Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
73% occupied
Based on a November 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 640
Capacity: 876
Deficiencies: 0
Date: Nov 18, 2025
Visit Reason
The visit was conducted in response to incident reports dated 10/27/2025 and 10/30/2025 involving a resident's unsupervised absences and safety concerns.
Complaint Details
The investigation was triggered by incidents involving a resident who was reported missing within the community but was found safe after two hours. The complaint was addressed with evaluations and increased supervision; no deficiencies were cited.
Findings
Staff evaluated the resident to require care and supervision after reported unsupervised absences. The resident was found missing within the community but was located by staff two hours later. Staff responded appropriately and planned to relocate the resident to a higher level of care. No deficiencies were cited.
Report Facts
Incident Reports: 2
Visit Duration Hours: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mathangi Rajagopal | Met during inspection and toured facility | |
| Aurora Pascual | Wellness Center Manager/LVN | Met during inspection and toured facility |
| Audrey Jeung | Licensing Program Analyst | Conducted the investigation and reviewed client file |
| Valerie Alves | Administrator/Director | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 594
Capacity: 876
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
The inspection was an unannounced Required 1-Year Annual inspection conducted to evaluate compliance with licensing requirements at the facility.
Findings
The facility was found to be clean, well-maintained, and compliant with regulations. No deficiencies were cited during the visit. Safety equipment, medication storage, resident rooms, and common areas were inspected and found in good condition. Emergency drills were conducted quarterly with the most recent drill on 2025-04-10.
Report Facts
Residents in care: 594
Facility capacity: 876
Resident rooms inspected: 8
Staff personnel records reviewed: 6
Resident records reviewed: 5
Emergency drills frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Koselak | Administrator | Named as facility administrator |
| Neda Armanfar | Director of Assisted Living | Met with Licensing Program Analyst during inspection |
| Valerie Alves | Administrator | Met with Licensing Program Analyst during inspection and received report |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection |
| April Cowan | Licensing Program Manager | Named on report |
Inspection Report
Census: 570
Capacity: 876
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
The visit was conducted to hand deliver an immediate exclusion letter for a staff member who engaged in conduct inimical to the facility.
Findings
No deficiencies were cited during the visit. The immediate exclusion letter was delivered and the administrator was instructed to remove the staff member from any contact with clients and the facility roster.
Report Facts
Capacity: 876
Census: 570
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valerie Alves | Administrator | Met with Licensing Program Analyst during the visit and received the immediate exclusion letter |
| Kiran Jain | Licensing Program Analyst | Conducted the Case Management - Other Inspection visit |
| John Koselak | Administrator/Director | Listed as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 536
Capacity: 876
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-02-22 alleging that staff do not provide residents with activities while in care and that staff do not ensure the facility remains free of odors.
Complaint Details
The complaint was unsubstantiated. Allegations included lack of activities for residents and presence of odors. Multiple interviews and document reviews did not support the allegations.
Findings
The investigation included interviews with staff and resident family members, review of activity logs, invoices for activity supplies, and facility tours. Evidence showed that activities were provided to residents, including those in memory care, and no odors were observed at the facility. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 876
Census: 536
Number of resident family members contacted: 5
Number of resident family members who answered: 2
Number of staff interviewed on 02/28/2024: 7
Number of housekeeping staff interviewed on 12/18/2024: 2
Number of staff interviewed on 02/28/2024 about activities: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Steve A. Brudnick | Administrator | Facility administrator named in report header |
| Valerie Alves | Administrator | Facility representative met during inspection and reviewed report |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 570
Capacity: 876
Deficiencies: 0
Date: Jan 9, 2025
Visit Reason
The inspection visit was conducted to deliver a Decision and Order for the exclusion of staff S1, whose Home Care Aide registration was revoked or deemed forfeited effective 12/30/2024.
Findings
No deficiencies were cited during the visit. The facility confirmed that S1 was never an employee or Private Duty Assistant and will be placed on the Do Not Return list. Documentation including visitor logs, payroll screenshots, and disassociation records were reviewed and showed no association with S1.
Report Facts
Facility capacity: 876
Census: 570
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Neda Armanfar | Director of Assisted Living | Met with Licensing Program Analyst during inspection and discussed exclusion order |
| Andrea Fadem | Director of Nursing | Met with Licensing Program Analyst during inspection and discussed exclusion order |
| John Koselak | Administrator | Named as facility administrator in report header |
| Kiran Jain | Licensing Program Analyst | Conducted the inspection visit |
| April Cowan | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 570
Capacity: 876
Deficiencies: 0
Date: Dec 5, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff restrained a resident and that staff were not following reporting requirements.
