifesaving oxygen, and 2) failure to meet the resident's oxygen needs resulting in oxygen saturation dropping below 60%. Both allegations were found to be unsubstantiated after thorough investigation including interviews with staff, residents, and review of medical and emergency reports.
Report Facts
Facility capacity: 237
Resident census: 136
Epinephrine doses administered: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lilit Mnatsakanyan | Administrator | Facility administrator interviewed during investigation |
| Stephanie Koffman | Senior Executive Director | Met with investigator during inspection |
| S2 | Staff member who administered medication and monitored resident's oxygen levels | |
| W1 | Private Caregiver | Resident's private caregiver interviewed during investigation |
Inspection Report
Annual Inspection
Census: 136
Capacity: 237
Deficiencies: 2
Mar 10, 2025
Visit Reason
An unannounced annual required visit was conducted using the CARE Inspection Tool to evaluate compliance with licensing regulations and facility conditions.
Findings
The facility was found to be clean, sanitary, and appropriately furnished with operational safety equipment and adequate food supplies. However, deficiencies were cited related to 9 employees not being associated on guardian and 3 employees lacking TB test/health screening documentation.
Deficiencies (2)
| Description |
|---|
| 9 facility employees not associated on guardian, including the executive director, posing an immediate health, safety or personal rights risk to persons in care. |
| 3 facility employees with no TB Test/Health Screening on file, posing a potential health, safety or personal rights risk to persons in care. |
Report Facts
Residents' service files reviewed: 5
Staff personnel files reviewed: 10
Medication Administration Records reviewed: 5
Bedrooms inspected: 7
Bathrooms inspected: 7
Living units: 188
Bathrooms: 225
Stories: 14
Fire/Disaster Drills last conducted: Sep 3, 2024
Facility employees not associated on guardian: 9
Facility employees with no TB test: 3
Civil penalty fine per citation: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Koffman | Executive Director | Met with Licensing Program Analyst during inspection and named in deficiency regarding staff association |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eva M Alvarez | Licensing Program Manager | Supervisor of the Licensing Program Analyst and named in the report |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 237
Deficiencies: 0
Dec 30, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff transported clients while under the influence of marijuana.
Findings
The investigation included interviews with the administrator, staff, and residents, as well as review of relevant documents. The Licensing Program Analyst found insufficient evidence to substantiate the allegation, concluding the complaint was unsubstantiated.
Complaint Details
The allegation was that a facility driver transported residents while under the influence of marijuana. Interviews and document reviews did not find sufficient evidence to support this claim. The allegation was found to be unsubstantiated.
Report Facts
Facility capacity: 237
Census: 100
Number of facility staff who drive residents: 5
Number of facility cars: 2
Resident interviews: 5
Staff interviews: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Koffman | Senior Executive Director | Met with Licensing Program Analyst during investigation and provided statements regarding staff and facility operations |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 96
Capacity: 237
Deficiencies: 0
Dec 17, 2024
Visit Reason
The inspection was a Case Management visit conducted by Licensing Program Analyst Alfonso Iniguez to review documentation related to an open investigation pertaining to a complaint.
Findings
The Licensing Program Analyst requested additional documentation regarding an open complaint investigation, which was provided by the Senior Executive Director. An exit interview was conducted and a copy of the Facility Evaluation Report was given to the facility representative.
Complaint Details
The visit involved review of documentation related to complaint #11-AS-20240910162855; no substantiation status was provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Koffman | Senior Executive Director | Met with Licensing Program Analyst during the Case Management visit and provided documentation related to the complaint. |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the Case Management visit and requested documentation regarding the open complaint investigation. |
Inspection Report
Capacity: 237
Deficiencies: 1
Nov 7, 2024
Visit Reason
The visit was a Case Management visit conducted to review records related to an ongoing investigation at the facility.
Findings
The Department discovered that the surveillance cameras in the common areas were equipped with audio recording capabilities, infringing upon the privacy rights of the residents. A deficiency was cited under California Code of Regulations, Title 22, Division 6, Chapter 8.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to accommodate the privacy level of the residents by having audio in the video camera system, posing a potential health and safety risk. | Type B |
Report Facts
Fine amount: 100
Plan of Correction Due Date: Nov 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Koffman | Senior Executive Director | Met with Licensing Program Analyst during the visit and received the Facility Evaluation Report |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the Case Management visit and authored the report |
| Eva M Alvarez | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Capacity: 237
Deficiencies: 0
Nov 7, 2024
Visit Reason
The visit was a Case Management visit conducted by Licensing Program Analyst Alfonso Iniguez to request additional documentation regarding an open investigation related to a complaint.
