Inspection Reports for TreVista Senior Living at Concord
1081 Mohr Ln, Concord, CA 94518, United States, CA
Back to Facility ProfileInspection Report Summary
Most inspections over the past two years found no deficiencies, including the most recent report dated September 18, 2025, which substantiated a repeat medication administration violation resulting in a civil penalty. Several complaint investigations were substantiated, primarily involving medication management failures, insufficient staffing leading to resident elopements, and sanitation issues such as rodent droppings and unclean areas, with some enforcement actions including civil penalties totaling at least $500. The facility also faced substantiated findings related to improper eviction notices and staff speaking inappropriately to residents, while many other complaints were unsubstantiated. Earlier reports showed ongoing challenges with cleanliness, staffing, and medication administration, but recent inspections indicate some efforts to address these issues, although not all deficiencies have been corrected promptly. Overall, the facility’s record shows a mix of isolated and repeated issues, with improvement needed in medication management, staffing, and environmental cleanliness.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 142
Capacity: 160
Deficiencies: 1
Sep 18, 2025
Visit Reason
The inspection was conducted as an investigation of a complaint regarding medication administration issues at the facility.
Findings
The facility failed to provide prescribed medications to residents R1 and R2 due to medication refills not being obtained timely and lack of proper medication orders, posing immediate health and personal rights risks. A repeat violation was cited and a civil penalty was assessed.
Complaint Details
Investigation of complaint Control # 15-AS-20250914203842 regarding medication administration failures for residents R1 and R2. Substantiated repeat violation with civil penalty assessed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain medication refills in a timely manner for resident R1 and lack of order for one of resident R2's medications, posing immediate health and personal rights risks. This is a repeat violation. | Type A |
Report Facts
Civil penalty amount: 250
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Clawson | Administrator | Named in discussion of deficiency, plan of correction, and civil penalty. |
| Alicia Delmundo | Licensing Program Analyst | Conducted the investigation and authored the report. |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the report. |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 160
Deficiencies: 2
Sep 4, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including unsanitary resident room conditions, presence of vermin in the facility, and improper eviction of residents.
Findings
The investigation substantiated that rodent droppings were found in a resident's room, the facility was aware and taking pest control measures, and that the facility improperly refused to readmit a resident who eloped and was hospitalized despite the resident's dementia and inability to leave unattended.
Complaint Details
The complaint was substantiated. Allegations included unsanitary conditions in a resident's room due to rodent droppings, presence of vermin in the facility, and improper eviction of residents. Evidence showed rodent droppings in resident room 124, the facility's awareness and pest control efforts, and refusal to readmit a resident with dementia who eloped and was hospitalized.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by the facility not cleaning a resident's room after rodent droppings were found. | Type B |
| The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by the facility refusing to take a resident back after they eloped and were admitted to a hospital. | Type B |
Report Facts
Capacity: 160
Census: 141
Plan of Correction Due Date: Sep 11, 2025
Plan of Correction Due Date: Sep 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| David Clawson | Administrator / Executive Director | Facility administrator involved in findings related to eviction procedures |
| Maria Collado | Facility Nurse | Met with Licensing Program Analyst during inspection |
Inspection Report
Follow-Up
Census: 141
Capacity: 160
Deficiencies: 4
Sep 4, 2025
Visit Reason
Unannounced proof of correction (POC) visit to verify correction of deficiencies cited during a prior complaint visit on 2025-08-15.
Findings
Four deficiencies cited during the complaint visit were not cleared by this POC visit, resulting in a civil penalty assessment. The facility remains subject to ongoing daily civil penalties until corrections are made.
Complaint Details
The visit followed a complaint investigation conducted on 2025-08-15 which cited the facility on 4 deficiencies. The POC due dates were 2025-08-26 and 2025-08-29. Deficiencies were not cleared by the follow-up visit.
