Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 0
Sep 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that facility staff were not properly addressing scabies, not ensuring residents have clean bed linens, and not maintaining passageways free from obstruction.
Findings
The investigation found that two residents were visually confirmed to have scabies and 17 residents had itching but were not confirmed. The facility took measures including calling a consultant and notifying public health. Observations and interviews did not corroborate the allegations regarding clean linens and passageway obstructions. The allegations were deemed unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint was unsubstantiated. Although some residents were confirmed with scabies, the facility was actively managing the outbreak with treatment and sanitation measures. No evidence supported the allegations about linens and passageways.
Report Facts
Facility capacity: 328
Residents visually confirmed with scabies: 2
Residents with itching but not confirmed: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sara Modugno | Administrator | Facility administrator met during investigation |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Plan of Correction
Census: 108
Capacity: 328
Deficiencies: 2
Aug 25, 2025
Visit Reason
Licensing Program Analyst Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon deficiencies cited on 08/13/2025.
Findings
The deficiencies cited under Title 22 Regulation 87309(a) pertaining to Storage Space and Title 22 Regulation 87464(f)(4) pertaining to Basic Services have been cleared. The licensee has complied with the terms of the Plan of Correction.
Deficiencies (2)
| Description |
|---|
| Deficiency cited under Title 22 Regulation 87309(a) pertaining to Storage Space |
| Deficiency cited under Title 22 Regulation 87464(f)(4) pertaining to Basic Services |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the Plan of Correction visit |
| Sara Modugno | Administrator | Met with the Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 328
Deficiencies: 0
Aug 13, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff does not ensure the facility is free of pests and that staff are not meeting residents' hygiene needs.
Findings
The investigation found that pest extermination services were regularly provided and no pests were observed. Staff confirmed residents' hygiene needs were met, with documentation of showers and incontinence care. The allegations were deemed unsubstantiated due to lack of evidence.
Complaint Details
The complaint was unsubstantiated after investigation. Documentation and staff interviews did not support the allegations of pest presence or unmet hygiene needs.
Report Facts
Facility capacity: 328
Resident census: 108
Pest extermination service dates: 3
Staffing levels: 6
Staffing levels: 2
Staffing levels: 5
Incontinence care frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Sara Modugno | Administrator | Facility administrator present during investigation |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 328
Deficiencies: 2
Aug 13, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations regarding staff not ensuring cleaning chemicals are inaccessible to residents and medications not being dispensed as prescribed, as well as allegations about inadequate supervision and sharp objects accessibility.
Findings
The investigation substantiated that cleaning chemicals were unsecured in kitchenettes and residents missed multiple medications due to pending refills, posing immediate health and safety risks. Allegations regarding inadequate supervision and sharp objects accessibility were unsubstantiated based on observations and interviews.
Complaint Details
The complaint investigation was substantiated for allegations related to unsecured cleaning chemicals and medication administration failures. Allegations regarding inadequate supervision and sharp objects accessibility were unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee failed to ensure cleaning supplies were secured, posing an immediate health and safety risk to residents. | Type A |
| Licensee failed to ensure residents were provided assistance with taking medication; Residents #1 and #2 missed multiple medications due to refills pending. | Type A |
Report Facts
Capacity: 328
Census: 108
Deficiencies cited: 2
Plan of Correction Due Date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Sara Modugno | Administrator | Facility administrator involved in the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 218
Capacity: 328
Deficiencies: 0
Aug 13, 2025
Visit Reason
The inspection visit was conducted to investigate complaint number 22-AS-20241209152259 through interviews and documentation collection.
Findings
The Licensing Program Analyst conducted interviews and collected documentation related to the complaint. An exit interview was held and a copy of the report was provided to the Executive Director.
Complaint Details
The visit was related to complaint number 22-AS-20241209152259. No substantiation status is provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sara Modugno | Executive Director | Met with Licensing Program Analyst during complaint investigation. |
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 0
Jul 10, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility failed to provide notice to a resident when changing room location.
Findings
The investigation found that the resident agreed to the move from Independent Living to Assisted Living due to health issues, with supporting documentation and physician reports confirming the need. The resident's room was observed to be clean and in order. The allegation was deemed unfounded.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Report Facts
Facility capacity: 328
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Sara Modugno | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 212
Capacity: 328
Deficiencies: 0
Jul 2, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not assist a resident with feeding, did not seek timely medical attention, did not administer medications, and did not safeguard the resident's personal belongings.