Findings
The Licensing Program Analyst met with the Senior Executive Director, Stephanie Koffman, and reviewed documentation related to an open complaint investigation. An exit interview was conducted and a copy of the Facility Evaluation Report was provided to the facility representative.
Complaint Details
The visit involved a request for documentation pertaining to an open investigation related to complaint #11-AS-20240910162855.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Koffman | Senior Executive Director | Met with Licensing Program Analyst during the Case Management visit and provided requested documentation. |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the Case Management visit and requested documentation related to an open complaint investigation. |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 237
Deficiencies: 1
Sep 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-04-19 regarding residents' pendants being disabled due to a transition between new management companies.
Findings
The investigation substantiated that residents' pendants were disabled for several days during the management transition, posing a health and safety risk. However, the allegation that residents missed meals due to phones not working was unsubstantiated. The pendant system was found operational at the time of the visit.
Complaint Details
The complaint was substantiated regarding disabled residents' pendants due to management transition. The allegation that residents missed meals due to phones not working was unsubstantiated. The investigation included interviews with staff and residents, facility tours, and pendant testing.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facilities shall have signal systems which shall meet the following criteria: operate from each resident's living unit, transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff and identify the specific resident living unit. The signal system was not operational during the transition, including residents' pendants, posing a health and safety risk. | Type B |
Report Facts
Capacity: 237
Census: 102
Deficiency count: 1
Plan of Correction Due Date: Sep 19, 2024
Pendant response time: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Koffman | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Lizeth Villegas | Licensing Program Analyst | Conducted complaint investigation and subsequent visit |
| Wendy Gibbs | Licensing Program Analyst | Conducted initial complaint investigation visit |
| Lilit Mnatsakanyan | Administrator | Facility administrator listed in report |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 98
Capacity: 237
Deficiencies: 0
Aug 30, 2024
Visit Reason
An unannounced Case Management visit was conducted following reports of a male dressed as a service worker entering community care facilities in the Westwood area.
Findings
The Licensing Program Analysts conducted a health and safety check, reviewed staff and resident rosters, and examined security measures. No deficiencies were observed and no citations were issued.
Report Facts
Capacity: 237
Census: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Koffman | Senior Executive Director | Met with Licensing Program Analysts during the visit and provided information about the incident and facility security |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the inspection visit |
| Yolanda Rosser | Licensing Program Analyst | Conducted the inspection visit |
| Eva M Alvarez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 102
Capacity: 237
Deficiencies: 0
Mar 27, 2024
Visit Reason
The visit was an unannounced one-year inspection to evaluate compliance with licensing regulations for the facility.
Findings
The facility was found to be in compliance with all applicable regulations. No deficiencies were cited. The kitchen, safety equipment, and premises were all inspected and found to be satisfactory.
Report Facts
Capacity: 237
Census: 102
Floors: 14
Resident bedrooms toured: 5
Hospice waiver: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lilit Mnatsakanyan | Executive Director | Met during inspection and received a copy of the report |
| Mariam Gezalian | Business Office Manager | Met during inspection |
| Sparkle Day | Licensing Program Analyst | Conducted the inspection |
| Janae Hammond | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 237
Deficiencies: 0
Jan 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that the facility was not following Emergency Disaster Plan protocols.
Findings
The investigation found that the facility maintains an updated register of residents indicating location and ambulatory status, staff were knowledgeable about their emergency roles, and the facility has an evacuation procedure plan. Resident feedback indicated some perceived chaos during drills but confidence in receiving help. The allegation was unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that the facility did not have a register of residents indicating location and ambulatory status readily available to first responders and that staff did not know what to do during emergency disaster drills. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 10
Staff interviewed: 7
Fire Drill Reports reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lilit Mnatsakanyan | Administrator | Met during the investigation and involved in providing the register of residents. |
| Ulysses Coronel | Licensing Program Manager | Conducted the complaint investigation. |
| Regina Cloyd | Licensing Program Analyst | Conducted the complaint investigation. |
| Mariam Gezalian | Business Office Manager | Met and explained the purpose of the visit. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 237
Deficiencies: 2
Oct 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address multiple allegations including failure to follow Covid-19 protocols, facility disrepair, lack of emergency disaster plan, unsafe environment, unsafe food handling practices, and inaccurate resident paperwork.
