Inspection Reports for Vienna at Santianna – Memory Care
2540 Faraday Ave, Carlsbad, CA 92010, United States, CA, 92010
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent report on September 4, 2025, which was clean and noted the facility to be safe, well-maintained, and in good repair. Several complaint investigations were unsubstantiated, though some substantiated deficiencies involved medication management errors, insufficient staffing affecting resident care, and a serious incident of staff sexual abuse with related reporting failures in late 2023. The facility also had isolated issues with food safety and an unlawful eviction, but no fines or license suspensions were listed in the available reports. Over time, the facility showed improvement, with the latest inspection free of deficiencies after earlier findings prompted corrective actions. Minor issues appeared sporadically, but recent visits suggest better compliance with regulations and resident safety.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
66% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Original Licensing
Census: 149
Capacity: 226
Deficiencies: 0
Date: Sep 4, 2025
Visit Reason
The visit was an announced pre-licensing inspection to ensure the facility's compliance with California Code of Regulations, Title 22, Division 6, prior to licensing approval.
Findings
The facility was found to be clean, safe, and in good repair with no pathway obstructions. Bathrooms and showers were in working order, hazardous materials and medications were securely stored, fire safety equipment was compliant, and required postings were observed. The facility had adequate food supplies and approved fire inspection status. No deficiencies were identified during this visit.
Report Facts
Facility capacity: 226
Current census: 149
Water temperature range: 105
Water temperature range: 120
Non-perishable food supply: 7
Perishable food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammie Sampedro | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the pre-licensing inspection visit |
| Sabel Martinez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 226
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
The visit was an office type evaluation involving a telephone interview with the administrator to verify identification and confirm understanding of community care facility licensing laws and regulations.
Findings
The report documents the administrator's participation in the COMP II interview process, confirming knowledge of licensing laws and regulations. No specific deficiencies or violations are listed in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammie Sampedro | Administrator | Participated in COMP II interview and confirmed understanding of licensing laws. |
| Biridiana Cisneros | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Stefania Fonteno | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
Inspection Report
Annual Inspection
Census: 141
Capacity: 226
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and supplies were present and in working order.
Report Facts
Residents present: 141
Total capacity: 226
Hospice waiver: 25
Bedridden residents allowed: 8
Inspection start time: 1130
Inspection end time: 1610
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justine Hernandez | Memory Care Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced required annual inspection |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 226
Deficiencies: 2
Date: Apr 2, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2024-12-20 that staff did not ensure a resident's food was free of hazardous material.
Complaint Details
The complaint was substantiated. The allegation was that staff did not ensure a resident's food was free of hazardous material due to metal pieces found in Resident 1's puree. The investigation included interviews, observations, and record reviews. A Plan of Correction was developed with the licensee.
Findings
The investigation substantiated that metal pieces were found in Resident 1's puree, posing a potential safety risk. The source of the metal was not conclusively identified, but precautionary measures were taken including discarding the metal fryer basket and replacing the blender blade. The resident remained at baseline with no signs of discomfort after the incident.
Deficiencies (2)
All food shall be selected, stored, prepared and served in a safe and healthful manner.
Licensee did not ensure that a batch of puree was prepared and served in a safe and healthful manner, posing a potential safety risk to 4 of 141 clients in care.
Report Facts
Census: 141
Total Capacity: 226
Clients at potential safety risk: 4
Plan of Correction Due Date: Apr 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justine Hernandez | Memory Care Director | Met with during the investigation and involved in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation |
| Jennifer Lott | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 226
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
The visit was conducted in response to recent self-reported incidents regarding resident falls, elopements, and medications at the facility.
Complaint Details
The visit was complaint-related due to self-reported incidents involving resident falls, elopements, and medication issues. No deficiencies were found, and no substantiation status was stated.
Findings
A wellness check was completed with no health or safety issues identified. No deficiencies were cited or observed during this unannounced case management visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced case management visit and interviews. |
| Sahar Mosalla | Operations Specialist | Met with the Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 226
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations that the licensee did not prevent a resident from eloping and did not arrange psychiatric medical care for residents.