Complaint Details
The complaint involved allegations that staff restrained a resident during suppository administration and failed to follow reporting requirements. The investigation found the resident was cooperative, no restraint was used, and documentation was properly maintained. The allegations were unsubstantiated.
Findings
Based on interviews with staff, a private caregiver, family members, and records review, the department found no preponderance of evidence to substantiate the allegations. The resident was cooperative during suppository administration, no restraint was used, and documentation was complete. The allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 876
Resident census: 570
Number of staff interviewed: 5
Date complaint received: Oct 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kiran Jain | Licensing Program Analyst | Conducted the complaint investigation visit |
| Andrea Fadem | Director of Nursing | Met with Licensing Program Analyst during investigation |
| Neda Armanfar | Director of Assisted Living | Met with Licensing Program Analyst during investigation and received report |
| Jean | Licensed Vocational Nurse who reported the alleged restraint incident | |
| Jing | Nurse alleged to have called CNAs to restrain resident |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 23, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident privacy, restraint protocols, pharmaceutical services, medication administration, food safety, and infection control.
Findings
The facility was found deficient in protecting resident confidentiality, proper use of bed rails and bed canes without required physician orders or consents, discrepancies in controlled drug records and medication administration records, medication errors, improper food storage practices, and lapses in infection prevention and control practices.
Deficiencies (6)
F 0583: The facility failed to protect residents' confidentiality by leaving computer screens with protected health information open and unattended in resident care hallways.
F 0700: The facility failed to follow restraint protocols for nine residents by not having physician orders, consents, assessments, or care plans for the use of side rails or bed canes.
F 0755: The facility failed to maintain accountability of controlled substances due to discrepancies between controlled drug records and medication administration records for two residents.
F 0759: The facility had a medication error rate of 7.59% with two medication errors involving improper timing of eye drops and failure to prime an insulin pen injector.
F 0812: The facility failed to ensure food safety by storing opened undated food items in the freezer and dry storage, risking food contamination for all residents.
F 0880: The facility failed to implement infection prevention practices including not disinfecting a glucometer, inadequate scrubbing of a PICC line hub, and failure to wear gloves or perform hand hygiene when handling medicated patches.
Report Facts
Medication error rate: 7.59
Residents affected by restraint protocol deficiency: 9
Residents affected by confidentiality deficiency: 2
Residents affected by infection control deficiency: 3
Residents affected by food safety deficiency: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named in medication error finding for improper eye drop administration and PICC line hub scrubbing. |
| LVN E | Licensed Vocational Nurse | Named in medication error finding for failure to prime insulin pen and infection control finding for not disinfecting glucometer. |
| RN D | Registered Nurse | Named in infection control finding for failure to wear gloves and perform hand hygiene when handling medicated patches. |
| CNA A | Certified Nursing Assistant | Named in confidentiality deficiency for leaving computer screen open and unattended. |
| CNA B | Certified Nursing Assistant | Named in confidentiality deficiency for leaving computer screen open and unattended. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including confidentiality, restraint protocols, medication administration, and infection control. |
Inspection Report
Annual Inspection
Census: 585
Capacity: 876
Deficiencies: 0
Date: Jun 10, 2024
Visit Reason
The inspection was an unannounced Required - 1 Year visit to evaluate the facility's compliance with regulations.
Findings
The Licensing Program Analyst toured the facility, including kitchen, storage, bathrooms, resident bedrooms, and outside areas, and found all areas compliant with no deficiencies cited. Safety systems and documentation were reviewed and found complete.
Report Facts
Water temperature range: 105
Water temperature range: 115
Resident bathrooms toured: 7
Resident bedrooms toured: 7
Resident medication logs reviewed: 7
Resident files reviewed: 7
Staff files reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the inspection and authored the report |
| Valerie Alves | Care Center Administrator | Met with the Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 22, 2024
Visit Reason
The investigation was conducted due to a complaint regarding inadequate assessment and supervision by physical therapy, which allegedly led to a resident's fall, injuries, and subsequent death.
Complaint Details
The complaint investigation found that physical therapy failed to assess Resident 1's functional level as ordered, contributing to a fall and fatal injuries. Resident 1 was high fall risk with a score of 17. The fall occurred when no staff was aware Resident 1 could stand and walk independently. Resident 1 died on 2024-08-20 due to injuries from the fall.