Deficiencies (4)
| Description |
|---|
| Surfaces such as floors shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary |
| The facility shall be clean, safe, sanitary and in good repair at all times |
| All window screens shall be clean and maintained in good repair |
| Outdoor activity areas that are easily accessible to residents shall be maintained |
Report Facts
Civil penalty amount: 2800
Capacity: 160
Census: 141
Number of deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Collado | Facility Nurse | Met with Licensing Program Analysts during the inspection |
| David Clawson | Executive Director | Named as facility administrator/director, informed of visit but not present |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the inspection and complaint visit |
| Harpreet Humpal | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 160
Deficiencies: 2
Aug 28, 2025
Visit Reason
The inspection was conducted as a Case Management visit following an incident report of a resident being given the wrong medication and a report of two residents eloping from the memory care unit.
Findings
The facility was found to have deficiencies including insufficient staffing leading to resident elopement and failure to properly administer medication. Civil penalties totaling $500 were assessed due to repeat violations.
Complaint Details
The visit was complaint-related due to an incident report of wrong medication administration and resident elopement. The deficiencies were substantiated and civil penalties were assessed.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Not having enough staff which led to two residents in memory care eloping from the facility, posing an immediate safety risk. | Type A |
| Licensee did not comply with medication administration requirements by giving a resident the incorrect medication. | Type A |
Report Facts
Civil penalties: 500
Plan of Correction Due Date: 09/11/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Collado | LVN | Facility staff who reported incidents and met with Licensing Program Analyst |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the inspection and signed the report |
| David J Clawson | Administrator/Director | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 160
Deficiencies: 1
Aug 15, 2025
Visit Reason
The inspection was a case management visit triggered by multiple elopements of residents from the memory care unit, including incidents on 6/04/2025, 6/15/2025, 6/21/2025, and 8/09/2025.
Findings
The facility failed to prevent resident R1 from eloping multiple times due to insufficient staffing, which posed an immediate safety risk. Resident R2 also eloped and suffered a fall requiring hospital evaluation. All egress doors were operational at the time of elopements.
Complaint Details
The visit was complaint-related due to multiple elopements by residents R1 and R2. The deficiencies were substantiated with evidence of repeated elopements and an immediate safety risk caused by inadequate staffing.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not prevent R1 from eloping | Type A |
Report Facts
Deficiencies cited: 1
Capacity: 160
Census: 132
Plan of Correction Due Date: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David J Clawson | Director | Met with Licensing Program Analyst during inspection and named in findings |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 160
Deficiencies: 4
Aug 15, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2025-08-01 regarding facility cleanliness, window screens, sanitation after body fluids, and locking of the memory care outdoor space.
Findings
The investigation substantiated several allegations including failure to keep the facility clean and sanitary, missing and damaged window screens, failure to sanitize after body fluids were found in common areas, and locking of the memory care outdoor space restricting resident access. Some allegations such as presence of insects and administrator qualifications were found unsubstantiated.
Complaint Details
The complaint investigation was substantiated based on the preponderance of evidence for allegations related to facility cleanliness, missing window screens, failure to sanitize after body fluids, and locking of the memory care outdoor space. Other allegations such as presence of insects and administrator qualifications were unsubstantiated.
Deficiencies (4)
| Description |
|---|
| Surfaces such as floors shall be cleaned and disinfected regularly and when contaminated with blood or body fluids. The facility failed to sanitize urine found in the courtyard until after 7/19/25. |
| The facility shall be clean, safe, sanitary and in good repair. Dirty dishes and dirt were observed in the memory care recreation room cabinets and walls. |
| All window screens shall be clean and maintained in good repair. Four windows in memory care were missing screens and at least two more had rips. |
| The licensee shall provide sufficient space for indoor and outdoor activities. The memory care patio was locked from the inside, restricting resident access. |
Report Facts
Capacity: 160
Census: 132
Plan of Correction Due Date: Aug 26, 2025
Plan of Correction Due Date: Aug 29, 2025
Number of missing window screens: 4
Number of damaged window screens: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Clawson | Administrator | Met with during investigation and named in findings |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 160
Deficiencies: 1
Aug 6, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that staff mishandled a resident's medication.
