Inspection Report Summary
Most inspections found no deficiencies, with the facility generally maintaining a clean, safe, and well-managed environment. Several complaint investigations were unsubstantiated, including concerns about staffing, supervision, and infection control. However, some deficiencies were noted: in September 2023, a serious issue occurred when a dementia resident was left unsupervised outside in extreme heat, posing immediate health and safety risks. In April 2025, a staff member was found to have violated a resident’s personal rights by videoing them in the bathroom, resulting in the staff member’s termination and a commitment to staff training. The most recent report from April 15, 2025, included this substantiated personal rights violation but no other deficiencies, showing some ongoing challenges but no new widespread problems.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
0.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
92% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 35
Capacity: 38
Deficiencies: 0
Apr 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2025-02-27 alleging neglect/lack of supervision, understaffing, and staff not answering call buttons.
Findings
The investigation found that although the resident had several falls and there were concerns about supervision and staffing, staff were present and available to meet residents' needs, including toileting schedules and call button responses. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint involved allegations of neglect/lack of supervision, understaffing, and staff not answering call buttons. The investigation included interviews with the administrator and eight staff members, and review of multiple documents. The findings were unsubstantiated.
Report Facts
Facility capacity: 38
Census: 35
Number of staff interviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lauren Crocker | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Antoya Lee | Administrator Assistant | Met with the investigator during the visit |
| Chablis Pasquale | Administrator | Administrator of the facility interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 38
Deficiencies: 1
Apr 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2025-02-27 alleging that staff did not treat a resident with dignity or respect.
Findings
The investigation substantiated the allegation that a staff person violated a resident's personal rights by videoing the resident on the toilet. The staff person involved was terminated. The administrator agreed to provide training to all staff regarding residents' personal rights.
Complaint Details
The complaint was substantiated based on investigation observations, interviews, and record reviews. The allegation involved violation of personal rights by staff videoing a resident in the bathroom. Appeal rights were provided.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personal Rights of Residents in All Facilities - Residents shall be free from punishment, humiliation, intimidation, abuse, or other punitive actions such as withholding money or interfering with daily living functions. The licensee/administrator did not protect the personal rights of a resident when a video was taken while the resident was on the toilet, posing an immediate risk to residents. | Type A |
Report Facts
Capacity: 38
Census: 35
Deficiency count: 1
Plan of Correction Due Date: Apr 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lauren Crocker | Licensing Program Manager | Oversaw the complaint investigation |
| Antoya Lee | Administrator Assistant | Met with the evaluator during the investigation |
| Chablis Pasquale | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Annual Inspection
Census: 28
Capacity: 38
Deficiencies: 0
Jan 28, 2025
Visit Reason
Unannounced Required-1 Year inspection conducted to ensure compliance with health and safety regulations for the facility.
Findings
The facility was found to be in compliance with no deficiencies cited. The environment was clean, safe, and well-maintained with all required equipment and documentation in order.
Report Facts
Food supply: 7
Food supply: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Benson | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lauren Crocker | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Chablis Pasquale | Administrator | Facility administrator with current certification |
| Antoya Lee | Administrator Assistant | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 32
Capacity: 38
Deficiencies: 0
Jan 29, 2024
Visit Reason
The inspection was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care at Townsend House facility.
Findings
The facility was observed to be clean, in good repair, and free of odors with no immediate health, safety, or personal rights violations. Some resident files lacked annual medical assessments and medical orders for bed rails, but the administrator reported these were conducted and orders exist though paperwork was not filed. No deficiencies were cited as a result of the inspection.
Report Facts
Residents' files reviewed: 6
Staff files reviewed: 3
Perishable food supply: 2
Non-perishable food supply: 7
Residents with dementia: 2
Residents with bed rails without medical order: 3
Residents with bed rails with medical order: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaynae Boyles | Licensing Program Analyst | Conducted the inspection and toured the facility |
| Chablis Pasquale | Administrator | Facility administrator met with Licensing Program Analyst and provided information |
| Lauren Crocker | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 38
Deficiencies: 1
Sep 18, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-16 regarding staff not supervising a resident while outside in extreme temperatures.
Findings
The investigation found that a dementia resident was left unsupervised outside for approximately 2 hours and 45 minutes in extreme heat reaching 108 degrees Fahrenheit, resulting in the resident being found unresponsive with a body temperature of 106.1 degrees Fahrenheit. The allegation was substantiated based on interviews and record reviews.