Complaint Details
The complaint alleged that the licensee failed to prevent Resident 1 from eloping and failed to arrange psychiatric medical care. The allegations were found to be unsubstantiated based on interviews, record reviews, and observations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Resident 1 was followed by staff during an exit attempt, was not left unsupervised, and was provided emergency medical care. There was no known history of exit seeking or aggressive behaviors requiring psychiatric care prior to the incident.
Report Facts
Facility capacity: 226
Census: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El-Rabaa | Executive Director | Met during investigation and named in findings |
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 226
Deficiencies: 1
Date: Jul 9, 2024
Visit Reason
The visit was conducted in response to a self-reported incident where Resident 1 eloped from the memory care unit on 2024-06-27.
Complaint Details
The visit was complaint-related due to the self-reported incident of Resident 1 eloping from the memory care unit. Deficiencies were cited and a Plan of Correction was required.
Findings
Deficiencies were cited related to failure to meet the individual supervision needs of Resident 1, posing a safety risk. A Plan of Correction was developed with the licensee to address these issues.
Deficiencies (1)
Failure to meet the individual supervision needs of Resident 1, posing a safety risk to 1 of 33 residents in care.
Report Facts
Residents affected: 1
Total residents in care: 33
Plan of Correction due date: Jul 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El Rabaa | Executive Director | Met during inspection and involved in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Jennifer Lott | Licensing Program Manager | Supervisor and named in the report |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 226
Deficiencies: 0
Date: May 24, 2024
Visit Reason
The visit was conducted in response to self-reported incidents involving two residents who suffered falls with injury.
Complaint Details
The visit was complaint-related due to incidents of Resident 1 and Resident 2 suffering falls with injury. No deficiencies were found, indicating no substantiated violations.
Findings
The Licensing Program Analyst interviewed staff and residents, conducted a wellness check, and found no health or safety issues. No deficiencies were cited or observed during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El Rabaa | Executive Director | Met with Licensing Program Analyst during the visit and involved in the exit interview. |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 226
Deficiencies: 1
Date: May 24, 2024
Visit Reason
The visit was conducted in response to a self-reported incident involving a medication error affecting one resident.
Complaint Details
The visit was complaint-related due to a self-reported medication error incident involving Resident 1. The deficiency was substantiated as staff failed to administer medication as ordered.
Findings
The inspection found that one resident did not receive medication according to the physician's directions, posing a potential health risk. Deficiencies were cited and a Plan of Correction was developed with the licensee.
Deficiencies (1)
Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, as evidenced by Licensee’s staff not giving one resident medication according to the physician's direction, posing a potential health risk.
Report Facts
Residents present: 162
Total licensed capacity: 226
Deficiencies cited: 1
Plan of Correction due date: May 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El Rabaa | Executive Director | Met during inspection and involved in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the inspection |
| Jennifer Lott | Licensing Program Manager | Supervisor and Licensing Evaluator |
Inspection Report
Annual Inspection
Census: 163
Capacity: 226
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety, sanitation, and licensing standards were met during the inspection.
Report Facts
Residents present: 163
Facility capacity: 226
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El Rabaa | Executive Director | Met with Licensing Program Analyst and Maintenance Director during inspection |
| Enoch Medrano | Maintenance Director | Met with Licensing Program Analyst and Executive Director during inspection |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 226
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-12-20 regarding staff sleeping on duty, failure to follow resident care plans, and unclean resident rooms.
Complaint Details
The complaint alleged staff slept on duty resulting in lack of supervision, failure to follow a resident's care plan regarding hourly checks, and failure to keep resident rooms clean. The investigation concluded these allegations were unsubstantiated based on interviews, observations, and records.
Findings
The investigation found no evidence to substantiate the allegations. Staff interviews, resident interviews, outside source interviews, records review, and direct observations all indicated that staff met resident needs, followed care plans, and maintained clean resident rooms.
