Deficiencies (last 6 years)
Deficiencies (over 6 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
208% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
33% occupied
Based on a March 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Census: 108
Capacity: 328
Deficiencies: 2
Date: Mar 27, 2026
Visit Reason
An unannounced case management visit was conducted to follow up on SOC 341 reports submitted on 2026-02-05 and an incident report regarding medication errors.
Findings
The inspection found that staff member S1 was rough and aggressive with residents R1 and R2, confirmed by video surveillance, resulting in immediate health and safety risks. Additionally, a medication error occurred where resident R4 consumed seven medications prescribed to resident R3 due to caregiver protocol not being followed.
Deficiencies (2)
Residents were not afforded dignity in care as staff member S1 was rough with residents R1 and R2, posing an immediate health and safety risk.
Basic services were not provided as resident R4 took seven of R3's medications unsupervised by a caregiver, posing an immediate health and safety risk.
Report Facts
Capacity: 328
Census: 108
Medications consumed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and reviewed video surveillance |
| Sara Modugno | Administrator/Director | Facility administrator named in the report header |
Inspection Report
Annual Inspection
Census: 111
Capacity: 328
Deficiencies: 5
Date: Dec 18, 2025
Visit Reason
The purpose of the visit was to conduct the Annual Required inspection of the Town & Country facility.
Findings
The facility was generally clean, safe, and sanitary with adequate supplies and emergency preparedness. However, several deficiencies were cited including a door in need of repair, lack of CPR training for most staff, missing annual training for all staff, missing physician orders for bed rails for some residents, and an outdated medical assessment for one resident.
Deficiencies (5)
Exit door in need of repair posing a potential health, safety or personal rights risk.
Four out of five staff without CPR training posing a potential health, safety or personal rights risk.
Five out of five staff without required annual training posing a potential health, safety or personal rights risk.
Resident #2 does not have an updated medical assessment posing a potential health, safety or personal rights risk.
Three out of five residents without physician orders for bed rails posing a potential health, safety or personal rights risk.
Report Facts
Residents on hospice care: 21
Licensed capacity: 328
Current census: 111
Staff files reviewed: 5
Staff without CPR training: 4
Staff without annual training: 5
Residents without physician orders for bed rails: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Modugno | Administrator | Facility administrator named in the report and joined the tour. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Lori Wear | Memory Care Liaison | Joined the tour of the facility. |
Inspection Report
Routine
Deficiencies: 18
Date: Nov 20, 2025
Visit Reason
Routine inspection of Town & Country nursing home to assess compliance with regulatory requirements including resident rights, medication management, abuse reporting, care planning, infection control, food safety, equipment maintenance, and safety of bed rails.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights regarding daily routines, improper use and documentation of psychotropic medications, failure to report abuse allegations to law enforcement, incomplete care plans, inadequate medication monitoring, improper respiratory and catheter care, food safety violations, failure to maintain essential equipment, and incomplete entrapment assessments for bed rails.
Deficiencies (18)
Failure to honor residents' rights to make choices about daily routines, including entering rooms early morning without consent and turning on lights.
Failure to ensure one resident was free from unnecessary psychotropic medications due to lack of prescriber's clinical rationale.
Failure to report an allegation of physical abuse to local law enforcement.
Failure to remove alleged perpetrator from facility during abuse investigation.
Failure to develop a comprehensive person-centered care plan for use of bed rails.
Failure to revise comprehensive care plan to reflect resumption of apixaban medication.
Failure to obtain physician's order to monitor blood pressure prior to antihypertensive medication administration.
Failure to accurately monitor and document fluid intake and output for resident with indwelling urinary catheter.
Failure to ensure physician's orders clearly indicated IV access type as PICC line.
Failure to properly clean and store nebulizer masks for residents, increasing risk of infection.
Failure to assess, obtain consent, physician order, and care plan for use of bed rails for one resident.
Failure to ensure safe storage and disposal of medications including leaving medications unattended at bedside, compromised packaging, expired medications, and improper refrigerator temperature.
Failure to ensure food served was palatable and met resident preferences, including serving dry shrimp scampi without sauce and serving pork to resident with no pork diet.
Failure to provide food in a form designed to meet individual needs for resident on soft and bite sized diet (served cereal not appropriate).
Failure to ensure proper hand hygiene after providing incontinence and catheter care and failure to wear gown during high-contact care for resident on enhanced barrier precautions.
Failure to maintain essential equipment in safe operating condition including improper calibration and quality control of glucometers.
Failure to ensure accurate and complete entrapment assessments for bed rails for multiple residents, missing assessment of Zone 7 (between head or foot board and mattress end).