Findings
The investigation found that medication refills for a resident were not ordered prior to the resident running out of medication, substantiating the allegation of mishandling medication. The licensee did not comply with regulations regarding timely medication refills, posing a potential health and safety risk.
Complaint Details
The allegation that staff mishandled a resident's medication was substantiated based on records review and interviews. The preponderance of evidence standard was met.
Deficiencies (1)
| Description |
|---|
| Failure to develop and implement a plan for incidental medical care, specifically not obtaining medication refills in a timely manner. |
Report Facts
Deficiency Type: 1
Plan of Correction Due Date: Aug 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Clawson | Director | Met with during investigation and named in findings |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 160
Deficiencies: 0
Jun 6, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff mistreated a resident and mishandled a resident's medications while in care.
Findings
The investigation found that the resident had a history of yelling at staff regarding medication handling, and the facility did not lose or miss any medication doses. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff mistreatment and medication mishandling. Evidence did not prove violations occurred.
Report Facts
Capacity: 160
Census: 118
Allegations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Clawson | Administrator | Met with during investigation and named in report |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 160
Deficiencies: 0
Jun 6, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to an allegation that the facility was engaging in punitive acts towards residents in care.
Findings
The investigation found that under new management, the facility intended to fill to capacity by placing roommates in memory care rooms that were previously single occupancy. Notices were sent to affected residents. However, there was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged punitive acts towards residents. The investigation included record reviews and interviews with staff and administration. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 160
Census: 118
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| David Clawson | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 160
Deficiencies: 0
Jun 6, 2025
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations regarding facility sanitation and food quality.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The food quality concern involved a single incident with a new staff member who was retrained, and sanitation practices were found to be adequate with regular cleaning schedules.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not maintaining facility sanitary conditions and not serving residents food of good quality. Interviews and observations did not support these claims.
Report Facts
Capacity: 160
Census: 118
Shower rooms: 8
Shower rooms: 12
Cleaning frequency: 3
Cleaning frequency: 4
Cleaning frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Clawson | Administrator | Met with Licensing Program Analyst during investigation |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 160
Deficiencies: 2
Jun 6, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including staff not maintaining resident's hygiene, not providing clean linens, and improper staff training.
Findings
The investigation substantiated that staff failed to maintain a resident's hygiene, with evidence of a resident found covered in dried feces and inadequate staffing to meet residents' needs. The allegation regarding staff not providing clean linens was substantiated by record review and interviews. The allegation that staff were not properly trained was unsubstantiated based on training records and interviews.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not maintain resident's hygiene, with evidence including a resident found covered in dried feces and inadequate staffing. The allegation that staff did not provide clean linens was substantiated. The allegation that staff were not properly trained was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Residents in all residential care facilities for the elderly shall have safe, healthful and comfortable accommodations, furnishings and equipment. | Type B |
| Based on observation and interviews there was not adequate staffing to meet residents needs. | Type B |
Report Facts
Capacity: 160
Census: 118
Plan of Correction Due Date: Jun 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Clawson | Administrator | Met with during investigation and named in findings |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 110
Capacity: 160
Deficiencies: 0
Apr 23, 2025
Visit Reason
The visit was an Informal Meeting held via video conference to discuss the Change of Ownership transition for the facility.
Findings
The facility is currently operating under the Trevista Concord license despite plans for a name change pending the full Change of Ownership process. The facility intends to operate at full capacity of 160 residents, increasing census from around 110. No deficiencies or violations were cited in this report.
Report Facts
Memory care residents: 25
Memory care capacity: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Clawson | Administrator | Met with during the Informal Meeting and discussed Change of Ownership |
| Harpreet Humpal | Licensing Program Manager | Attended the Informal Meeting |
| Jill Clancy-Czuleger | Licensing Program Analyst | Attended the Informal Meeting |
Inspection Report
Census: 110
Capacity: 160
Deficiencies: 0
Apr 9, 2025
Visit Reason
The visit was an unannounced Case Management inspection conducted to assess the facility during a change of ownership process and to follow up on complaint investigations.