Report Facts
Capacity: 226
Census: 163
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El Rabaa | Executive Director | Met with Licensing Program Analyst during the investigation and named in the report |
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
Inspection Report
Census: 163
Capacity: 226
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
The visit was an unannounced Case Management visit in response to a self-reported incident involving a resident who suffered a fall with injuries.
Findings
The Licensing Program Analyst interviewed staff and residents, conducted a wellness check, and found no health or safety issues. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El Rabaa | Executive Director | Met with Licensing Program Analyst during the visit and involved in the exit interview. |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 226
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the Licensee did not address concerns regarding door egress, resulting in injury.
Complaint Details
The complaint alleged that the Licensee did not address concerns regarding door egress, resulting in injury. The allegation was found to be unsubstantiated after investigation.
Findings
The investigation found that while the doors were heavy and closed quickly, resulting in a prior minor injury, the Licensee had been actively addressing the issue since November 2023 through contractor adjustments and communication with residents. The allegation was unsubstantiated based on interviews, observations, and records review.
Report Facts
Capacity: 226
Census: 162
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El Rabaa | Executive Director | Met during investigation and named in findings |
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 226
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the licensee did not maintain a resident's hygiene and did not assist the resident with medical care for a pressure sore.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to maintain resident hygiene and failure to assist with medical care for a pressure sore. Evidence showed attempts to provide care and communication with the resident's physician. The pressure sore was at a low stage and treated prior to resident transfer.
Findings
The investigation found that the resident frequently refused showers, staff communicated with the family and made scheduling adjustments, and staff made regular attempts to provide care. The pressure sore was monitored and treated with prescribed barrier cream after the resident had moved out. The allegations were unsubstantiated based on interviews, observations, and records review.
Report Facts
Capacity: 226
Census: 162
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sam El Rabaa | Executive Director | Facility representative met during investigation |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 226
Deficiencies: 2
Date: Feb 26, 2024
Visit Reason
The visit was conducted in response to an LIC624 Incident Report regarding a medication error involving Resident #1, who was found with three transdermal medication patches simultaneously instead of the prescribed one.
Complaint Details
The visit was complaint-related, triggered by an incident report about medication errors involving Resident #1. The complaint was substantiated with evidence of medication mismanagement and lack of required medical assessment.
Findings
The investigation found that staff did not assist Resident #1 with medication as prescribed, resulting in multiple patches being applied simultaneously. Additionally, the facility lacked a current medical assessment for the resident diagnosed with dementia. Two deficiencies were cited and plans of correction were developed.
Deficiencies (2)
Licensee’s staff did not assist 1 of 163 residents (R1) with self-administered medications as needed/prescribed, posing a potential health risk.
Licensee did not ensure that 1 of 163 residents (R1), diagnosed with dementia, had a medical assessment performed within the last year.
Report Facts
Residents present: 163
Total licensed capacity: 226
Medication patches found on resident: 3
Prescribed medication patches: 1
Deficiencies cited: 2
Plan of Correction due date: Mar 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El Rabaa | Executive Director | Met during inspection and named in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervised the inspection and signed the report |
| Staff #1 | Staff member retrained due to involvement in medication error | |
| Staff #2 | Staff member who applied patch on 01/19/2024 and no longer employed at facility |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 226
Deficiencies: 0
Date: Dec 28, 2023
Visit Reason
An unannounced complaint investigation was conducted following an allegation that staff neglect resulted in unexplained bruising on a resident.
Complaint Details
The complaint alleged neglect resulting in unexplained bruising on Resident 1. The allegation was found to be unsubstantiated after investigation including staff and outside source interviews, records review, and observations.
Findings
The investigation included interviews, record reviews, and observations, concluding that there was no preponderance of evidence to substantiate the allegation of neglect. The bruising was noted to be related to the resident's agitation episodes and no evidence of staff abuse or neglect was found.
Report Facts
Capacity: 226
Census: 161
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sam El Rabaa | Executive Director | Facility administrator involved in the investigation and exit interview |
| Jason Bottom | Memory Care Director | Met with the investigator during the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 226
Deficiencies: 0
Date: Dec 7, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the licensee did not follow physician's orders, obtained a Home Health service provider without consent, and did not allow a Home Health agency to visit a resident.