Failure to ensure call light system consoles at nurse stations had audible sound to alert staff to resident calls.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 10
Residents affected: 2
Residents affected: 2
Glucometers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Named in resident rights deficiency for entering room without consent | |
| LVN 13 | Named in resident rights deficiency for turning on lights without consent | |
| Administrator | Acknowledged multiple deficiencies including abuse reporting, medication, and care planning | |
| DON | Director of Nursing | Acknowledged multiple deficiencies including medication, abuse reporting, and care planning |
| CNA 1 | Failed to perform proper hand hygiene after catheter care | |
| COTA 1 | Failed to wear gown during transfer of resident on enhanced barrier precautions | |
| LVN 3 | Left medications unattended at bedside during administration | |
| LVN 9 | Left medications unattended at bedside during administration | |
| LVN 10 | Verified medication storage deficiencies | |
| LVN 2 | Verified medication storage deficiencies | |
| Executive Chef | Verified food safety deficiencies | |
| RD | Registered Dietitian | Verified food safety and diet form deficiencies |
| IP | Infection Preventionist | Verified infection control deficiencies and call light system issues |
| Unit Secretary | Verified call light system volume issues | |
| Maintenance Staff | Verified incomplete entrapment assessments and bed rail safety issues |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 328
Deficiencies: 0
Date: Nov 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding inadequate staffing resulting in residents' needs not being met and failure to provide activities for residents in care.
Complaint Details
The complaint investigation was unsubstantiated for inadequate staffing, meaning there was insufficient evidence to prove the allegation. The allegation regarding lack of activities was deemed unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found that the facility uses agency staff to fill staffing gaps and that residents' needs are being met, leading to the allegation of inadequate staffing being unsubstantiated. The allegation that facility staff do not provide activities was found to be unfounded, with evidence of a robust activity schedule and confirmation from staff and residents.
Report Facts
Capacity: 328
Census: 110
Staffing: 8
Staffing: 4
Staffing: 6
Activity Coordinators: 3
Activity Coordinators: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sara Modugno | Administrator | Facility administrator present during the investigation |
| Cristina Garcia | Met with during the investigation | |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 1
Date: Oct 28, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following complaints received on 2025-08-20 regarding staff not meeting residents' care needs due to lack of staff, staff not having access to supplies, and facility disrepair.
Complaint Details
The complaint investigation was initiated based on allegations received on 2025-08-20. The allegations included staff not meeting residents' care needs due to lack of staff, staff not having access to supplies, and facility disrepair. The allegation regarding lack of staff was unsubstantiated, the allegation regarding access to supplies was unfounded, and the allegation regarding facility disrepair was substantiated.
Findings
The investigation found the allegation of staff not meeting residents' care needs due to lack of staff to be unsubstantiated. The allegation that staff do not have access to supplies was deemed unfounded. However, the allegation that the facility is in disrepair was substantiated due to a delay in walkie-talkie response time posing a potential health and safety risk.
Deficiencies (1)
The walkie-talkie experienced a delay in alert between 2-3 minutes when the two patio doors were opened, posing a potential health and safety risk to persons in care.
Report Facts
Capacity: 328
Caregivers on August 13, 2025 AM shift: 8
Caregivers on August 13, 2025 PM shift: 7
Caregivers on August 13, 2025 night shift: 6
Caregivers on August 15, 2025 AM/PM shifts: 7
Caregivers on August 15, 2025 night shift: 4
Caregivers on August 16, 2025 AM/PM shifts: 7
Caregivers on August 16, 2025 night shift: 6
Walkie-talkie delay: 2
Walkie-talkie delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation and unannounced visits |
| Sara Modugno | Director of Resident Services, RN, BSN | Met with Licensing Program Analyst during investigation and named in findings |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 1
Date: Oct 28, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2025-08-20 alleging staff were not meeting residents' care needs due to lack of staff, staff lacked access to supplies, and the facility was in disrepair.
Complaint Details
The complaint investigation was initiated based on allegations received on 2025-08-20. The allegations included staff not meeting residents' care needs due to lack of staff, staff lacking access to supplies, and facility disrepair. The allegation of lack of staff was unsubstantiated, the lack of supplies allegation was unfounded, and the facility disrepair allegation was substantiated.
Findings
The investigation found the allegation of staff not meeting residents' care needs due to lack of staff to be unsubstantiated. The allegation that staff lacked access to supplies was deemed unfounded. However, the allegation that the facility was in disrepair was substantiated due to a delay in walkie-talkie response time posing a potential health and safety risk.
Deficiencies (1)
The walkie-talkie experienced a delay in alert between 2-3 minutes when the two patio doors were opened, posing a potential health and safety risk to persons in care.
Report Facts
Facility capacity: 328
Caregivers on shift: 8
Caregivers on shift: 7
Caregivers on shift: 6
Caregivers on shift: 7
Caregivers on shift: 4
Caregivers on shift: 6
Walkie-talkie alert delay: 2
Walkie-talkie alert delay: 3
Plan of Correction due date: Nov 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation and unannounced visits |
| Sara Modugno | Director of Resident Services | Met with Licensing Program Analyst during investigation and exit interviews |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 0
Date: Sep 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff were not properly addressing scabies, not ensuring residents had clean bed linens, and not maintaining passageways free from obstruction.