Findings
The facility failed to provide adequate assessment and supervision to prevent an accident for Resident 1 when physical therapy did not follow physician's orders to assess the resident's functional ability upon admission and develop a resident-centered plan of care. This failure resulted in Resident 1's fall, head injuries, multiple fractures, and death.
Deficiencies (1)
F 0689: The facility did not ensure the nursing home area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Physical therapy did not assess Resident 1's functional ability level upon admission, leading to a fall with serious injuries and death.
Report Facts
Fall Risk Assessment Score: 17
Date of Fall: 2023
Date of Death: 2024
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall during a mechanical lift transfer.
Complaint Details
The investigation was triggered by a complaint about a resident fall during a mechanical lift transfer. The fall was substantiated as the CNA transferred the resident alone, causing bruises and fear. The CNA failed to report the fall, and the facility lacked a system to monitor and maintain lift equipment.
Findings
The facility failed to ensure an environment free of accident hazards when a resident fell during a Hoyer lift transfer, resulting in bruises and fear during transfers. The CNA transferred the resident alone despite policy requiring two staff members, and the incident was not properly reported or monitored.
Deficiencies (1)
F0689: The facility failed to ensure a nursing home area was free from accident hazards and provided inadequate supervision to prevent accidents, resulting in a resident fall during a mechanical lift transfer. The CNA transferred the resident alone contrary to policy requiring two staff members and did not report the fall.
Inspection Report
Census: 536
Capacity: 876
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
The visit was conducted to amend the LIC809 Case Management report from 12/28/2023.
Findings
No deficiencies were cited at this time as per California Code of Regulations Title 22.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Valerie Alves | Met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 536
Capacity: 876
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
The visit was an unannounced Case Management visit to address an Incident Report submitted by the facility regarding a reported sexual assault incident involving resident R1 on 08/15/2023.
Complaint Details
The complaint involved an alleged sexual assault by three teenage individuals entering resident R1's living unit. The allegation was investigated through interviews and document reviews. R1 indicated the incident may have been imagined. The Responsible Person was satisfied with the facility's handling and security measures.
Findings
The investigation included interviews with resident R1, staff, and R1's Responsible Person, review of medical and facility documents, and confirmed that R1 may have experienced confusion or delusions related to the incident. The facility staff responded appropriately, providing care and monitoring. No deficiencies were cited during this visit.
Report Facts
Facility capacity: 876
Resident census: 536
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and interviews |
| Valerie Alves | Care Center Administrator | Facility administrator met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 526
Capacity: 876
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-10-27 regarding financial abuse and theft of personal belongings by facility staff.
Complaint Details
The complaint involved allegations that facility staff financially abused the resident and stole personal belongings. After investigation, including interviews and observations, the allegations were found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews with the resident, family members, and staff. Despite allegations of theft and financial abuse, the evidence was insufficient to substantiate the claims. No deficiencies were cited under California Code of Regulations Title 22.
Report Facts
Capacity: 876
Census: 526
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Robinetta Wheeler | Director of Resident Services | Met with during the investigation and reviewed the report |
| Sarah Yip | Licensing Program Manager | Reviewed the complaint investigation report |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 15, 2023
Visit Reason
The inspection was conducted to identify deficiencies related to the facility's provision of a summary of the baseline care plan to residents or their representatives.
Findings
The facility failed to provide Resident 1 and/or their representative with a summary of the baseline care plan, which could limit communication and development of a person-centered plan of care. Interviews with nursing staff confirmed the lack of documentation of providing the baseline care plan summary.
Deficiencies (1)
F 0655: The facility failed to provide the resident and/or their representative with a summary of the baseline care plan within 48 hours of admission. This failure had the potential to limit communication concerning the resident's needs and development of a person-centered plan of care.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Supervisor | Interviewed regarding documentation of baseline care plan summary | |
| Director of Nursing | Acknowledged licensed nurses should document provision of baseline care plan summaries |
Inspection Report
Complaint Investigation
Census: 538
Capacity: 876
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
The visit was conducted in response to an Unusual Incident Report self-reported by the facility regarding an allegation of physical abuse by staff towards a resident on 03/26/2023.
Complaint Details
The complaint involved an allegation that staff S1 physically abused resident R1 on 03/26/2023. The facility conducted an internal investigation and reported no injuries or signs of abuse. Interviews with family member FM1, staff S2, and resident R1 did not substantiate the allegation.