Complaint Details
The complaint was unsubstantiated based on interviews, records review, and outside source corroboration. The allegations included failure to follow physician's orders, obtaining Home Health services without consent, and denying Home Health agency access. Evidence showed consent was obtained and care was provided by the Home Health agency.
Findings
The investigation found that the facility staff could not provide the wound care as it was not a medical facility, but assisted the resident in obtaining Home Health services which provided the care. The resident had signed consent for the Home Health agency care. No evidence was found that the Home Health agency was denied access to the resident. The allegations were unsubstantiated.
Report Facts
Capacity: 226
Census: 164
Allegations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sam El Rabaa | Executive Director | Facility representative met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 226
Deficiencies: 0
Date: Dec 5, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that lack of supervision resulted in a resident going AWOL.
Complaint Details
The complaint alleged lack of supervision resulting in a resident AWOL. The allegation was found to be unsubstantiated after investigation.
Findings
The investigation found that the resident exited through a door that did not completely latch after being opened by staff, and the door alarm was deactivated by a staff member assisting an outside individual. However, all other delayed egress doors were functioning properly and staff responded promptly when alarms sounded. The allegation was unsubstantiated based on interviews, observations, and records review.
Report Facts
Capacity: 226
Census: 164
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sam El Rabaa | Executive Director | Facility representative interviewed during the investigation |
| Christopher Tharp | Administrator | Named as facility administrator |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 226
Deficiencies: 1
Date: Dec 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-03-13 regarding staff not allowing residents access to their rooms and not meeting residents' basic needs.
Complaint Details
The complaint investigation was triggered by allegations that staff did not allow residents access to their rooms and did not meet residents' basic needs. The first allegation was unsubstantiated, while the second was substantiated with evidence of insufficient staffing leading to delays in meal service and incontinence care.
Findings
The allegation that staff did not allow residents access to their rooms was unsubstantiated based on interviews, observations, and records review. However, the allegation that staff did not meet residents' basic needs due to low staffing was substantiated, with evidence of residents waiting long periods for meals and incontinence care.
Deficiencies (1)
Residents in privately operated residential care facilities for the elderly shall have the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers. This requirement was not met.
Report Facts
Residents affected: 34
Capacity: 226
Census: 164
Estimated Days of Completion: 0
Plan of Correction Due Date: Dec 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sam El Rabaa | Executive Director | Facility representative met during the investigation and exit interview |
| Christopher Tharp | Administrator | Facility administrator named in the report |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 226
Deficiencies: 3
Date: Nov 17, 2023
Visit Reason
The visit was conducted in response to a self-submitted SOC341 Report of Suspected Dependent Adult/Elder Abuse involving Resident #1 and Staff #1, to investigate allegations of abuse and ensure resident safety.
Complaint Details
The complaint was substantiated based on a preponderance of evidence showing staff sexual abuse of a resident and failure to meet reporting requirements.
Findings
The investigation found that Staff #1 engaged in inappropriate sexual touching of Resident #1, who has dementia and was unable to reliably report the incident. The facility suspended and then terminated Staff #1. The licensee failed to report the incident to local law enforcement as required and did not provide a written incident report to the resident's responsible person within seven days. Three deficiencies were cited related to abuse prevention and reporting requirements.
Deficiencies (3)
Licensee’s staff did not ensure that Resident #1 was free from physical or sexual abuse, posing an immediate safety and personal rights risk.
Licensee did not report suspected physical abuse to local law enforcement within 24 hours as required.
Licensee did not submit a written incident report to the person responsible for the resident within seven days of the incident occurrence.
Report Facts
Deficiencies cited: 3
Resident count: 164
Facility capacity: 226
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El-Rabaa | Executive Director | Met during inspection and participated in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 226
Deficiencies: 2
Date: Sep 26, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation of unlawful eviction of a resident due to disruptive behavior of the resident's visitor.