Complaint Details
The complaint investigation was unsubstantiated. Although some residents had scabies, the facility was actively managing the outbreak and maintaining cleanliness and safety standards. No evidence supported the allegations of failure to address scabies properly, unclean linens, or obstructed passageways.
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 of unclean linens or blocked passageways. The allegations were deemed unsubstantiated due to lack of sufficient evidence.
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 | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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 the 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)
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/Director | Facility representative met during the inspection |
Inspection Report
Plan of Correction
Census: 108
Capacity: 328
Deficiencies: 2
Date: 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)
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: 218
Capacity: 328
Deficiencies: 0
Date: Aug 13, 2025
Visit Reason
The inspection visit was conducted to investigate complaint number 22-AS-20241209152259 by conducting interviews and collecting documentation.
Complaint Details
Complaint number 22-AS-20241209152259 was investigated during the visit.
Findings
The Licensing Program Analyst conducted interviews and obtained requested documents related to the complaint. An exit interview was conducted and a copy of the report was provided to the Executive Director.
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
Census: 108
Capacity: 328
Deficiencies: 0
Date: Aug 13, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff does not ensure the facility is free of pests and that staff are not meeting residents' hygiene needs.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.
Findings
The investigation found documentation of pest extermination services and no observed pests during the visit. Staff and observations confirmed residents' hygiene needs were being met, with residents appearing clean and adequate staffing levels observed. The allegations were deemed unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 328
Resident census: 108
Pest extermination service dates: 3
Staffing levels: 6
Staffing levels: 2
Staffing levels: 1
Staffing levels: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sara Modugno | Administrator | Facility administrator present during the investigation |
| Christina Garcia | Met with the evaluator during the visit | |
| Alisa Ortiz | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 328
Deficiencies: 2
Date: Aug 13, 2025
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff did not ensure cleaning chemicals were inaccessible to residents and medications were dispensed as prescribed, as well as concerns about supervision and sharp objects accessibility.
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.
Findings
The investigation substantiated that cleaning chemicals were unsecured in kitchenettes and that residents missed multiple medications due to pending refills, posing immediate health and safety risks. Allegations regarding inadequate supervision and accessibility of sharp objects were unsubstantiated.
Deficiencies (2)
Licensee failed to ensure disinfectants and cleaning solutions were secured and not left unattended outside locked storage.
Licensee failed to ensure residents were provided assistance with taking prescribed medications; Residents #1 and #2 missed multiple medications due to refills pending.
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 |
| Sara Modugno | Administrator | Facility administrator involved in the investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 328
Deficiencies: 0
Date: 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.
Complaint Details
The complaint was unsubstantiated after investigation. Documentation and staff interviews did not support the allegations of pest presence or unmet 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.
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
Date: 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.
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.
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.
Deficiencies (2)
Licensee failed to ensure cleaning supplies were secured, posing an immediate health and safety risk to residents.
Licensee failed to ensure residents were provided assistance with taking medication; Residents #1 and #2 missed multiple medications due to refills pending.
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
Date: Aug 13, 2025
Visit Reason
The inspection visit was conducted to investigate complaint number 22-AS-20241209152259 through interviews and documentation collection.
Complaint Details
The visit was related to complaint number 22-AS-20241209152259. No substantiation status is provided.
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.
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
Routine
Deficiencies: 3
Date: Jul 24, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care planning, monitoring, and treatment, specifically focusing on the care provided to Resident 1 who had an ileostomy and experienced a change in condition including nausea, vomiting, poor meal intake, and significant weight loss.
Findings
The facility failed to initiate a baseline care plan for Resident 1's ileostomy care and monitoring within 48 hours of admission, failed to develop a care plan addressing Resident 1's nausea and weight loss, and failed to notify the physician timely regarding the resident's discharge instructions and significant weight loss. These failures posed risks of inadequate resident-centered care and delayed necessary interventions.
Deficiencies (3)
Failed to ensure the baseline care plan for Resident 1 was initiated upon admission to address ileostomy care and nutritional interventions.
Failed to develop a care plan for Resident 1's change in condition including nausea, vomiting, poor meal intake, and weight loss.
Failed to notify Resident 1's physician regarding discharge instructions for fluid intake and to monitor intake and output, and failed to notify physician timely about significant weight loss.
Report Facts
Weight loss: 17
Fluid intake: 2
Dates of weight measurements: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Verified Resident 1's intake and output was not monitored and care plans were not initiated. |
| DON | Director of Nursing | Verified baseline care plan and care plan for weight loss were not initiated and acknowledged findings. |
| RD | Registered Dietitian | Verified resident was at risk for weight loss and no care plan was initiated until MDS completion. |
| Attending Physician | Stated she was not aware of discharge instructions regarding fluid intake and was not informed of weight loss. | |
| LVN 2 | Licensed Vocational Nurse | Received complaint from Family Member 1 about lack of monitoring intake and output. |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 0
Date: Jul 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility failed to provide notice to a resident when changing room location.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
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. Therefore, the allegation was deemed unfounded.