Findings
The investigation found that the resident initially refused food and medication but was offered and consumed food later. Medical attention was provided timely according to physician instructions. The facility offered a refund for missing personal belongings. All allegations were determined to be unfounded with no deficiencies cited.
Complaint Details
The complaint was investigated and found to be unfounded based on documentation and interviews. Allegations included failure to assist with feeding, failure to seek timely medical attention, failure to administer medications, and failure to safeguard personal belongings.
Report Facts
Capacity: 328
Census: 212
Refund amount: 2500
Resident stay duration: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sara Modugno | Executive Director | Facility representative present during exit interview |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 0
Jun 16, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on March 26, 2024, alleging that the facility's call system was not operational, staff failed to provide adequate care and supervision to prevent falls, and the facility was not providing adequate toileting care to a resident.
Findings
The investigation included record reviews, staff and resident interviews, and direct observation. The call system was found to be operational with acceptable response times. The facility followed protocols for a resident identified as a fall risk, and staff interviews corroborated proper care. Toileting care allegations were denied by staff and observed caregivers were seen appropriately responding to incontinence care needs. The allegations were deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint was unsubstantiated. The investigation found no preponderance of evidence to validate the allegations regarding the call system, fall prevention care, and toileting care.
Report Facts
Response time: 26
Response time: 15
Response time: 115
Resident falls: 3
Observation watch duration: 72
Facility capacity: 328
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sara Modugno | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 213
Capacity: 328
Deficiencies: 0
Jun 4, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility failed to provide care and supervision resulting in multiple falls.
Findings
The investigation found that the allegation was unfounded. The facility provided necessary care and supervision to resident R1, who experienced multiple falls but without injury or hospitalization. Staff and medical records confirmed appropriate monitoring and response to incidents.
Complaint Details
The complaint alleged failure to provide care and supervision resulting in multiple falls. The allegation was investigated through interviews, record reviews, and facility tour, and was found to be unfounded.
Report Facts
Incident reports of falls: 5
Total incident reports reviewed: 6
Facility capacity: 328
Resident census: 213
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sara Modugno | Executive Director | Facility representative who granted access and participated in exit interview |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Stephenie Jukic | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 218
Capacity: 328
Deficiencies: 0
May 22, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not ensure the facility was free of pests.
Findings
The investigation included facility tours, interviews with staff and residents, and record reviews. No evidence of pests was found, and the allegation was determined to be unsubstantiated. No deficiencies were cited during the visit.
Complaint Details
The complaint alleged that staff did not ensure the facility was free of pests. After interviews with three residents and three staff members, and review of monthly pest inspection records, the allegation was found to be unsubstantiated due to insufficient evidence.
Report Facts
Facility capacity: 328
Census: 218
Pest inspection service dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Sara Modugno | Administrator | Facility administrator present during inspection and exit interview |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 328
Deficiencies: 0
Mar 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-03-12 that staff were not meeting residents' needs and did not have access to supplies for residents.
Findings
The investigation included observations and interviews with residents and staff. The Licensing Program Analyst observed staff assisting residents and found that residents generally felt their care needs were met and that staff had access to necessary supplies. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint consisted of allegations that staff were not meeting residents' needs and did not have access to supplies. Interviews with residents and staff, as well as observations, revealed that most residents felt their needs were met and supplies were adequately available. The allegations were unsubstantiated.
Report Facts
Capacity: 328
Census: 121
Resident interviews: 7
Staff interviews: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sara Modugno | Executive Director | Met with Licensing Program Analyst and involved in exit interview |
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation |
| Lourdes Montoya | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 328
Deficiencies: 1
Mar 17, 2025
Visit Reason
The inspection was an unannounced case management visit to follow up on an incident report received regarding a resident being served shrimp despite having a seafood allergy.
Findings
The facility failed to ensure care was provided to a resident with a seafood allergy, as a new server mistakenly served shrimp to the resident. The resident took a bite but showed no side effects. A deficiency was cited for this failure to provide appropriate care.
Complaint Details
The visit was triggered by an incident report dated 01/25/2025 regarding a resident served shrimp despite a seafood allergy. The resident experienced no side effects and has since moved out of the facility.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to ensure care was provided to resident. Resident was served shrimp while resident's allergy was noted by facility, posing a potential health and safety risk. | Type B |
Report Facts
Deficiency Type: 1
Capacity: 328
Census: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report. |
| Sara Modugno | Administrator | Facility administrator interviewed during the inspection and exit interview. |
| Alisa Ortiz | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 328
Deficiencies: 0
Dec 26, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2024-12-19 alleging that the facility did not ensure it was free of pests.