Findings
The facility was in the process of a change of ownership and was still operating under the Trevista Concord license. The administrator was replaced, and the facility was using a new name on documents, which was not yet authorized. Licensing staff requested documentation to verify the new administrator's credentials.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Clawson | Administrator | Met with Licensing Program Analyst during the inspection and discussed change of ownership and facility operations. |
| Nelson Rodrigues | Executive Director | Former Executive Director replaced prior to the inspection. |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 160
Deficiencies: 1
Mar 21, 2025
Visit Reason
The inspection was an unannounced Case Management visit conducted to investigate a complaint (15-AS-20250317123152) regarding facility compliance.
Findings
The Licensing Program Analyst observed that individual S4 was not associated with the facility, resulting in a cited deficiency related to fingerprints and criminal records requirements for individuals in contact with clients.
Complaint Details
Complaint investigation (15-AS-20250317123152) was conducted and substantiated by the observation that S4 was not associated with the facility.
Deficiencies (1)
| Description |
|---|
| Fingerprints and criminal records of individuals in contact with clients were not properly recorded, specifically the exemption from the State Department of Social Services before initial presence in the facility. |
Report Facts
Deficiency Type: 1
Plan of Correction Due Date: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| David Clawson | Administrator | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Annual Inspection
Census: 102
Capacity: 160
Deficiencies: 0
Nov 20, 2024
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was inspected thoroughly with no deficiencies cited. The physical plant, equipment, supplies, and resident records were found to be in compliance with regulations.
Report Facts
Residents records reviewed: 10
Staff records reviewed: 4
Staff fingerprint clearance: 4
Water temperature: 110.3
Fire extinguisher service date: Jan 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nelson Rodrigues | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Capacity: 160
Deficiencies: 0
Jun 14, 2024
Visit Reason
The visit was an unannounced Case Management inspection conducted following receipt of a death report for a resident who passed away shortly after moving in.
Findings
The report noted that the resident had hypernatremia, acute kidney injury, and was receiving palliative care. No cause of death was listed, and no additional follow-up was needed. It was also noted that the Executive Director no longer works at the facility and the position is actively being recruited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Perez | Wellness Coordinator | Met with Licensing Program Analyst during the inspection. |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 160
Deficiencies: 0
May 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-11-28 alleging unsafe furniture, unsanitary conditions, improper food storage and preparation, inadequate food portions, and facility disrepair.
Findings
The investigation found that the facility was generally clean and food portions were properly maintained and served. A plumbing issue was identified and resolved, and unsafe furniture (a glass table top) was removed. However, there was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.
Complaint Details
The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred. Allegations included unsafe furniture, unsanitary conditions, improper food storage and preparation, inadequate food portions, and facility disrepair.
Report Facts
Capacity: 160
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| Siobhan Lehman | Executive Director | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 160
Deficiencies: 2
May 14, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including staff speaking to residents in an inappropriate manner and other facility concerns.
Findings
One allegation regarding staff speaking to residents in an inappropriate manner was substantiated, with evidence that staff was removed from cleaning a resident's room after a complaint. Other allegations such as failure to prevent communicable disease spread, facility repair issues, food service adequacy, evacuation assistance, and response times were investigated and found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for the allegation that staff spoke to residents in an inappropriate manner. Other allegations regarding communicable disease prevention, facility repair, food service, evacuation assistance, and response times were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. | Type B |
| Based on LPAs interview licensee did not comply with the section above by the facility staff yelling at residents. | Type B |
Report Facts
Capacity: 160
Census: 96
Plan of Correction Due Date: Jun 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| Siobhan Lehman | Executive Director | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 160
Deficiencies: 0
May 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not give a resident notice of change in level of care.
Findings
The investigation found that the facility did notify residents about changes to the level of care point system through multiple notices sent between February 2023 and February 2024. Although concerns were expressed by residents, there was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that facility staff did not give a resident notice of change in level of care. The investigation found that notices were sent on February 2, 2023, May 1, 2023, and February 1, 2024, explaining changes to the point system and timelines. Residents were informed and concerns were addressed. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 160
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
| Siobhan Lehman | Executive Director | Met with during the investigation and interviewed |
| Lori Thames | Administrator | Facility Administrator named in report |
Inspection Report
Annual Inspection
Census: 92
Capacity: 160
Deficiencies: 0
Dec 4, 2023
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was inspected thoroughly with no deficiencies cited. The physical plant, resident rooms, supplies, medication storage, and safety equipment were all found to be in compliance.