Complaint Details
The complaint was substantiated. The resident was found unresponsive outside after being left unattended for nearly three hours in extreme heat. The investigation was conducted by Evaluators Jaynae Boyles and Avila.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide necessary services, as evidenced by leaving a dementia resident unsupervised outside for an extended period in extreme heat, posing immediate health, safety, and personal rights risks. | Type A |
Report Facts
Resident body temperature: 106.1
Outside temperature: 108
Census: 31
Total capacity: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chablis Pasquale | Administrator | Met with during the investigation and appeal rights were left with this individual |
| Jaynae Boyles | Licensing Program Analyst | Conducted the complaint investigation |
| Lauren Crocker | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 38
Deficiencies: 1
Jul 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-03-13 regarding resident care issues and improper fee increase at Townsend House facility.
Findings
The investigation substantiated the allegation that the facility increased resident fees without proper written notice following a change in level of care. Other allegations related to timely medical care, incontinence care, mobility device accessibility, medication assistance, shower assistance, and pendant access were found to be unsubstantiated or unfounded.
Complaint Details
The complaint investigation was substantiated for the allegation that resident facility fees were increased without proper notice as required by California Health and Safety Code 1569.657(a). Other allegations including failure to seek timely medical care, improper incontinence care, mobility device accessibility, medication assistance, shower assistance, and pendant access were unsubstantiated or unfounded.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Rate increase due to change in level of resident care; notice not properly provided in writing within two business days. | Type B |
Report Facts
Capacity: 38
Census: 28
Deficiency count: 1
Plan of Correction Due Date: Aug 11, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chablis Pasquale | Administrator | Interviewed regarding rate increase and facility operations |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Troy Ordonez | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Annual Inspection
Census: 28
Capacity: 38
Deficiencies: 0
Feb 9, 2023
Visit Reason
Unannounced Required 1 Year Inspection Visit utilizing the infection control domain to ensure health and safety compliance.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during the inspection.
Report Facts
Hot water temperature: 113.4
Fire extinguisher last inspection date: Oct 10, 2022
Thermostat temperature: 74.5
Client records reviewed: 4
Staff records reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Wallace | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Stephen Richardson | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 38
Deficiencies: 0
Jan 31, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not ensure a visitor followed the Covid 19 mask guidance.
Findings
The investigation found no evidence to substantiate the allegation. Interviews with the administrator, five staff members, and three residents revealed no indication that a visitor failed to follow the Covid 19 mask guidance. The findings were unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint was unsubstantiated as there was no preponderance of evidence to prove the alleged violation occurred.
Report Facts
Capacity: 38
Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and met with the administrator |
| Susan Hertzfeldt | Administrator | Facility administrator interviewed during the investigation |
| Chablis Pasquale | Met with Licensing Program Analyst during the investigation | |
| Rayna L Bryson | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 38
Deficiencies: 0
Dec 14, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 08/17/2021 regarding staff leaving a resident unattended during toileting and insufficient staff to meet residents' telephone needs.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Staff and administrator interviews, along with reviews of resident care plans and logs, indicated that the resident was not left unattended during toileting and that staffing was generally sufficient to meet telephone call needs. Both allegations were unsubstantiated.
Complaint Details
The complaint involved two allegations: 1) Staff left resident unattended during toileting, and 2) Staff were not sufficient in numbers to provide services to meet the resident's need for telephone calls. Both allegations were investigated and found to be unsubstantiated.
Report Facts
Facility capacity: 38
Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and met with facility staff |
| Susan Hertzfeldt | Administrator | Facility administrator interviewed during the investigation |
| Chablis Pasquale | Facility representative met during the investigation | |
| Rayna L Bryson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 28
Capacity: 38
Deficiencies: 0
Dec 13, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection to evaluate infection control and ensure the health and safety of residents in care.
Findings
No immediate health, safety, or personal rights violations were observed. The facility was found to be in substantial compliance with infection control requirements and no deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chablis Pasquale | administrator | Met with Licensing Program Analyst during inspection and involved in infection control domain evaluation. |
| Rebecca Knight | Licensing Program Analyst | Conducted the Required-1 Year Inspection and infection control evaluation. |
| Rayna L Bryson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
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