Findings
The investigation found no evidence of pests or rodents in the facility based on observations, interviews with staff and residents, and review of a recent Public Health Services inspection report. The allegation was determined to be unfounded with no deficiencies cited.
Complaint Details
The complaint alleged that pests were present in the Independent Living dining room. The allegation was investigated and determined to be unfounded based on observations and interviews with 3 residents and 6 staff who denied the presence of pests.
Report Facts
Capacity: 328
Census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Cristina Garcia | LVN | Met with during the investigation and explained reason for visit |
| Pedro Miranda | Head Chef | Accompanied Licensing Program Analyst during facility tour |
| Anthony Montes | Sous Chef | Accompanied Licensing Program Analyst during facility tour |
Inspection Report
Annual Inspection
Census: 210
Capacity: 328
Deficiencies: 0
Dec 17, 2024
Visit Reason
An unannounced required annual visit was conducted by Licensing Program Analysts to evaluate compliance with regulations.
Findings
The facility was toured including Independent Living, Assisted Living, and Memory Care units. All required elements were observed, emergency systems tested operational, and resident files reviewed contained required documents. No deficiencies were cited during this inspection.
Report Facts
Residents in assisted living: 54
Residents in memory care: 58
Residents on hospice: 14
Resident files reviewed: 10
Last sprinkler and smoke detector inspection: Oct 23, 2024
Emergency fire drill date: 202411
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sara Modungo | Administrator | Administrator present during the tour with a valid certificate |
| Lori Wear | Care Coordinator | Met with Licensing Program Analysts during the visit |
| Andrea Mendivil | Licensing Program Analyst | Conducted the inspection |
| Fred Arias | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Follow-Up
Census: 161
Capacity: 328
Deficiencies: 1
Oct 21, 2024
Visit Reason
The visit was an unannounced case management follow-up to verify the presence of a current Administrator at the facility after an email complaint indicated the previous Administrator was no longer employed as of February 19, 2024.
Findings
The facility did not have proper documentation on file for the change of Administrator in February 2024, which is required by regulation. A new signed LIC 200 form was obtained to change the Administrator to Sara Modugno, who holds a valid Administrator certificate.
Complaint Details
The visit was triggered by an email complaint received by the Centralized Complaint and Information Bureau (CCIB) on October 14, 2024, regarding the absence of a current Administrator at the facility.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator Recertification Requirements. The licensee did not provide written notice within thirty days of a certified administrator assuming or relinquishing responsibility, posing an immediate health, safety, or personal rights risk to all persons in care. | Type A |
Report Facts
Capacity: 328
Census: 161
Plan of Correction Due Date: Oct 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sara Modugno | Administrator | Current Administrator interviewed during the visit and named in the deficiency finding |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Alisa Ortiz | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 328
Deficiencies: 0
Aug 23, 2024
Visit Reason
An unannounced complaint investigation was conducted due to allegations that residents were not changed timely due to lack of staff and that staff did not respond to call bells in a timely manner.
Findings
The investigation included facility tours, record reviews, staff and resident interviews, and documentation checks. Staff training and response times were verified, and residents confirmed timely assistance. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was triggered by allegations of inadequate staffing leading to residents not being changed timely and delayed staff response to call bells. The investigation concluded these allegations were unsubstantiated.
Report Facts
Staff on file: 19
Staff on file: 17
Alarms pulled: 55
Alarms cleared upon departure: 14
Alarms cleared upon arrival: 41
Staff training verified: 11
Staff interviewed: 12
Residents interviewed: 8
Residents confirming timely assistance: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and inspection visit |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager on report |
| Nikka Solomon | Assisted Living Coordinator | Met with Licensing Program Analyst during investigation |
| Stephanie Jukic | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 328
Deficiencies: 0
Aug 23, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following allegations that due to lack of staff, colostomy care was provided by unqualified staff and residents did not receive their medications on time.
Findings
The investigation included interviews with staff and residents, review of records, and observation. The complaint was found to be unfounded as residents confirmed adequate staffing and timely medication administration, and staff training for colostomy care was verified.