Report Facts
Residents' records reviewed: 10
Staff records reviewed: 5
Fingerprint clearance: 5
Facility bedrooms: 112
Hospice waiver capacity: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Siobhan Lehman | Executive Director | Met with Licensing Program Analyst during inspection |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 160
Deficiencies: 0
Sep 12, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2023-05-23 regarding multiple allegations including failure to safeguard resident valuables and medications, facility disrepair, and improper notice for rent increase.
Findings
The investigation included interviews and records review, and found that while some allegations may have occurred or are valid, there was not a preponderance of evidence to prove violations. The facility followed regulations regarding medication management and rent increase notice, and repairs were contracted for the facility roof. Therefore, the allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to safeguard resident valuables and medications, facility disrepair, and failure to provide proper notice for rent increase. The facility was found to have followed required procedures and no violations were substantiated.
Report Facts
Complaint control number: 15-AS-20230523152123
Number of allegations: 4
Date complaint received: May 23, 2023
Date of physician's report: Oct 13, 2022
Date of rate increase notice: May 26, 2023
Effective date of rate increase: Aug 1, 2023
Date of roof repairs: Feb 9, 2023
Length of metal cooping sealed: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation visit |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
| Siobhan Lehman | Executive Director | Met with Licensing Program Analyst during visit |
| Lori Thames | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 160
Deficiencies: 0
Sep 12, 2023
Visit Reason
The visit was conducted as an unannounced complaint investigation following a complaint received on 04/06/2023 alleging that a resident was charged for services not received.
Findings
The investigation found that the resident was receiving the level of care paid for, with a noted miscommunication about services provided. The allegations were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that a resident was charged for services not received. The investigation concluded the allegations were unsubstantiated.
Report Facts
Concession amount: 4500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation visit |
| Siobhan Lehman | Executive Director | Met with Licensing Program Analyst during the visit |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 96
Capacity: 160
Deficiencies: 0
Jul 7, 2023
Visit Reason
The visit was conducted as a Case Management follow-up to an incident report involving staff hitting a resident.
Findings
The Licensing Program Analyst confirmed that the staff involved in the incident had their employment terminated. No additional follow-up was needed at this time.
Complaint Details
The visit was complaint-related, following up on an incident report of staff hitting a resident. The complaint was substantiated by the termination of the staff's employment.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Siobhan Lehman | Executive Director | Met with Licensing Program Analyst during the visit. |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the Case Management visit and follow-up on the incident report. |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 160
Deficiencies: 0
Feb 17, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following allegations received on 08/10/2021 regarding the facility's failure to open resident rooms immediately in emergencies and concerns about food quality.
Findings
The investigation found that the allegations were unsubstantiated. The master key worked on randomly checked rooms, and staff and residents reported no consistent issues with emergency room access. Food quality was generally observed to be good, with mixed resident and staff opinions but no evidence of raw vegetables being served frequently.
Complaint Details
The complaint involved two main allegations: failure to open resident rooms immediately during emergencies and food served not being of good quality. Interviews with residents and staff, inspections of keys and food supplies, and menu reviews were conducted. The complaint was closed as unsubstantiated due to insufficient evidence to prove the alleged violations.
Report Facts
Residents interviewed: 5
Staff interviewed: 5
Master keys: 2
Rooms checked with master key: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Delmundo | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Bennett Fong | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Shiobhan Lehman | Executive Director | Met with Licensing Program Analyst during the investigation |
| Lori Thames | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 160
Deficiencies: 1
Oct 20, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted due to an allegation that the facility is unsanitary.