Findings
The investigation substantiated that the facility failed to report positive Covid-19 cases and was in disrepair with patio lifters caving inward. Other allegations regarding emergency disaster plan, safe environment, food handling, and resident paperwork were found unsubstantiated based on interviews, observations, and record reviews.
Complaint Details
The complaint investigation was substantiated for failure to follow Covid-19 protocols including unreported positive cases and facility disrepair. Other allegations such as lack of emergency disaster plan, unsafe environment, unsafe food handling, and inaccurate resident paperwork were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report 6 positive Covid-19 cases to licensing within 24 hours. | Type B |
| Facility was not clean, safe, sanitary and in good repair; patio lifters caving inward. | Type B |
Report Facts
Positive Covid-19 cases not reported: 6
Residents interviewed: 7
Residents confirming Covid-19 allegation: 1
Staff interviewed: 7
Staff confirming Covid-19 allegation: 1
Residents interviewed regarding disrepair: 7
Staff confirming disrepair allegation: 5
Residents interviewed regarding emergency disaster plan: 7
Residents confirming emergency disaster plan allegation: 2
Staff confirming emergency disaster plan allegation: 1
Residents interviewed regarding safe environment: 7
Staff confirming safe environment allegation: 1
Residents interviewed regarding food handling: 7
Staff confirming food handling allegation: 1
Residents interviewed regarding resident paperwork: 7
Staff confirming resident paperwork allegation: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation and exit interviews. |
| Lilit E. Mnatsakanyan | Administrator | Met with Licensing Program Analyst during investigation and exit interview. |
| Kimberly Davis | Resident Care Service Director | Met with Licensing Program Analyst during initial 10-day visit. |
| Patricia Murphy | Administrator | Facility Administrator named in report header. |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 237
Deficiencies: 0
Sep 5, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation to address allegations that facility staff were not safeguarding residents' personal property and that a resident was being financially abused while in care.
Findings
The investigation included interviews with residents and staff, a tour of the facility, and record reviews. The allegations were found to be unsubstantiated as the majority of residents and staff denied the allegations and there was insufficient evidence to prove the violations occurred.
Complaint Details
The complaint investigation was triggered by allegations of staff not safeguarding residents' personal property and financial abuse of a resident. The allegations were unsubstantiated based on interviews and evidence reviewed.
Report Facts
Residents interviewed: 5
Staff interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the complaint investigation |
| Lilit Mnatsakanyan | Administrator | Facility administrator met during investigation |
| Ulysses Coronel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 237
Deficiencies: 0
Aug 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff do not assist residents with bathing.
Findings
The investigation included interviews with residents and staff, review of shower schedules, and observations. All residents interviewed stated they had no issues with bathing and sometimes refused showers. Staff confirmed they assist residents with bathing as scheduled. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff do not assist residents with bathing. The investigation found no evidence to substantiate the allegation; residents and staff confirmed bathing assistance was provided as scheduled.
Report Facts
Capacity: 237
Census: 91
Staff interviewed: 6
Residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lilit Mnatsakanyan | Executive Director | Met with Licensing Program Analyst during the investigation |
| Diane Parras | Wellness Director | Accompanied Licensing Program Analyst during the facility tour |
Inspection Report
Annual Inspection
Census: 76
Capacity: 237
Deficiencies: 8
Apr 11, 2023
Visit Reason
The visit was conducted as a Case Management - Annual Continuation to complete the facility annual inspection originally conducted on 03/28/2023 and 03/29/2023 at Watermark at Westwood Village.
Findings
Multiple deficiencies were observed including exposed walls with holes and no posted signs in fire escape stairways on all 14 floors, a machine blocking an emergency exit door in the Memory Care Unit stairwell, a non-operational van blocking a parking garage entrance, knives and cleaning chemicals improperly stored in the kitchen, lack of CPR training for 3 staff, lack of educational verification for staff, expired and outdated food, and missing records of medication dosages maintained by the facility. Plans of correction were developed for all deficiencies.