Report Facts
Facility capacity: 328
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Sara Modugno | Administrator | Facility administrator present during investigation |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 0
Date: 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.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
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.
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
Date: Jul 2, 2025
Visit Reason
An unannounced complaint investigation 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.
Complaint Details
The complaint involved allegations of neglect related to feeding assistance, medical attention, medication administration, and safeguarding personal belongings. The allegations were determined to be unfounded after review of records and interviews.
Findings
The investigation found all allegations to be unfounded based on documentation and interviews. The resident was documented to have refused food and medication at times but was offered alternatives and medical care was provided timely. The facility addressed the personal belongings claim with a refund accepted by the family. No deficiencies were cited.
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 | Administrator / Executive Director | Facility representative named in the report and exit interview |
Inspection Report
Complaint Investigation
Census: 212
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Date: Jun 16, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to 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.
Complaint Details
The complaint contained allegations regarding a non-operational call system, inadequate care and supervision to prevent falls, and inadequate toileting care. The investigation was unable to substantiate these allegations based on record reviews, staff interviews, direct observations, and testing of the call system.
Findings
The investigation found that the call system was operational based on tests and records, the facility followed protocols for a resident identified as a fall risk including observation and caregiver services which were declined by the resident's POA, and staff interviews and observations confirmed adequate toileting care. The allegations were deemed unsubstantiated due to insufficient evidence of violations.
Report Facts
Capacity: 328
Response time: 26
Response time: 15
Response time: 115
Falls: 3
Observation period: 72
Date: Apr 11, 2024
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
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Date: Jun 4, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility failed to provide care and supervision resulting in multiple falls.
Complaint Details
The complaint alleged failure to provide care and supervision resulting in multiple falls. The allegation was found to be unfounded after investigation.
Findings
The investigation found that the facility provided necessary care and supervision to resident R1, who experienced multiple falls but without injury or hospitalization. The allegation was determined to be unfounded based on interviews, medical record reviews, and incident reports.
Report Facts
Incident reports: 6
Falls: 5
Capacity: 328
Census: 213
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Evaluator | Conducted the complaint investigation and authored the report |
| Sara Modugno | Executive Director | Facility representative who granted access and participated in the investigation |
| Alisa Ortiz | Supervisor | Supervisor overseeing the licensing evaluation |
| Stephenie Jukic | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 213
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Date: May 22, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2025-02-18 regarding allegations that staff did not ensure the facility was free of pests.
Complaint Details
The complaint alleged that staff did not ensure the facility was free of pests. After investigation, including interviews and record review, the allegation was found to be unsubstantiated due to insufficient evidence.
Findings
The investigation included interviews with residents and staff, a tour of the facility, and a review of pest inspection records. No evidence of pests was found, and the allegation was determined to be unsubstantiated. No deficiencies were cited during the visit.
Report Facts
Pest and rodent inspection service dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit. |
| Sara Modugno | Administrator | Facility administrator present during the investigation and exit interview. |
Inspection Report
Complaint Investigation
Census: 218
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Date: Mar 19, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that staff were not meeting residents' needs and did not have access to supplies for residents.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not meeting residents' needs and lack of access to supplies. Interviews with residents and staff, as well as observations, did not corroborate these allegations.
Findings
The investigation included observations and interviews with residents and staff. The findings revealed that staff were meeting residents' needs, providing assistance with meals, medications, toileting, and other activities. Supplies such as diapers and wipes were available and accessible to staff. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 328
Census: 121
Staff interviewed: 10
Residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sara Modugno | Executive Director | Facility administrator met during investigation and exit interview |
| Lourdes Montoya | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Date: Mar 17, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report received regarding a resident being served shrimp despite having a seafood allergy.
Complaint Details
The visit was complaint-related, following an incident report dated 01/25/2025 about a resident served shrimp despite a seafood allergy. The resident experienced no side effects and has since moved out of the facility.
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 had no side effects. The facility protocols for allergies were observed but not fully effective in preventing the incident.
Deficiencies (1)
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.
Report Facts
Capacity: 328
Census: 104
Plan of Correction Due Date: Mar 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Modugno | Administrator | Met during inspection and participated in exit interview |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Alisa Ortiz | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 328
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Date: 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.
Complaint Details
The complaint alleged that pests were present in the Independent Living dining room. The allegation was investigated through facility tours, staff and resident interviews, and review of cleaning logs and health inspection reports. The complaint was determined to be unfounded.
Findings
The investigation found no evidence of pests or rodents in the facility. Interviews with residents and staff denied the allegation, and a recent Public Health Services inspection report was passed. The complaint was determined to be unfounded.
Report Facts
Capacity: 328
Census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation visit |
| Pedro Miranda | Head Chef | Present during facility tour and investigation |
| Anthony Montes | Sous Chef | Present during facility tour and investigation |
| Cristina Garcia | LVN | Explained the reason for the visit and interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Date: Dec 17, 2024
Visit Reason
An unannounced required annual visit was conducted by Licensing Program Analysts to evaluate the facility's compliance with regulations.
