Inspection Report Summary
Most inspections before 2025 found the facility generally compliant with safety and environment standards, including a clean prelicensing inspection on June 14, 2023. However, more recent reports show some serious issues. On July 18, 2024, inspectors cited the facility for privacy violations due to unauthorized audio video monitoring in residents’ rooms and for having an unauthorized staff member present, resulting in $500 in civil penalties. The most recent report from September 25, 2025, substantiated a neglect complaint involving a resident who developed an open wound with maggots and required hospitalization; this led to an immediate $500 civil penalty with additional fines pending. These findings indicate a worsening pattern of resident care and supervision concerns over time.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 1
Sep 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation of neglect/lack of care and supervision resulting in hospitalization of a resident.
Findings
The investigation substantiated the allegation that Resident #1 developed an open wound with maggots due to neglect by facility staff. The facility failed to develop a care plan or arrange timely medical attention for the resident, posing an immediate health and safety risk.
Complaint Details
The complaint was substantiated. It involved neglect/lack of care and supervision that resulted in hospitalization of Resident #1. Evidence included medical records, staff interviews, and hospital photographs. An immediate civil penalty of $500 was assessed, with additional penalties pending review.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a plan for incidental medical and dental care and to arrange timely medical attention for Resident #1's feet. | Type A |
Report Facts
Capacity: 10
Census: 10
Civil penalty amount: 500
Plan of Correction Due Date: Sep 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janira Arreola | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Carolyn Tuba | Licensing Program Manager | Oversaw the complaint investigation |
| Rommel Abedoza | Staff | Met with Licensing Program Analyst during investigation |
| Zayden Chen | Licensee | Discussed plan of correction and notified of findings |
| Lynn Drummond | Administrator | Informed of investigation findings and discussed plan of correction |
Inspection Report
Census: 9
Capacity: 10
Deficiencies: 2
Jul 18, 2024
Visit Reason
An unannounced visit was conducted by Licensing Program Analyst Janira Arreola for an unrelated matter, including a health and safety check on facility residents and review of staff.
Findings
Deficiencies were observed including unauthorized use of video monitors with audio in residents' private rooms and presence of a staff member not associated with the facility. Civil penalties totaling $500 were cited.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Use of video monitors with audio capabilities in residents' private rooms, violating privacy rights. | Type B |
| Staff member present who was not associated with the facility, posing immediate health, safety, or personal rights risk. | Type A |
Report Facts
Civil penalty amount: 500
Number of video monitors observed: 2
Plan of Correction due date: Jul 25, 2024
Plan of Correction due date: Jul 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janira Arreola | Licensing Program Analyst | Conducted the unannounced visit and documented deficiencies. |
| Odette Derafera | House Manager | Met with Licensing Program Analyst during the visit and involved in plan of correction. |
| Tess Derafera | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Original Licensing
Census: 9
Capacity: 10
Deficiencies: 0
Jun 14, 2023
Visit Reason
The visit was conducted as a prelicensing inspection for a residential care facility for the elderly seeking a change of ownership and licensing for 10 residents aged 60 and up.
Findings
The facility was inspected and found to have appropriate furnishings, safety measures, and supplies for 10 residents. The fire clearance was approved, safety equipment was operational, and the environment was free of hazards. Residents were observed engaged in activities, and documentation was properly maintained and secured.
Report Facts
Hot water temperature: 109.7
Capacity: 10
Census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janira Arreola | Licensing Program Analyst | Conducted the prelicensing inspection |
| Teresa Derafera | Administrator | Facility administrator present during inspection |
| Zayden Chen | Applicant | Applicant seeking change of ownership |
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