Findings
The investigation found no evidence of physical abuse; wellness checks showed no injuries or signs of abuse, interviews with involved parties and the resident confirmed no abuse occurred, and no deficiencies were cited.
Report Facts
Facility capacity: 876
Resident census: 538
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valerie Alves | Care Center Administrator | Met during visit and discussed facility's plan to prevent abuse |
| David Marrufo | Licensing Program Analyst | Conducted the inspection and interviewed resident R1 |
Inspection Report
Census: 538
Capacity: 876
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
The visit was an unannounced Case Management visit to respond to a Death Report and Incident Report regarding a resident falling on a treadmill and subsequently passing away.
Findings
During the visit, no deficiencies were cited. The licensing analysts reviewed resident records and found no indication that assisted living services or supervision were required for the resident involved in the incident.
Report Facts
Capacity: 876
Census: 538
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Valerie Alves | Care Center Administrator | Met with during the visit and discussed the report |
| Mark Nelson | Associate Executive Director of Independent Living | Discussed the facility's plan to remind residents about proper use of exercise equipment |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 17, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, respiratory care, food safety, infection control, and antibiotic stewardship at the nursing home VI at Palo Alto.
Findings
The facility was found deficient in multiple areas including failure to provide and document restorative nursing assistant treatments, improper oxygen humidifier maintenance, unsanitary food storage and preparation practices, inadequate infection control practices, and failure to implement an antibiotic stewardship program properly.
Deficiencies (5)
F 0688: The facility failed to provide and document restorative nursing assistant treatments for one resident, resulting in potential functional decline.
F 0695: The facility failed to administer oxygen according to professional standards when the oxygen humidifier bottle was empty and not changed weekly.
F 0812: The facility failed to ensure food was stored and prepared under sanitary conditions, including unlabeled food, dented cans, a contaminated ice machine, and improper sanitizer testing.
F 0880: The facility failed to implement infection control practices when a nurse used one syringe for irrigating two nephrostomy tubes and did not perform hand hygiene between tasks.
F 0881: The facility failed to implement an antibiotic stewardship program properly by administering antibiotics to a resident who did not meet criteria for treatment.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 34
Residents affected: 2
Residents affected: 1
Antibiotic dosage: 800
Antibiotic dosage: 160
Antibiotic treatment duration (days): 14
Oxygen flow rate (LPM): 2
Urine culture colony count (cfu/ml): 100000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse C | Licensed Vocational Nurse | Named in oxygen humidifier and hand hygiene findings |
| Director of Nursing | Director of Nursing | Acknowledged documentation failures and infection control practices |
| Restorative Nursing Assistant A | Restorative Nursing Assistant | Named in restorative nursing assistant treatment documentation finding |
| Registered Nurse D | Registered Nurse | Named in nephrostomy tube irrigation infection control finding |
| Kitchen Attendant B | Kitchen Attendant | Named in food sanitation and sanitizer testing finding |
| Director of Dining Services | Director of Dining Services | Named in ice machine sanitation finding |
| Director of Staff Development | Director of Staff Development | Named in antibiotic stewardship program finding |
| Executive Chef | Executive Chef | Named in food sanitation findings |
Inspection Report
Complaint Investigation
Census: 598
Capacity: 876
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2022-11-14 regarding care planning, admission agreements, feeding assistance, medication administration, refusal of medications, and choice of home care companion for a resident.
Complaint Details
The complaint investigation was initiated due to allegations that the facility had not created a care plan or admission agreement for the resident, staff were not assisting with feeding, not administering medications properly, not allowing the resident to refuse medications, and restricting choice of home care companion. The investigation included interviews with staff, residents, and Durable Powers of Attorney, review of service plans, medication administration records, and observations. The allegations were found to be unfounded or unsubstantiated with no regulatory violations confirmed.
Findings
The investigation found the allegations related to care planning, admission agreements, feeding assistance, medication administration, refusal of medications, and home care companion choice to be either unfounded or unsubstantiated based on interviews, observations, and record reviews. No deficiencies were cited under California Code of Regulations Title 22.
Report Facts
Capacity: 876
Census: 598
Staff interviewed: 6
Residents interviewed: 7
Medication refusal dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Steve A. Brudnick | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 598
Capacity: 876
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-01-18 regarding failure to clean resident's bodily waste and improper medication administration.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to clean resident's bodily waste and improper medication administration. Interviews with staff and durable power of attorney representatives, as well as record reviews, did not support the allegations.