Findings
The facility was toured including Independent Living, Assisted Living, and Memory Care units. Observations found all required elements in resident rooms, operational safety equipment, and proper documentation in resident files. 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 Modugno | Administrator | Named as facility administrator with 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 |
| Alisa Ortiz | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 210
Capacity: 328
Deficiencies: 0
Date: 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
Routine
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control practices, specifically regarding the use of personal protective equipment (PPE) by certified nursing assistants (CNAs) during resident care.
Findings
The facility failed to ensure CNAs followed evidence-based practices requiring both gloves and gowns during high-contact resident care activities, posing a risk for transmission of disease-causing microorganisms. Interviews and observations confirmed inconsistent gown use despite facility policies and CDC guidelines.
Deficiencies (1)
Failure to ensure CNAs wore gowns in addition to gloves during high-contact resident care activities as required by evidence-based practices and facility policy.
Report Facts
Date of survey completion: Nov 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Interviewed regarding PPE use and verified gown use was required |
| MDS RN | Registered Nurse | Interviewed and verified gown and gloves were required for contact with residents with EBP |
| DSD | Interviewed and verified gown and gloves were required for contact with residents with EBP | |
| Administrator | Acknowledged the findings of the inspection | |
| IP | Infection Preventionist | Interviewed regarding PPE requirements for EBP and confirmed yellow gown was required |
Inspection Report
Follow-Up
Census: 161
Capacity: 328
Deficiencies: 1
Date: 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 a complaint was received by the Centralized Complaint and Information Bureau on October 14, 2024.
Complaint Details
The visit was triggered by an email complaint received by the Centralized Complaint and Information Bureau on October 14, 2024, regarding the absence of a current Administrator on file. The complaint was substantiated by the findings.
Findings
The facility did not have proper documentation on file for the change of Administrator that occurred in February 2024, which posed an immediate health, safety, or personal rights risk. A new signed LIC 200 form was obtained to update the Administrator to Sara Modugno, and a deficiency was cited for failure to comply with Administrator recertification requirements.
Deficiencies (1)
Failure to provide written notice within 30 days of a certified administrator assuming responsibility, violating CCR 87407(k).
Report Facts
Capacity: 328
Census: 161
Deficiencies cited: 1
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Modugno | Administrator | Current Administrator interviewed during the inspection and named in deficiency |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Alisa Ortiz | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 161
Capacity: 328
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Routine
Census: 77
Deficiencies: 17
Date: Sep 13, 2024
Visit Reason
Routine inspection of Town & Country nursing home to assess compliance with regulatory requirements including resident rights, medication administration, infection control, food safety, and bed safety.
Findings
The facility had multiple deficiencies including failure to obtain informed consent for psychotropic medication and side rail use, failure to maintain advance directives, improper use of personal cell phones for resident photos, inadequate activity programming, medication administration errors, improper medication storage and documentation, failure to follow pureed food recipes, unpalatable food, food safety violations, inadequate infection control practices, and incomplete bed rail entrapment assessments.
Deficiencies (17)
Failed to obtain informed consent for side rail and alprazolam medication for Resident 43.
Failed to obtain and maintain advance directives for six residents.
Director of Activities used personal cell phone to take pictures of residents.
Failed to provide individualized and ongoing activity program for Resident 43.
Failed to follow physician's orders and document effectiveness of medications for Residents 37, 52, and 621.
Failed to ensure accurate reconciliation and disposal of controlled medications for Residents 31 and 670.
Failed to ensure medications were administered per physician's ordered parameters for Residents 2 and 56.
Failed to monitor side effects related to alprazolam medication for Resident 43.
Failed to store orally administered medications separate from external medications and failed to maintain clean medication bottles.
Failed to follow pureed food recipes for biscuit and rice.
Failed to ensure green beans served to residents were palatable.
Failed to properly clean ice machines and store ice scoopers, and failed to discard food items on or before best by date.
Failed to ensure kitchen utensils and equipment were in good, sanitary, and cleanable condition; kitchen staff failed to wear hair and beard restraints; blender had water inside; water liners uncovered during transport; and kitchen staff failed to perform hand hygiene.
Facility policy on use and storage of foods brought by visitors was outdated and visitors were not educated on safe food handling.
Failed to ensure contact and droplet precautions were practiced for Resident 569; infection control lapses in laundry room; and inconsistent documentation of Legionella testing protocols.
Failed to ensure ice machines were cleaned per manufacturer instructions.
Failed to complete and document bed entrapment assessments and measurements for 16 residents with bed rails.