Deficiencies (8)
| Description |
|---|
| Exposed walls with holes and no posted signs of work in fire escape/stairway on all 14 floors, including no lights and water obstructing stairways. |
| Machine blocking emergency exit door in Memory Care Unit stairwell. |
| Non-operational watermark van parked in front of gate entrance to parking garage. |
| Knives left on counter and cleaning chemicals not stored under lock in kitchen area. |
| No CPR training observed for 3 staff members. |
| No educational verification observed for a number of staff. |
| Expired and outdated food observed in facility's food supply. |
| No record of dosages of centrally stored medications maintained by the facility. |
Report Facts
Facility capacity: 237
Census: 76
Plan of Correction due date: May 11, 2023
Number of floors with exposed walls deficiency: 14
Number of staff without CPR training: 3
Inspection Report
Annual Inspection
Census: 76
Capacity: 237
Deficiencies: 0
Mar 29, 2023
Visit Reason
An unannounced annual inspection visit was conducted at the Watermark at Westwood Village to evaluate compliance with licensing requirements.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst reviewed resident medication records, resident and staff interviews, client and staff records, and inspected the facility and grounds. A subsequent visit is required due to time constraints.
Report Facts
Resident medication records reviewed: 4
Resident interviews conducted: 5
Staff interviews conducted: 8
Client records reviewed: 5
Staff records reviewed: 5
Licensed capacity: 237
Current census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lilit Mnatsakanyan | Administrator | Met with Licensing Program Analyst during inspection and received exit interview report |
| David Espana | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Axinya Khliyan | Human Resources Director | Provided access and entry to the facility for the Licensing Program Analyst |
| Jim Howland | Director | Provided access and entry to the facility for the Licensing Program Analyst |
Inspection Report
Annual Inspection
Census: 76
Capacity: 237
Deficiencies: 0
Mar 28, 2023
Visit Reason
An unannounced comprehensive annual inspection visit was conducted at the Watermark at Westwood Village on 03/28/2023.
Findings
No deficiencies were cited during the visit. The inspection included review of resident medication records, resident and staff interviews. A subsequent visit is required due to time constraints.
Report Facts
Resident medication records reviewed: 4
Resident interviews conducted: 1
Staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Espana | Licensing Program Analyst | Conducted the inspection visit |
| Lilit Mnatsakanyan | Administrator | Met with Licensing Program Analyst during inspection and received exit interview report |
| Shakeb Rafat | Administrator | Provided access and answered questions during inspection |
| Jim Howland | Dining Services Director | Provided access during inspection |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 237
Deficiencies: 0
Jan 18, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not safeguard residents' personal property.
Findings
The investigation found that although there were allegations of missing personal items from a resident's apartment, the facility had functioning cameras and locks, staff denied taking items, and most residents did not report problems. There was insufficient evidence to substantiate the complaint, resulting in an unsubstantiated finding.
Complaint Details
The complaint alleged that staff do not safeguard resident's personal property, specifically that Resident 1's clothing, shoes, jewelry, undergarments, and watch had gone missing. The investigation included interviews with staff and residents, review of camera footage, and file review. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 237
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jewel Baptiste | Licensing Program Analyst | Conducted the complaint investigation visit |
| Shakeb Rafat | Administrator | Facility administrator met during investigation and provided information |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 237
Deficiencies: 3
Feb 10, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 12/06/2021 regarding the facility not meeting residents' needs, medication administration issues, insufficient staffing, and failure to respond to emergency pendants.
Findings
The investigation substantiated the allegations that the facility did not meet residents' needs due to staffing shortages, failed to dispense medications according to doctors' orders, lacked sufficient staff to meet resident needs, and did not respond adequately to emergency pendants. These deficiencies pose potential health and safety risks.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to meet residents' needs, improper medication administration, insufficient staffing, and failure to respond to emergency pendants. Interviews with staff, residents, and witnesses confirmed these issues, and record reviews supported the findings.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| 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. | Type B |
| Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications. | Type B |
| Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of additional staff for the provision of adequate services. | Type B |
Report Facts
Capacity: 237
Census: 36
Deficiency count: 3
Plan of Correction Due Date: Mar 3, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Angela J Kendrick | Licensing Program Manager | Oversaw the complaint investigation |
| Patricia Murphy | Administrator | Facility administrator named in the report |
| Amber Hernandez | Acting Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 237
Deficiencies: 2
Feb 9, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that the facility did not have an Emergency Disaster Plan and was not following COVID-19 guidelines.