Findings
The investigation found no evidence to substantiate the allegations. Observations and interviews indicated that bodily waste was generally cleaned promptly, and medication administration was in accordance with prescriptions. No deficiencies were cited.
Report Facts
Number of resident living units observed: 7
Number of staff interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Steve A. Brudnick | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 588
Capacity: 876
Deficiencies: 1
Date: Nov 17, 2022
Visit Reason
The visit was an unannounced Case Management visit to inquire about an incident self-reported by the facility involving staff neglect observed by a family member on 10/29/2022.
Complaint Details
The visit was triggered by a complaint involving staff S1 observed sitting and watching television while resident R1 was unattended and soiled. The complaint was substantiated by the facility's disciplinary record and care plan review.
Findings
A deficiency was cited for failure to ensure that resident R1 received assistance with dressing as required by their care plan. The facility provided verbal disciplinary action to the staff involved and conducted in-service training to address staff responsibilities.
Deficiencies (1)
Licensee did not ensure that resident R1 received assistance to meet R1's dressing needs, which poses a potential safety risk to residents in care.
Report Facts
Deficiency Type: 1
Plan of Correction Due Date: Nov 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report. |
| Valerie Alves | Care Center Administrator | Met with Licensing Program Analyst during the visit and provided information about the incident. |
| Jose Toribio | Director of Staff Development | Reviewed the report with the Licensing Program Analyst. |
| Sarah Yip | Licensing Program Manager | Supervisor of the licensing evaluation. |
Inspection Report
Annual Inspection
Census: 436
Capacity: 876
Deficiencies: 0
Date: Sep 19, 2022
Visit Reason
An unannounced Required 1 Year visit was conducted as part of the annual inspection process.
Findings
The facility was toured inside and outside, with observations including visitor screening, availability of soap and paper towels in bathrooms, hand washing posters, adequate food supplies, and a 30-day supply of PPEs. No deficiencies were cited during this inspection.
Report Facts
Capacity: 876
Census: 436
PPE supply duration: 30
Perishable food supply duration: 2
Non-perishable food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nelson | Associate Executive Director | Met with Licensing Program Analyst during inspection and report review |
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Required 1 Year visit |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 640
Capacity: 876
Deficiencies: 0
Date: Jan 27, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility was not following physician's orders, withholding resident's medical records, and not meeting resident's needs.
Complaint Details
Complaint allegations were investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.
Findings
The complaint allegations were found to be unfounded after investigation, interviews, and record reviews. Resident R1 was determined not to be an Assisted Living resident and does not receive assisted living services. No deficiencies were cited.
Report Facts
Capacity: 876
Census: 640
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Jackie Jin | Licensing Program Manager | Named in report as Licensing Program Manager |
| Mark Nelson | Facility representative met during the investigation |
Inspection Report
Census: 640
Capacity: 876
Deficiencies: 0
Date: Jan 24, 2022
Visit Reason
The visit was a Case Management - COVID-19 tele-visit conducted via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.
Findings
No deficiencies were cited as per California Code of Regulations, Title 22. Recommendations were made to place social distancing signs in activity rooms and hand washing signs near the kitchen hand washing station.
Report Facts
COVID-19 positive staff: 9
COVID-19 positive residents: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted tele-visit and provided technical assistance |
| Jackie Jin | Licensing Program Manager | Conducted tele-visit and provided technical assistance |
| Cristina Wong | Nurse | Provided recommendations during tele-visit |
| Mark Nelson | Facility representative met during the visit and reported COVID-19 status |
Inspection Report
Census: 532
Capacity: 876
Deficiencies: 0
Date: Dec 23, 2021
Visit Reason
The visit was an unannounced Case Management visit to obtain documents for resident R1, who was reported deceased on 12/20/2021, and to conduct a health and wellness check with residents.
Findings
No deficiencies were cited during the visit. Health and wellness checks for residents R2-R6 indicated they were feeling well and receiving meals and medication assistance as needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the unannounced Case Management visit and requested documents. |
| Yannick Gilbert | Met with Licensing Program Analyst during the visit and provided information. |
Inspection Report
Routine
Census: 439
Capacity: 876
Deficiencies: 0
Date: Jun 16, 2021
Visit Reason
An unannounced Required - 1 Year COVID-19 Infection Control visit was conducted to evaluate compliance with infection control regulations.
Findings
The Licensing Program Analyst observed appropriate COVID-19 infection control measures including visitor screening, hand hygiene supplies, social distancing signage, PPE availability, and staff mask usage. No deficiencies were cited during this inspection.