Complaint Details
The complaint alleged that due to lack of staff, colostomy care was provided by unqualified staff and residents did not receive their medications on time. The complaint was investigated and found to be unfounded.
Report Facts
Capacity: 328
Census: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and inspection visit |
| Stephanie Jukic | Administrator | Facility administrator named in the report |
| Nikka Solomon | Assisted Living Coordinator | Met with Licensing Program Analyst during investigation |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 328
Deficiencies: 0
Aug 23, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following allegations that staff may be financially abusing residents and violating residents' personal rights.
Findings
The investigation included record reviews, interviews, and observations, which found no evidence of financial abuse or violation of personal rights. The complaint was determined to be unfounded, with residents and staff confirming proper care, respect, and facility conditions.
Complaint Details
The complaint alleged staff financial abuse of residents and violation of residents' personal rights. The investigation found the complaint to be unfounded, meaning the allegations were false or without reasonable basis.
Report Facts
Staff interviewed: 12
Residents interviewed: 8
Facility capacity: 328
Facility census: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and inspection visit. |
| Stephanie Jukic | Administrator | Facility administrator mentioned in the report. |
| Nikka Solomon | Assisted Living Coordinator | Met with Licensing Program Analyst during the investigation. |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 0
Dec 21, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2023-10-16 alleging that staff handle residents in a rough manner.
Findings
The investigation included interviews with staff and residents and review of pertinent documents. Based on the preponderance of evidence, the allegation that staff handle residents in a rough manner was determined to be unsubstantiated. No deficiencies were cited.
Complaint Details
The complaint alleged that staff handle residents in a rough manner. Interviews with 2 out of 2 staff and 2 out of 4 residents indicated no rough handling. Two other residents were not oriented to time and space and could not provide answers. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 328
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Jukic | Director of Residential Service | Met with Licensing Program Analyst during the investigation |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 328
Deficiencies: 1
Nov 2, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident eloped from the facility due to lack of supervision.
Findings
The investigation substantiated the allegation that Resident 1 eloped from the facility by exiting the second story of the Memory Care community. The resident was found uninjured and placed on 1:1 care for a month. The facility has implemented monthly elopement drills, contracted a company for feedback, ordered additional alarms, and assigned employees near each exit.
Complaint Details
The complaint was substantiated, meaning the allegation of lack of supervision leading to resident elopement was valid and a violation occurred.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by Resident 1 was able to elope from the facility. | Type A |
Report Facts
Capacity: 328
Census: 205
Plan of Correction Due Date: Nov 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Jukic | Director of Residential Care Services | Met with Licensing Program Analyst during investigation and provided information about elopement drills and facility measures |
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 191
Capacity: 328
Deficiencies: 1
Oct 27, 2023
Visit Reason
The visit was conducted as a Case Management - Deficiencies visit to issue a citation after discovering a deficiency during an investigation related to a complaint about failure to report a fire incident.
Findings
The facility failed to report a fire caused by an electrical circuit from the steam well that occurred on July 18, 2023, to the licensing agency by the next working day as required by Title 22 regulations. This failure poses a potential Health, Safety, and Personal Rights risk to persons in care.
Complaint Details
The visit was triggered by a complaint investigation (Complaint Control Number: 22-AS-20230719155923). The complaint investigation found that the facility did not report a fire incident as required, meeting the preponderance of evidence standard.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report a fire to the licensing agency immediately and no later than the next working day as required by Title 22, Division 6, Chapter 8 of the California Code of Regulations. | Type B |
Report Facts
Capacity: 328
Census: 191
Deficiency Type Count: 1
Plan of Correction Due Date: Due date for Plan of Correction is 11/03/2023 (date extracted as string, not numeric)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the visit and delivered findings |
| Rob Goerzen | Chief Executive Officer/President | Met with during the visit and involved in exit interview |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 191
Capacity: 328
Deficiencies: 0
Oct 27, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that staff were not providing adequate food service and were not properly storing food.
Findings
The investigation found the allegation of inadequate food service to be unsubstantiated due to lack of preponderance of evidence, with residents and staff interviews indicating meals were provided adequately. The allegation of improper food storage was found to be unfounded, with observations confirming proper food storage procedures were followed.
Complaint Details
The complaint investigation was initiated based on allegations received on 07/19/2023 regarding inadequate food service and improper food storage. After interviews, observations, and record reviews, the allegation of inadequate food service was deemed unsubstantiated and the allegation of improper food storage was deemed unfounded.
