Inspection Report
Annual Inspection
Census: 27
Capacity: 48
Deficiencies: 0
Aug 28, 2025
Visit Reason
An unannounced annual inspection was conducted as a required 1-year visit to evaluate compliance with licensing requirements.
Findings
The facility was found to be generally compliant with no deficiencies cited. A wood rot issue on the roof corner was observed and a repair plan was submitted. A Technical Assistance was issued regarding one resident bathroom water temperature being below 105 F.
Report Facts
Resident bedrooms toured: 25
Resident bathrooms toured: 7
Resident records reviewed: 5
Medication records reviewed: 5
Staff records reviewed: 5
Smoke and carbon monoxide detectors last inspected: Jun 17, 2025
Fire extinguishers last serviced: Sep 17, 2024
Last emergency drill date: Jun 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josephine Arcilla | Licensee/Administrator | Met during inspection and exit interview |
| Jesus Arcilla | Licensee | Met during inspection |
| Minerva Velasco | ADM | Met during inspection and toured facility |
| Marcella Tarin | Licensing Program Analyst | Conducted the inspection |
| Jin Jackie | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 48
Deficiencies: 0
Aug 13, 2025
Visit Reason
The visit was an unannounced case management incident inspection triggered by a death report received on 2025-08-12 for Resident R1, who passed away on 2025-08-10 at the facility.
Findings
The Licensing Program Analyst conducted interviews with staff and reviewed documentation related to the incident. No deficiencies were cited during the visit, but further investigation was deemed necessary.
Complaint Details
The visit was triggered by a death report for Resident R1. The case management incident requires further investigation as determined by the Licensing Program Analyst.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josephine Arcilla | Licensee | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Marcella Tarin | Licensing Program Analyst | Conducted the unannounced case management incident visit. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 48
Deficiencies: 0
Apr 23, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection triggered by a Death Report received on 02/07/2025 concerning Resident R1 who died on 02/01/2025 after a fall on 01/27/2025.
Findings
The Licensing Program Analyst reviewed Resident R1's file including physician's report, progress notes, and service plan. The facility stated it would request and submit the death certificate. The incident requires further investigation. No citations were issued during this visit.
Complaint Details
The visit was complaint-related due to a Death Report for Resident R1. The incident requires further investigation. No substantiation status is stated.
Report Facts
Staff count: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josephine Arcilla | Administrator | Met with Licensing Program Analyst during the visit and provided information about the facility and Resident R1 |
| Marcella Tarin | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Census: 28
Capacity: 48
Deficiencies: 0
Apr 23, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted due to a report that a resident (R1) had gone for a walk and was found approximately 2 miles from the facility, requiring further investigation.
Findings
The Licensing Program Analyst reviewed the resident's file and documentation, including physician's report and service plan. No citations were issued during the visit, but a Plan of Action was to be submitted by the facility to ensure the resident's health and safety. The incident requires further investigation.
Report Facts
Residents present: 28
Total licensed capacity: 48
Staff present: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josephine Arcilla | Administrator | Met with Licensing Program Analyst during inspection and involved in incident discussion |
| Marcella Tarin | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 48
Deficiencies: 0
Apr 15, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-04-10 regarding staff sedating a resident, failure to ensure the resident was fed resulting in weight loss, and not providing nutritious foods.
Findings
Based on interviews with staff, residents, witnesses, hospice personnel, and review of medication and weight records, the department found the allegations to be unfounded. Staff were observed redirecting the resident rather than sedating, residents and staff confirmed assistance with eating, and the resident's weight was stable with no dietary restrictions noted. No deficiencies were cited.
Complaint Details
The complaint alleged that staff were sedating resident 1, not ensuring the resident was fed resulting in weight loss, and not providing nutritious foods. The investigation included interviews with staff, residents, witnesses, hospice staff, and review of medication and weight records. The allegations were found to be unfounded.
Report Facts
Weight range: 186
Weight range: 192
Number of staff interviewed: 5
Number of residents interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josephine Arcilla | Administrator | Met with during investigation and named in findings |
| Marcella Tarin | Licensing Program Analyst | Conducted complaint investigation |
| Manuel Monter | Licensing Program Analyst | Conducted complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 48
Deficiencies: 0
Sep 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2024-05-08 that a staff member sexually abused a resident while in care.
Findings
Based on interviews with the resident, staff, other caregivers, and a relative, as well as record review, the allegation was found to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited.
Complaint Details
The complaint alleged that staff member S1 sexually abused resident R1. Interviews revealed conflicting statements, with R1 uncertain about the incident and staff denying the allegations. The relative stated no penetration occurred. The investigation concluded the allegation was unsubstantiated.
Report Facts
Facility capacity: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josephine Arcilla | Administrator | Met with Licensing Program Analysts during the investigation and review of the report |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 28
Capacity: 48
Deficiencies: 0
Aug 29, 2024
Visit Reason
The inspection was an unannounced required 1-year annual inspection conducted to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in compliance with no deficiencies cited. The inspection included a tour of resident areas, review of staff and resident files, and verification of safety and emergency preparedness measures.
Report Facts
Staff files reviewed: 5
Resident files reviewed: 5
Fire extinguisher last serviced: Sep 20, 2023
Refrigerator temperature range: 30
Freezer temperature: 0
Emergency drills frequency: 4
Facility capacity: 48
Resident census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josephine Arcilla | Administrator/Licensee | Met with Licensing Program Analyst during inspection and involved in facility operations |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 27
Capacity: 48
Deficiencies: 0
Aug 3, 2022
Visit Reason
An unannounced annual inspection was conducted as a required 1-year visit to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and compliant with infection control and safety requirements. No deficiencies were cited during the visit.
Report Facts
Food supply: 2
Food supply: 7
PPE supply: 30
Fire extinguisher service date: Aug 16, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josephine Arcilla | Administrator | Met with Licensing Program Analyst during inspection and reviewed report |
| Ryker Heberle | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Sarah Yip | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 24
Capacity: 48
Deficiencies: 0
Aug 31, 2021
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well maintained, and compliant with health and safety standards. No deficiencies were cited during the visit.
Report Facts
Food supply: 2
Food supply: 7
PPE supply: 30
Fire extinguisher service month: 8
Bedrooms: 25
Bathrooms: 14
Living rooms: 2
Kitchens: 2
Dining rooms: 2
Offices: 2
Storage rooms: 2
Medication rooms: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josephine Arcilla | Administrator | Met with Licensing Program Analyst during inspection and reviewed report |
| Ryker Heberle | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Sarah Yip | Licensing Program Manager | Named in report header |
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