Report Facts
Residents present: 77
Residents receiving pureed diet: 3
Residents with bed rails: 53
Controlled medication morphine tablets: 10
Controlled medication oxycodone/acetaminophen tablets: 103
Discontinued hydrocodone/acetaminophen tablets: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Verified lack of informed consent for Resident 43's medication and side rail use |
| LVN 3 | Licensed Vocational Nurse | Observed medication administration errors and controlled drug record issues |
| Director of Activities | Used personal cell phone for resident photos and verified activity deficiencies for Resident 43 | |
| DON | Director of Nursing | Verified multiple findings including consent, medication, infection control, and bed rail assessments |
| Administrator | Verified findings related to staff photo use and infection control | |
| Laundry Aide 1 | Observed personal items in clean laundry area | |
| Dishwasher 3 | Observed unclean ice machines | |
| Maintenance Staff | Verified ice machine cleaning schedule and condition | |
| CNA 1 | Certified Nursing Assistant | Verified use of side rails for Resident 1 |
| CNA 6 | Certified Nursing Assistant | Verified use of side rails for Resident 4 and Resident 569 |
| LVN 7 | Licensed Vocational Nurse | Verified use of side rails for Resident 569 and lack of entrapment assessment |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 328
Deficiencies: 0
Date: Aug 23, 2024
Visit Reason
An unannounced complaint investigation was conducted due to allegations that, due to lack of staff, residents were not changed timely and staff did not respond to call bells in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of timely resident care and delayed staff response to call bells. Interviews and records showed adequate staffing and timely responses, leading to the conclusion that the allegations were not proven.
Findings
The investigation included facility tours, record reviews, staff and resident interviews, and documentation analysis. The allegations were found to be unsubstantiated as there was insufficient evidence to prove the violations occurred, and staff and residents confirmed timely responses and adequate staffing.
Report Facts
Facility capacity: 328
Census: 110
Staffing: 19
Staffing: 17
Call alarms pulled: 55
Alarms cleared upon departure: 14
Alarms cleared upon arrival: 41
Staff interviewed: 12
Residents interviewed: 8
Residents confirming timely assistance: 5
Employees with completed training: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and inspection visit |
| Stephanie Jukic | Administrator | Facility administrator named in report header |
| Nikka Solomon | Assisted Living Coordinator | Met with Licensing Program Analyst during investigation |
| Lourdes Montoya | Supervisor | Supervisor named in report |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 328
Deficiencies: 0
Date: Aug 23, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations that, due to lack of staff, colostomy care was provided by unqualified staff and residents did not receive their medications on time.
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.
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 appropriate for qualified personnel.
Report Facts
Capacity: 328
Census: 110
Staff interviewed: 6
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and inspection visit |
| Nikka Solomon | Assisted Living Coordinator | Facility staff member met with during investigation |
| Lourdes Montoya | Supervisor | Supervisor overseeing the investigation |
| Stephanie Jukic | Administrator | Facility administrator |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 328
Deficiencies: 0
Date: Aug 23, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff may be financially abusing residents and violating residents' personal rights.
Complaint Details
Complaint alleging staff may be financially abusing residents and violating residents' personal rights was investigated and found to be unfounded.
Findings
The investigation included record reviews, interviews with staff and residents, and observations. The complaint was found to be unfounded, with no evidence of financial abuse or violation of residents' personal rights. The facility was found to be providing appropriate care, meals, medications, and maintaining utilities and infection control policies.
Report Facts
Staff interviewed: 12
Residents interviewed: 8
Facility 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 the Licensing Program Analyst during the investigation. |
| Lourdes Montoya | Supervisor | Supervisor overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Date: 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.
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.
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.
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
Deficiencies: 1
Date: Apr 9, 2024
Visit Reason
The inspection was conducted in response to an alleged abuse complaint involving a staff member (CNA 1) and Resident 1, specifically regarding the facility's failure to remove the accused staff from resident care areas pending investigation.
Complaint Details
The complaint was substantiated based on interviews and record reviews showing the accused staff was not removed or suspended after the abuse allegation, exposing the resident to potential harm.
Findings
The facility failed to remove CNA 1 from resident care areas after an alleged abuse incident reported by Resident 1 on 4/7/24. Interviews confirmed CNA 1 continued working her shift despite the allegation, contrary to facility policy requiring immediate removal and suspension pending investigation.
Deficiencies (1)
Failure to remove a staff member from resident care areas pending an alleged abuse investigation as per facility policy.
Report Facts
Date of alleged abuse: Apr 7, 2024
Date of interview with CNA 1: Apr 9, 2024
Date of interview with LVN 3: Apr 9, 2024
Date of interview with Administrator: Apr 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Accused staff member who was not removed from resident care pending abuse investigation |
| LVN 3 | Licensed Vocational Nurse | Interviewed regarding care of Resident 1 and abuse allegation |
| Administrator | Facility Administrator | Interviewed about facility protocol and acknowledged failure to remove accused staff |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-10-16 alleging that staff handle residents in a rough manner.
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 unable to respond due to orientation issues. The allegation was found unsubstantiated.
Findings
The investigation included interviews with staff and residents and review of pertinent documents. The allegation that staff handle residents in a rough manner was determined to be unsubstantiated based on interviews and evidence reviewed. No deficiencies were cited.