Report Facts
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the inspection and authored the report |
| Mark Nelson | Facility representative met during the inspection and report review | |
| Steve A. Brudnick | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Capacity: 876
Deficiencies: 1
Date: Feb 24, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 02/24/2021 regarding the inclusion of settlement and attorney fees costs in the community operating account affecting resident monthly care fees.
Complaint Details
The complaint was substantiated based on a preponderance of evidence that the provider improperly included settlement and attorney fees costs in the operating account, affecting resident fees. The Department rejected residents' arguments that these costs should not be considered operating costs and required disclosure and adjustment prior to any COS changes.
Findings
The Department substantiated the complaint, finding that the provider included costs related to a wage and hour lawsuit settlement and attorney fees in the operating account, which reduced the Community Operating Surplus (COS) and impacted monthly care fees. The Department required a corrective action plan to disclose the apportionment of settlement costs and adjust the COS accordingly.
Deficiencies (1)
For monthly fee continuing care contracts, except prepaid contracts, changes in monthly care fees shall be based on projected costs, prior year per capita costs, and economic indicators.
Report Facts
Settlement amount: 1000000
Expense allocated to 2020 operating account: 350000
Projected attorney fees for 2021: 175000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Walden | Evaluator | Conducted the complaint investigation |
| Tara Cope | General Counsel | Met with Department during investigation |
| Gary Smith | CFO | Met with Department during investigation |
| Paul Gordon | Met with Department during investigation | |
| Rachel Raymond | Assistant Chief Counsel | Delivered findings of investigation |
| Carla Nuti-Martinez | Regional Manager | Delivered findings of investigation |
| Allison Nakatomi | Manager of the Continuing Care Contracts Bureau | Delivered findings of investigation and Licensing Program Manager |
| Katie Hernandez | Reviewed the report with the Department |
Inspection Report
Census: 548
Capacity: 876
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
The visit was a Case Management - Other type conducted via tele-visit to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.
Findings
No deficiencies were cited at this time as per California Code of Regulations Title 22. The visit included discussions about communication responsiveness and a COVID-19 positive resident who was hospitalized.
Report Facts
Census: 548
Total Capacity: 876
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nelson | Care Center Administrator | Met with Licensing Program Analyst and discussed COVID-19 positive resident hospitalization and communication responsiveness |
| Yannick Gilbert | Associate Executive Director | Met with Licensing Program Analyst and discussed COVID-19 related technical assistance |
| Angela Brand | HFEN Nurse | Conducted tele-visit and provided technical assistance; no recommendations given |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 23, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication management, and pharmaceutical services at the nursing home.
Findings
The facility failed to accurately code the Minimum Data Set (MDS) for seven sampled residents, including incorrect coding of bed rails as physical restraints and medication use. The pharmacy failed to remove expired medication from an emergency kit. The facility did not monitor side effects of psychotropic medications for one resident and had an 8% medication error rate during medication administration.
Deficiencies (4)
F 0641: The facility failed to accurately code the MDS for seven residents, incorrectly coding bed rails as physical restraints and medication use, potentially leading to inappropriate care planning.
F 0755: The facility's pharmacy failed to ensure no expired medication was present in one of three emergency kits, risking residents receiving medication with decreased potency.
F 0758: The facility failed to monitor for side effects of psychotropic medications for one resident, potentially negatively affecting the resident's health and well-being.
F 0759: The facility had an eight percent medication error rate, including crushing a medication that should not be crushed and administering incorrect eye drops, risking resident health and safety.
Report Facts
Medication error rate: 8
Medication errors observed: 2
Vancomycin Hydrochloride expiration date: Aug 1, 2019
Plavix dosage: 75
Seroquel dosage: 12.5
Lamotrigine dosage: 100
Klor-Con dosage: 10
Resident count sampled for MDS coding: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDSN B | Minimum Data Set Nurse | Interviewed regarding MDS coding and medication monitoring. |
| MDSN C | Minimum Data Set Nurse | Interviewed regarding MDS coding and bed rail restraint status. |
| RN D | Registered Nurse | Interviewed regarding resident mobility and medication administration errors. |
| RN A | Registered Nurse | Confirmed expired medication in emergency kit. |
| LVN E | Licensed Vocational Nurse | Observed administering crushed medication incorrectly. |
| Consultant Pharmacist | Pharmacist | Interviewed regarding medication expiration and monitoring. |
| Registered Nurse Supervisor | RNS | Interviewed regarding resident mobility assistance. |
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