Most inspections found no deficiencies, showing the facility generally met health and safety standards with clean and safe conditions. The most recent report from September 3, 2025, did cite two minor deficiencies related to maintenance issues like a loose sink knob and unsteady grab bar, as well as two residents not being on hospice or having an approved exception despite needing care. Earlier reports, including those from October 1, 2024, and September 29, 2022, were free of deficiencies, indicating some improvement after previous issues. Past deficiencies mainly involved safety concerns such as an outdoor gate not self-latching and a privacy violation when staff escorted residents through a private bedroom. Several complaint investigations were unsubstantiated or not present, and no fines or enforcement actions were listed in the available reports.
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure health and safety standards are met.
Findings
The facility was generally found to be clean, safe, and in compliance with regulations, including proper maintenance of fire safety equipment, kitchen cleanliness, and medication storage. However, some maintenance issues were noted such as a loose sink knob, unsteady grab bar, broken towel holder, and inoperable self-latching mechanisms on side gates. Additionally, two residents were identified as not capable of self-care without hospice or an approved exception.
Severity Breakdown
Type B: 2
Deficiencies (2)
Description
Severity
Facility had maintenance issues including a broken towel holder, loose sink knob, unsteady grab bar, and inoperable self-latching mechanisms on side gates.
Type B
Two residents were found not capable of self-care and not on hospice, with no exception request submitted to the department.
Type B
Report Facts
Number of residents not capable of self-care: 2Number of bathrooms: 3Number of bedrooms: 6Number of bedrooms designated for resident use: 5Number of residents: 6Facility capacity: 6Emergency drill last conducted: Jul 17, 2025
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 regulations and ensure health and safety standards were met.
Findings
The facility was found to be in compliance with all applicable regulations, including fire safety, cleanliness, medication storage, and record keeping. No deficiencies were cited during the inspection.
Report Facts
Days of non-perishable food supply: 7Days of perishable food supply: 2Number of bathrooms: 3Number of bedrooms: 6Number of resident bedrooms: 5Number of residents: 6Temperature of hot water: 117.9Facility temperature: 71Date of last emergency drill: Jul 5, 2024Date of last fire extinguisher service: May 10, 2024
Employees Mentioned
Name
Title
Context
Evelyn Rayas
Administrator
Administrator present during inspection and named in report
Valeria Conway
Licensing Program Analyst
Conducted the inspection
Gerardo Gonzalez
Facility staff initially met by Licensing Program Analyst
The Licensing Program Analyst conducted an unannounced required annual visit to evaluate the facility's compliance with Title 22 regulations and ensure health and safety standards are met.
Findings
The facility was generally found to be in compliance with regulations including cleanliness, safety equipment functionality, and record keeping. However, two deficiencies were cited related to safety and resident privacy: the outdoor gate was not self-closing or self-latching, and staff were escorting all residents through a private resident bedroom to access a bathroom.
Deficiencies (2)
Description
Outdoor facility gate was observed not self-latching or self-closing, posing a potential safety risk to residents.
Facility staff used a walk-in shower located off a shared resident room as a passageway for all residents to reach the bathroom, violating resident privacy rights.
Report Facts
Days non-perishable food supply: 7Days perishable food supply: 2Number of bathrooms for resident use: 3Number of bedrooms: 6Number of staff files reviewed: 5Number of resident files reviewed: 5Number of residents whose medications were reviewed: 5Date of last emergency disaster drill: Jul 14, 2023
Employees Mentioned
Name
Title
Context
Evelyn Rayas
Administrator
Met during inspection and involved in plan of correction discussions
The Licensing Program Analyst arrived unannounced to conduct a required annual visit with a specific emphasis on infection control practices and procedures.
Findings
The facility was found to be in compliance with Title 22 Regulations with no health or safety hazards observed. Infection control practices were adequate, with all staff and visitors wearing masks and sufficient PPE supplies. No deficiencies were cited.
The inspection was an unannounced required annual visit with a specific emphasis on infection control practices and procedures.
Findings
The facility was found to be in compliance with Title 22 Regulations with no health or safety hazards observed. Infection control practices were adequate, with staff and visitors wearing masks and sufficient PPE supplies, though residents were not consistently encouraged to wear face coverings in common areas. No deficiencies were cited.
Report Facts
Number of bedrooms: 6Number of restrooms: 3
Employees Mentioned
Name
Title
Context
Kelly Dulek
Licensing Program Analyst
Conducted the inspection and authored the report
Kristin Heffernan
Licensing Program Manager
Named in the report as Licensing Program Manager
Debbie Katapody
Administrator
Facility Administrator spoken to regarding infection control practices
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