Complaint Details
The complaint alleged unlawful eviction of resident 1 due to ongoing disruptive behaviors by the resident's visitor. The allegation was substantiated based on interviews, records review, and regulatory standards.
Findings
The investigation substantiated that the facility unlawfully evicted resident 1 (R1) based on the disruptive behavior of R1's visitor, which is not supported by regulation. The licensee did not issue a lawful eviction notice to R1, posing a personal rights risk to residents in care.
Deficiencies (2)
Eviction Procedures 87224(a) The licensee may evict a resident for one or more of the reasons listed in section 87224(a)(1) through (5)... (3) Failure of the resident to comply with general policies of the facility.
Based on interviews and records review, the Licensee did not issue a lawful eviction notice to 1 of 171 residents (R1), which posed a Personal Rights Risk to residents in care.
Report Facts
Capacity: 226
Census: 171
Deficiency count: 2
Plan of Correction Due Date: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sam El-Rabaa | Executive Director | Facility representative interviewed during the investigation |
| Christopher Tharp | Administrator | Facility administrator named in the report |
| Lizzette Tellez | Licensing Program Manager | Oversaw the licensing program related to this investigation |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 226
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 08/07/2023 regarding allegations that staff did not ensure a family council was generated for a resident and that staff denied an authorized representative access to the facility.
Complaint Details
The complaint investigation addressed allegations that staff did not assist with the creation of a Family Council upon request and that staff denied an authorized representative access to a resident. The investigation included multiple unannounced visits, interviews with staff, residents, and outside sources, and records review. The findings concluded the allegations were unsubstantiated.
Findings
The investigation found no preponderance of evidence to support that the Licensee prohibited the formation of a Family Council or denied an authorized representative access to the facility. The allegations were determined to be unsubstantiated based on interviews, records review, and observations.
Report Facts
Capacity: 226
Census: 171
Complaint received date: Aug 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El-Rabaa | Executive Director | Met with during the investigation and named in findings |
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 226
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations received on 08/07/2023 that staff left a resident unsupervised for extended periods and that a facility gate was in disrepair.
Complaint Details
The complaint was unsubstantiated after investigation, which included interviews, record reviews, and direct observations. Allegations involved resident supervision and facility gate safety.
Findings
The investigation found no evidence to substantiate the allegations. The resident was observed to be independent and did not require supervision, and the facility gate was found to be in good repair with ongoing upgrades in progress.
Report Facts
Capacity: 226
Census: 172
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El Rabaa | Executive Director | Met with during the investigation and exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 226
Deficiencies: 0
Date: Jun 9, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report regarding a resident who eloped from the secured memory care unit without staff supervision.
Complaint Details
The complaint involved a resident eloping from the secured memory care unit. The incident was self-reported by the licensee. The investigation found no substantiated deficiencies or staff neglect.
Findings
The resident was found unharmed and no deficiency was cited. The investigation found no evidence of staff neglect or lack of supervision. The delayed egress doors functioned correctly except for an inconsistent self-closing mechanism on one door, which was not a violation. Staff were retrained on elopement policies.
Report Facts
Door self-closing mechanism test: 7
Door self-closing mechanism test: 10
Staff retraining sessions: 3
Inspection visit duration: 5.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit and investigation |
| Sam El-Rabaa | Executive Director | Facility representative met during the visit and involved in the investigation |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 226
Deficiencies: 0
Date: Jun 9, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report regarding Resident #1 who fell on 04/23/2023 and later was diagnosed with lumbar spine fractures after going to the ER on 04/28/2023.
Complaint Details
The complaint involved an incident where Resident #1 fell and initially refused emergency transport but later was taken to the ER and diagnosed with lumbar spine fractures. The investigation found no preponderance of evidence that the licensee failed to arrange timely emergency medical care.
Findings
No deficiencies were identified or cited during the visit. The facility timely notified the physician and responsible person, kept the resident under observation, and arranged emergency care appropriately. A Technical Violation/Education was delivered regarding reporting requirements.
Report Facts
Facility capacity: 226
Resident census: 164
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Sam El-Rabaa | Executive Director | Facility representative interviewed during the visit |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 226
Deficiencies: 1
Date: Mar 7, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not administer medications as prescribed.