Report Facts
Capacity: 328
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Jukic | Director of Residential Service | Met with Licensing Program Analyst during the investigation and named in the report |
| Andrea Mendivil | Licensing Evaluator | Conducted the complaint investigation |
| Alisa Ortiz | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Date: Nov 2, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that, due to lack of supervision, a resident eloped from the facility.
Complaint Details
The complaint was substantiated based on evidence from records and interviews. Resident 1 eloped due to lack of supervision. The resident was assessed uninjured and placed on 1:1 care for a month. The facility has taken corrective actions including elopement drills and additional safety measures.
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 after being located by a local business manager. The facility has since implemented monthly elopement drills, contracted a company for assessment, ordered additional alarms for egress doors, and placed employees near each exit.
Deficiencies (1)
Basic services shall at a minimum include 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 being able to elope from the facility.
Report Facts
Capacity: 328
Census: 205
Deficiency Type A: 1
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 and involved in investigation interviews |
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 328
Deficiencies: 1
Date: 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.
Complaint Details
The complaint was substantiated, meaning the allegation of lack of supervision leading to resident elopement was valid and a violation occurred.
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.
Deficiencies (1)
(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.
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
Date: Oct 27, 2023
Visit Reason
The visit was conducted as a Case Management - Deficiencies visit following a complaint investigation related to the facility's failure to report a fire incident as required by regulations.
Complaint Details
The visit was triggered by Complaint Control Number 22-AS-20230719155923. The complaint investigation found that the facility did not report the fire incident as required, meeting the preponderance of evidence standard.
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, violating Title 22 regulations. A deficiency citation was issued based on this finding.
Deficiencies (1)
Failure to report a fire incident to the licensing agency within the required timeframe as mandated by Title 22, Division 6, Chapter 8 of the California Code of Regulations.
Report Facts
Deficiency Type: 1
Capacity: 328
Census: 191
Plan of Correction Due Date: Nov 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rob Goerzen | CEO/President | Named in relation to the deficiency and exit interview |
| Jessica Cho | Licensing Program Analyst | Conducted the visit and issued findings |
Inspection Report
Complaint Investigation
Census: 191
Capacity: 328
Deficiencies: 0
Date: Oct 27, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not providing adequate food service to residents and were not properly storing food.
Complaint Details
The complaint investigation was initiated based on allegations that staff were not providing adequate food service and were not properly storing food. The allegation regarding food service was unsubstantiated, and the allegation regarding food storage was unfounded.
Findings
The investigation found the allegation of inadequate food service to be unsubstantiated due to lack of preponderance of evidence, while the allegation of improper food storage was deemed unfounded after observations and interviews confirmed proper food storage practices.
Report Facts
Capacity: 328
Census: 191
Number of residents interviewed: 12
Number of staff interviewed: 6
Number of staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rob Goerzen | Chief Executive Officer/President | Met with during investigation and exit interview |
| Stephanie Jukic | Director of Residential Services | Accompanied LPA during kitchen tour for food storage investigation |
Inspection Report
Complaint Investigation
Census: 191
Capacity: 328
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Date: 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.
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.
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.
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
Date: Aug 24, 2023
Visit Reason
The visit was an unannounced complaint investigation initiated due to an allegation that staff does not provide residents with dignity and respect.
Complaint Details
The complaint alleged that staff does not provide residents with dignity and respect. The allegation was unsubstantiated based on interviews and record reviews.
Findings
The investigation found that seven out of seven individuals interviewed could not corroborate the allegation, and although one individual reported personal experience of disrespect, details were unspecified. Therefore, the allegation was deemed unsubstantiated.
Report Facts
Capacity: 328
Census: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Jukic | Director of Residential Services | Met during investigation and exit interview |
| Nikka Solomon | Director of Health & Wellness | Met during investigation and exit interview |
| Jessica Cho | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Sheila Santos | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Date: May 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident sustained injury from a fall due to lack of care and supervision.
Complaint Details
The complaint alleged that a resident sustained injury from a fall as a result of lack of care and supervision. The allegation was investigated and deemed unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found that the resident was independent and receiving no assistance in activities of daily living. The fall occurred despite facility protocols for resident checks, and the allegation of neglect was deemed unfounded based on interviews and record reviews.
Report Facts
Capacity: 328
Census: 195
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Jukic | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 195
Capacity: 328
Deficiencies: 0
Date: 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.
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.
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.
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
Complaint Investigation
Census: 72
Capacity: 328
Deficiencies: 0
Date: Nov 28, 2022
Visit Reason
An unannounced complaint investigation 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.
Complaint Details
The complaint investigation was unannounced and focused on two allegations: failure to ensure dialysis attendance and a resident fall. The allegations were found to be unfounded based on interviews, documentation review, and investigation findings.
Findings
The investigation found that the resident was denied dialysis treatment due to fever and was isolated upon return to the facility. The resident later fell in the bathroom and was hospitalized, testing positive for Covid-19 and subsequently passing away. The resident was not a fall risk and had no prior falls. The allegations were deemed unfounded.