Report Facts
Resident interviews: 12
Staff interviews: 6
Staff interviews: 5
Servers observed: 4
Meal serving time: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rob Goerzen | CEO/President | Met with Licensing Program Analyst during investigation and exit interview |
| Stephanie Jukic | Director of Residential Services | Accompanied Licensing Program Analyst during kitchen tour |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 328
Deficiencies: 0
Aug 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit initiated due to a complaint alleging that staff does not provide residents with dignity and respect.
Findings
The investigation found that seven out of seven individuals interviewed could not corroborate the allegation, and one individual who experienced disrespect was unable to specify details or identify the staff involved. Therefore, the allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff does not provide residents with dignity and respect. The allegation was investigated through interviews and record reviews and was found unsubstantiated.
Report Facts
Capacity: 328
Census: 185
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Jukic | Director of Residential Services | Met during investigation and involved in exit interview |
| Nikka Solomon | Director of Health & Wellness | Met during investigation and involved in exit interview |
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 195
Capacity: 328
Deficiencies: 0
May 30, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident sustained injury from a fall due to lack of care and supervision.
Findings
The investigation found that the resident was independent, with no history of falls or need for assistance, and the facility followed protocols for checking on residents. The allegation was deemed unfounded as there was no evidence of neglect or lack of supervision.
Complaint Details
The complaint alleged that a resident sustained injury from a fall due to lack of care and supervision. After investigation including interviews and record reviews, the allegation was found to be unfounded.
Report Facts
Facility capacity: 328
Resident census: 195
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Jukic | Administrator | Facility administrator interviewed during the investigation |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 72
Capacity: 328
Deficiencies: 0
Nov 28, 2022
Visit Reason
Licensing Program Analysts conducted an unannounced visit for the purpose of conducting a required annual visit.
Findings
The facility appeared clean, sanitary, and well maintained with residents observed to be happy and well taken care of. No deficiencies were noted during the visit.
Report Facts
Residents in assisted living: 44
Residents in memory care: 28
Residents on hospice: 7
Facility capacity: 328
Facility census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Jukic | Administrator / Director of Residential Services | Met with Licensing Program Analysts and involved in facility tour and inspection |
| Jimmy Troge | Facilities Director | Participated in facility tour with Licensing Program Analysts |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 328
Deficiencies: 0
Nov 28, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not ensure a resident attended dialysis treatment and that a resident sustained a fall while in care.
Findings
The investigation found that the resident was denied dialysis treatment due to fever and was isolated upon return to the facility. The resident subsequently fell in the bathroom and was hospitalized, later passing away. The resident was not considered a fall risk and had no prior falls. The allegations were deemed unfounded.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, and/or were without a reasonable basis.
Report Facts
Capacity: 328
Census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Mendivil | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Stephanie Jukic | Administrator / Director | Facility administrator met during the investigation |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 55
Capacity: 240
Deficiencies: 0
May 26, 2021
Visit Reason
The visit was an unannounced case management follow-up on an investigation related to an incident involving a resident found deceased from a self-inflicted gunshot wound.
Findings
The investigation found no substantial evidence of neglect or lack of care by the facility. No deficiencies were cited during this visit.
Complaint Details
The visit followed an incident where Resident 1 was found deceased from a self-inflicted gunshot wound. The investigation did not find evidence of neglect or lack of care by the facility. The resident was independent and had recently returned from a skilled nursing facility after contracting COVID-19.
Report Facts
Facility capacity: 240
Resident census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Jukic | Administrator | Facility Administrator present during the visit and reported no knowledge of the pistol onsite |
| Heather Lopez | Director of Health and Wellness | Present during the visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Census: 143
Capacity: 240
Deficiencies: 0
Feb 22, 2021
Visit Reason
An unannounced health and safety visit was conducted following a reported resident death and related incident involving emergency responders and the coroner's office.
Findings
No immediate health and safety concerns or citations were noted during the visit; however, further investigation will be required.
Report Facts
Capacity: 240
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Jukic | Director of Residential Services | Reported the resident death and accompanied LPAs during the visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced health and safety visit |
| Jenifer Tirre | Licensing Program Analyst | Conducted the unannounced health and safety visit |
| Alisa Ortiz | Licensing Program Manager | Named in the report header |
Report
August 13, 2025
File
report_27_300600977_inx26_2025-08-13.pdf
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