Complaint Details
The complaint was substantiated. The medication error involved Resident 1 receiving another resident's medication in February 2023. Emergency services were contacted, and safety checks were conducted. No side effects were reported by the resident.
Findings
The investigation found that in February 2023, a resident was given another resident's medication, which posed an immediate health risk. The allegation was substantiated based on interviews and records review.
Deficiencies (1)
Failure to ensure Resident 1 received medications as prescribed when given another resident's medication, posing an immediate health risk.
Report Facts
Capacity: 226
Census: 150
Deficiency Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Sam El-Rabaa | Executive Director | Facility representative interviewed during the investigation and named in findings |
| Christopher Tharp | Administrator | Named as facility administrator |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 226
Deficiencies: 1
Date: Mar 7, 2023
Visit Reason
A complaint investigation visit was conducted to review an incident involving Resident 1 (R1) in February 2023, where an incident report was not submitted to the Department as required.
Complaint Details
Complaint investigation visit conducted; an unrelated deficiency was discovered. The incident involved a medication error with Resident 1, with no injuries reported but 911 was contacted. The deficiency was substantiated by interviews and records review.
Findings
The investigation revealed that the licensee failed to submit an incident report regarding a medication error involving Resident 1, posing a potential safety risk to all 150 residents in care.
Deficiencies (1)
Failure to submit an incident report to the licensing agency regarding a medication error involving Resident 1 within seven days as required by California Code of Regulations Title 22.
Report Facts
Residents in care: 150
Total capacity: 226
Deficiency count: 1
Plan of Correction Due Date: Mar 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit and cited the deficiency |
| Sam El-Rabaa | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Lizzette Tellez | Licensing Program Manager / Supervisor | Supervisor of the Licensing Program Analyst and named in the report |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 226
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2022-11-10 alleging that the facility had not conducted an emergency drill.
Complaint Details
The complaint alleging the facility had not conducted an emergency drill was investigated and found to be unfounded, meaning the allegation was false and without reasonable basis.
Findings
The investigation found the complaint to be unfounded. Records and interviews confirmed that multiple emergency drills and emergency preparedness trainings had been conducted since April 2022.
Report Facts
Complaint control number: 08-AS-20221110142442
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit. |
| John Rante | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Sam El-Rabaa | Executive Director | Met with Licensing Program Analyst during the investigation. |
| Christopher Tharp | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 226
Deficiencies: 0
Date: Dec 23, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that the facility did not post the Community Care Licensing poster at the main entryway and that the Facility Ombudsman poster was not visible to residents.
Complaint Details
The complaint was investigated and found to be unfounded based on observations and interviews. The allegations regarding missing posters were not supported by evidence.
Findings
The investigation found that the Community Care Licensing poster was posted near the main entrance down a hallway and the Ombudsman poster was posted in the residents' activity room. There was insufficient evidence to support the allegations, and the complaint was deemed unfounded.
Report Facts
Capacity: 226
Census: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Sam El-Rabaa | Executive Director | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 226
Deficiencies: 0
Date: Dec 22, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility elevator was not maintained in good repair.
Complaint Details
The complaint alleged that the facility elevator was not maintained in good repair. The investigation included interviews with staff, residents, and outside sources, as well as review of maintenance records and observations. The allegation was found unsubstantiated.
Findings
The investigation found that while there were operational issues with one elevator in September 2022, the facility maintained regular elevator maintenance and inspections. Only one elevator was out of service at a time, and the other was available for resident use. The allegation was deemed unsubstantiated based on observations, interviews, and record review.
Report Facts
Facility capacity: 226
Census: 134
Dates of elevator maintenance service calls: August 17, September 18, and September 22, 2022
Elevator maintenance contract period: July 21 to December 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sam El-Rabaa | Executive Director | Facility representative met during the investigation and exit interview |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 226
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that the facility was not sanitary and that the facility garage was not well lit.