Findings
The investigation found that the memory care side of the facility was not being cleaned regularly due to lack of housekeeping staff, substantiating the allegation that the facility was unsanitary and not in compliance with cleanliness regulations.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation was that the facility was unsanitary, specifically the memory care side not being cleaned regularly due to lack of housekeeping staff.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by the memory care unit not being kept clean, posing a potential health and safety risk to persons in care. | Type B |
Report Facts
Capacity: 160
Census: 60
Plan of Correction Due Date: Nov 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Perez | Wellness Coordinator | Met with the Licensing Program Analyst during the investigation |
| Lori Thames | Administrator | Agreed to review regulation and submit self-certification as part of plan of correction |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 160
Deficiencies: 0
Oct 20, 2022
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 09/29/2022 regarding inoperative residents' toilets.
Findings
The investigation found that the facility is timely on repairs reported to maintenance, though delays may occur if parts need to be ordered. There was insufficient evidence to substantiate the allegations, and therefore the complaint was unsubstantiated.
Complaint Details
The complaint alleged that residents' toilets were inoperative. The investigation was unannounced and included interviews and document review. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 15-AS-20220929093215
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Stephanie Perez | Wellness Coordinator | Met with the Licensing Program Analyst during the investigation. |
| Lori Thames | Administrator | Named as facility administrator. |
| Harpreet Humpal | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Annual Inspection
Census: 60
Capacity: 160
Deficiencies: 0
Oct 20, 2022
Visit Reason
The visit was an unannounced required 1-year infection control inspection conducted to evaluate the facility's compliance with infection control standards.
Findings
The inspection found the facility to be compliant with infection control requirements, including proper PPE use, sufficient food supply, secured storage, and a mitigation plan. No deficiencies were cited during the visit.
Report Facts
Capacity: 160
Census: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Perez | Wellness Coordinator | Met with during inspection and joined the visit |
| Sandra Oliver | Activities Director | Met with during inspection and explained the purpose of the visit |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the infection control inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 160
Deficiencies: 0
Mar 18, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident was unlawfully evicted.
Findings
The investigation found that the resident was issued a 30-day eviction notice on 02/12/2020 and moved out on 03/30/2020. Although the allegation may have been valid, there was insufficient evidence to substantiate the claim, and the allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that a resident was unlawfully evicted. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 160
Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Siobhan Lehman | Executive Director | Met with Licensing Program Analyst during the investigation |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 76
Capacity: 160
Deficiencies: 1
Nov 8, 2021
Visit Reason
The inspection was an unannounced infection control inspection conducted as part of the required 1-year comprehensive inspection.
Findings
The facility was generally clean, well-maintained, and compliant with safety and infection control standards, including adequate food supply and proper kitchen conditions. However, deficiencies were noted related to hot water temperature controls, with temperatures measured at 128.2 and 96.3 degrees Fahrenheit, outside the required range.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Faucets used by residents for personal care such as shaving and grooming did not maintain hot water temperature controls to automatically regulate the temperature between 105 and 120 degrees Fahrenheit. | Type A |
Report Facts
Hot water temperature: 128.2
Hot water temperature: 96.3
Census: 76
Total capacity: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lori Thames | Director | Facility Director met with the Licensing Program Analyst during the inspection |
| Harpreet Humpal | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 160
Deficiencies: 1
Aug 19, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations received on 2021-08-10 regarding cleanliness issues at the facility.
Findings
The complaint that dining furniture was not properly cleaned was substantiated due to observation of dried spilled food on a dining chair. The allegation that utensils used for serving meals were not properly cleaned was unsubstantiated after inspection and staff interviews.
Complaint Details
The complaint investigation was substantiated for the allegation of dining furniture not properly cleaned. The allegation regarding utensils not properly cleaned was unsubstantiated. The substantiated deficiency was cited under Title 22 California Code of Regulations 87303(a).
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Dining chair with dried spilled food observed, posing potential health and personal rights risks. | Type B |
Report Facts
Capacity: 160
Census: 80
Deficiency count: 1
Plan of Correction Due Date: Sep 2, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Thames | Executive Director | Met with Licensing Program Analysts during inspection and discussed deficiency and plan of correction |
| Alicia Delmundo | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
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