Report Facts
Capacity: 328
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Jukic | Administrator / Director | Facility representative met during investigation |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 72
Capacity: 328
Deficiencies: 0
Date: Nov 28, 2022
Visit Reason
Licensing Program Analysts conducted an unannounced visit for the purpose of conducting a required annual inspection of the facility.
Findings
The facility was observed to be clean, sanitary, and well-maintained with residents appearing happy and well cared for. 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
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Jukic | Administrator / Director of Residential Services | Met with Licensing Program Analysts during the inspection and holds an administrator certificate |
| Jimmy Troge | Facilities Director | Accompanied Licensing Program Analysts during the facility tour |
Inspection Report
Annual Inspection
Census: 72
Capacity: 328
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
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
Annual Inspection
Deficiencies: 9
Date: Nov 18, 2021
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided to residents.
Findings
The facility was found deficient in multiple areas including resident rights notification, care planning, accident hazard prevention, feeding tube management, respiratory care, staff competency, medication storage, infection control, and vaccination education. Deficiencies posed risks ranging from minimal to potential actual harm to residents.
Deficiencies (9)
Failed to ensure residents knew how to contact the state long-term care ombudsman.
Failed to develop and implement a comprehensive care plan for Resident 205's continuous oxygen use.
Failed to provide a safe environment free from accident hazards related to Resident 10's smoking materials.
Failed to provide accurate enteral feeding and documentation for Resident 37.
Failed to provide safe and appropriate respiratory care for Residents 30 and 44, including oxygen administration and titration documentation.
Failed to ensure licensed nurses had competencies to use enteral feeding pumps and obtain feeding history.
Failed to ensure safe medication storage; expired central line dressing kit and Remedy cream found in medication carts.
Failed to ensure proper infection control measures during medication preparation for Resident 207, including hand hygiene and aseptic technique.
Failed to provide education on risks and benefits of influenza vaccination to Resident 52 who refused the vaccine.
Report Facts
Residents sampled: 17
Medication carts inspected: 8
Expired central line dressing kit date: Oct 31, 2021
Expired Remedy cream date: 202108
Oxygen flow rate ordered: 3
Oxygen flow rate observed: 2
Feeding rate: 60
Feeding volume discrepancy: 260
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in infection control deficiency related to hand hygiene and aseptic technique during medication preparation for Resident 207 |
| LVN 3 | Licensed Vocational Nurse | Verified feeding volume discrepancy for Resident 37 |
| LVN 4 | Licensed Vocational Nurse | Unable to demonstrate competency in obtaining enteral pump feeding history for Resident 37 |
| LVN 5 | Licensed Vocational Nurse | Observed oxygen administration for Resident 30 and verified oxygen flow rate discrepancy |
| Activity Director | Responsible for notifying residents about ombudsman contact information and smoking materials management | |
| DON | Director of Nursing | Acknowledged multiple findings including care plan, respiratory care, competency, medication storage, infection control, and vaccination education deficiencies |
| Administrator | Acknowledged failure to notify residents about ombudsman contact information | |
| DSD/IP 1 | Director of Staff Development/Infection Preventionist | Unable to demonstrate competency in obtaining enteral pump feeding history for Resident 37 |
| IP 2 | Infection Preventionist | Verified expired medication findings and vaccination education deficiency |
| IP 1 | Infection Preventionist | Unable to demonstrate competency in obtaining enteral pump feeding history for Resident 37 |
| LVN 2 | Licensed Vocational Nurse | Verified expired Remedy cream in Treatment Cart 1 |
| LVN 1 | Licensed Vocational Nurse | Observed oxygen administration for Resident 44 and lack of documentation for oxygen titration |
Inspection Report
Census: 137
Capacity: 328
Deficiencies: 0
Date: Aug 12, 2021
Visit Reason
The visit was an announced case management visit initiated by the licensee to observe the new memory care building.
Findings
No health and safety violations were noted during the visit, and the facility is approved to accept residents per fire clearance granted on 07/02/2021.
Report Facts
Bed count in new memory care building: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Jukic | Administrator and Director of Residential Services | Greeted Licensing Program Analyst and toured the new memory care building. |
| Heather Lopez | Director of Health and Wellness | Participated in the tour of the new memory care building. |
| Lindsay Troge | Director of Marketing | Participated in the tour of the new memory care building. |
| Jimmy Troge | Director of Facilities | Participated in the tour of the new memory care building. |
Inspection Report
Follow-Up
Census: 55
Capacity: 240
Deficiencies: 0
Date: May 26, 2021
Visit Reason
The visit was an unannounced case management follow-up on an investigation regarding 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.
Report Facts
Capacity: 240
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
Follow-Up
Census: 55
Capacity: 240
Deficiencies: 0
Date: 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.
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.
Findings
The investigation found no substantial evidence of neglect or lack of care by the facility. No deficiencies were cited during this visit.
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
Date: 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 |
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