Complaint Details
The complaint was unsubstantiated based on direct observations, staff interviews, and records review. The alleged sewage leak was determined to be groundwater from a cable box crack, not sewage, and lighting was confirmed to be sufficient and functional.
Findings
The investigation found no evidence of a sewage leak or unsanitary conditions in the parking garage, and the lighting in the garage was observed to be operable and adequate. Both allegations were determined to be unsubstantiated.
Report Facts
Estimated Days of Completion: 90
Lighting specifications: 6000
Lighting specifications: 66
Lighting count: 20
Lighting warranty: 50000
Lighting warranty years: 5.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Sam El-Rabaa | Executive Director | Facility representative met during the investigation and exit interview |
| Christopher Tharp | Administrator | Facility administrator named in the report |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 226
Deficiencies: 1
Date: Dec 6, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility did not issue a refund as required for a pre-admission fee.
Complaint Details
The complaint was substantiated. The allegation was that the licensee did not issue a refund of a $6,000 pre-admission fee after the prospective client withdrew their application on August 5, 2022. The refund was issued on September 8, 2022, which was beyond the 30 calendar day requirement.
Findings
The investigation substantiated the allegation that the facility failed to issue a refund of a $6,000 pre-admission fee within the required 30-day timeframe after the prospective client withdrew their application. A deficiency was cited and a plan of correction was developed with the Executive Director.
Deficiencies (1)
Preadmission fees shall be refunded according to the following conditions: a 100 percent refund of a preadmission fee shall be provided if the applicant decides not to enter the facility prior to the facility completing a preadmission appraisal.
Report Facts
Pre-admission fee refund amount: 6000
Census: 134
Total capacity: 226
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam El-Rabaa | Executive Director | Named in relation to the complaint investigation and plan of correction |
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation |
| Icela Estrada | Interim Assistant Program Administrator | Conducted the complaint investigation |
Inspection Report
Census: 83
Capacity: 226
Deficiencies: 0
Date: Aug 11, 2022
Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan on the COVID-19 protocols and procedures including cleaning and disinfection, testing, isolation and quarantine, hand hygiene and screening protocols, and use of personal protective equipment (PPE).
Findings
During the visit, the team interviewed facility staff and conducted a walk-through of the facility. No deficiencies were cited during this assessment visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Lopez | Licensing Program Analyst | Conducted the on-site HAI assessment visit and identified themselves during the visit. |
| Elena Madsen | Regional Operations Specialist | Interviewed during the visit and participated in the exit interview. |
| Enoch Medrano | Maintenance Director | Interviewed during the visit. |
Inspection Report
Original Licensing
Capacity: 226
Deficiencies: 0
Date: Apr 20, 2022
Visit Reason
The visit was an announced pre-licensing/component III inspection to ensure Title 22 compliance for initial licensing of the facility with a requested capacity of 226 non-ambulatory residents.
Findings
The facility was found to be clean, sanitary, and in good repair with no obstructions or slip hazards. Hot water temperatures were within acceptable ranges, and the facility had sufficient space and equipment for resident activities and safety measures including locked medication storage and operational signal systems. Fire clearance was granted, approving the facility for 226 elderly residents.
Report Facts
Capacity: 226
Bedridden capacity: 8
Hospice waiver: 15
Hot water temperature range: 106-118
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Tharp | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Tamara Fernandez | Vice President of Operation | Met with Licensing Program Analyst during inspection and named in report |
| Natasha Persaud | Licensing Program Analyst | Conducted the announced pre-licensing inspection |
| Lizzette Tellez | Licensing Program Manager | Named in report header |
Inspection Report
Original Licensing
Capacity: 226
Deficiencies: 0
Date: Feb 17, 2022
Visit Reason
Initial licensing evaluation conducted via telephone call with the administrator to confirm understanding of licensing requirements and program policies.
Findings
The applicant and administrator successfully completed the Component II evaluation, confirming understanding of facility operation, staff qualifications, program policies, and application requirements. No clients were in care at the time of the evaluation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Tharp | Administrator | Participated in the Component II telephone call and confirmed understanding of licensing requirements. |
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