Findings
The investigation substantiated that the facility lacked a proper Emergency Disaster Plan, had not trained staff or residents on emergency procedures, and did not conduct required drills. Additionally, the facility failed to ensure unvaccinated staff were tested weekly as required by COVID-19 guidelines.
Complaint Details
The complaint investigation was substantiated. Allegations included lack of an Emergency Disaster Plan and failure to follow COVID-19 testing guidelines for unvaccinated staff. Interviews with staff, residents, and witnesses, along with record reviews, supported these findings.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to train staff or capable community members on the Emergency Disaster Plan, including evacuation procedures and drills. | Type B |
| Facility staff were not testing unvaccinated staff per PIN 21-32.1 ASC as required. | Type B |
Report Facts
Capacity: 237
Census: 36
Plan of Correction Due Date: Mar 2, 2022
Number of staff with exemptions not tested weekly: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Angela J Kendrick | Licensing Program Manager | Oversaw the complaint investigation |
| Patricia Murphy | Administrator | Facility administrator named in the report |
| Amber Hernandez | Acting Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 237
Deficiencies: 0
Nov 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations that unqualified staff were administering medications to residents and that residents' belongings were not being safeguarded while in care.
Findings
The investigation included interviews with staff and residents, a facility tour, and record reviews. All staff and residents interviewed denied the allegations. Medication administration records and training documentation were verified. The facility does not have a surety bond and residents are discouraged from bringing high-value items. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unqualified staff administering medications and residents' belongings not being safeguarded. Interviews with 9 staff and residents denied these claims. Medication administration training and records were verified. The facility denies liability for personal belongings unless delivered for safeguarding. The preponderance of evidence standard was not met.
Report Facts
Staff interviewed denying allegation: 9
Residents enrolled in medication administration program: 4
Residents interviewed regarding belongings: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Troy Agard | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Angela J Kendrick | Licensing Program Manager | Oversaw the complaint investigation |
| Nicolle Hoznor | Resident’s Care Services Director / LVN | Met with Licensing Program Analyst during investigation |
| Patricia Murphy | Administrator | Facility administrator named in report |
Inspection Report
Original Licensing
Capacity: 237
Deficiencies: 0
Mar 16, 2021
Visit Reason
An announced virtual pre-licensing evaluation visit was conducted to assess the facility for an initial license as a Residential Care Facility for the Elderly serving assisted living, independent living, and memory care residents aged 60 and older.
Findings
The facility was found to be in substantial compliance with applicable laws and regulations during the pre-licensing inspection. No items of noncompliance were observed. The facility is approved for a capacity of 237 residents, including provisions for non-ambulatory and bedridden residents, and is equipped with safety features such as a sprinkler system and backup generator.
Report Facts
Capacity: 237
Non-ambulatory capacity: 212
Bedridden capacity: 25
Water temperature: 117
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Murphy | Administrator / Executive Director | Facility representative met during the pre-licensing evaluation |
| Troy Agard | Licensing Program Analyst | Conducted the announced virtual pre-licensing visit |
| Angela J Kendrick | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Original Licensing
Capacity: 237
Deficiencies: 0
Dec 1, 2020
Visit Reason
Initial licensing evaluation visit conducted via phone call (COMP II) with applicant and administrator to verify identification and confirm understanding of Title 22 regulations and facility operation requirements.
Findings
Applicant and administrator successfully completed the COMP II component, demonstrating understanding of licensing requirements including staff qualifications, program policies, and application document review. No deficiencies or violations are noted in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Murphy | Administrator | Facility administrator who participated in the licensing evaluation and COMP II call. |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager overseeing the evaluation. |
| Bethany Hunter | Licensing Program Analyst | Licensing Program Analyst who conducted the COMP II call and signed the report. |
Loading inspection reports...
