Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. However, some reports cited deficiencies primarily related to medication management, resident care, and timely staff responses, including missed medication doses and delayed assistance to residents. The most serious issues involved substantiated medication errors and failures to assist residents with self-administered medications, with citations issued in early 2025 and late 2024. The most recent report from July 1, 2025, had no deficiencies and found no evidence to support medication-related complaints, showing improvement in that area. Overall, the facility’s record shows progress over time, with isolated issues addressed and no enforcement actions or fines listed in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 0
Jul 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation following allegations that facility staff were not providing resident's medication dosage as prescribed and had not requested required medication refills.
Findings
The investigation found that resident R1's medications were provided as prescribed and medication refills were requested and received as required. There was no evidence to support the allegations, and no deficiencies were cited.
Complaint Details
The complaint was unsubstantiated based on interviews, record reviews, and investigation findings indicating no violations occurred regarding medication administration and refill requests.
Report Facts
Facility capacity: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met during inspection and exit interview |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 80
Deficiencies: 0
May 21, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that staff did not ensure residents' bathing needs were met and that residents did not have access to assistive devices.
Findings
The investigation found that resident R1 sometimes refused bathing, but staff offered bathing repeatedly and provided it as needed. Staff also offered assistive devices such as walkers and glasses when residents were observed without them. There was no evidence to support the allegations, and no deficiencies were cited.
Complaint Details
The complaint was unsubstantiated based on interviews, record reviews, and observations. Allegations included failure to meet bathing needs and lack of access to assistive devices, but no violations were found.
Report Facts
Capacity: 80
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with during inspection and exit interview |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 66
Capacity: 80
Deficiencies: 0
Apr 2, 2025
Visit Reason
The inspection was a Required - 1 Year unannounced visit conducted to evaluate compliance with licensing requirements, including infection control, emergency disaster preparedness, staff training, and facility safety.
Findings
The facility was found to be clean, orderly, and compliant with regulations. All resident and staff records reviewed were complete and up to date. Emergency plans, infection control, and fire safety measures were in place and drills conducted. No deficiencies were cited during this inspection.
Report Facts
Hospice care waiver residents: 13
Fire clearance capacity: 80
Fire drills conducted: 3
Elopement drills conducted: 1
Resident records reviewed: 10
Staff records reviewed: 10
Emergency supply duration: 72
Hot water temperature 1st floor: 119.8
Hot water temperature 2nd floor: 114.4
Generators: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gao Yang | Journey Director | Met with Licensing Program Analysts during inspection and exit interview |
| Jose Moreno | Maintenance Director | Accompanied Licensing Program Analysts during facility tour |
Inspection Report
Capacity: 80
Deficiencies: 1
Mar 18, 2025
Visit Reason
The case management inspection was conducted to review a resident incident reported by the facility Administrator to the Department.
Findings
It was identified that staff inappropriately handled a resident (R1) when trying to provide incontinent care, and the resident reacted by screaming and kicking. Staff did not use a different approach or allow time for the resident to be agreeable to the care needed, resulting in a cited deficiency related to residents' personal rights.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff inappropriately handled resident (R1) during incontinent care, failing to use alternative approaches or allow time for resident cooperation, violating personal rights. | Type B |
Report Facts
Capacity: 80
Plan of Correction Due Date: Mar 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with Licensing Program Analyst during inspection and involved in incident report |
| Dina Alviso | Licensing Program Analyst | Conducted the case management inspection |
| Bethany Moellers | Licensing Program Manager | Supervisor and named in report |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 1
Jan 28, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that medications were not provided to a resident as prescribed.
Findings
The investigation substantiated that resident R1 missed eight doses of a routine medication due to delayed refill orders and that a PRN medication was administered outside prescribed hours and for unapproved reasons. A violation was cited for failure to assist residents with self-administered medications as needed.
Complaint Details
The complaint alleged that medications were not provided to the resident as prescribed. The allegation was substantiated based on record reviews, interviews, and observations. The resident missed eight doses of a routine medication and received PRN medication outside prescribed times and for unapproved indications.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, including timely medication refills and adherence to physician's orders for PRN medications. | Type A |
Report Facts
Missed medication doses: 8
Civil penalty amount: 250
Facility capacity: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with Licensing Program Analyst during inspection and exit interview. |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation. |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation. |
| Gao Yang | Memory Care Director | Met with Licensing Program Analyst during inspection. |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 1
Dec 17, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that medications were not provided to a resident as prescribed.
Findings
The investigation substantiated the allegation that medications were not provided as prescribed to resident R1. Documentation and timely ordering of medications by the responsible party were lacking, resulting in missed doses and a risk to the resident's health and safety.
Complaint Details
The complaint was substantiated. The allegation was that medications were not provided to the resident as prescribed. The investigation found insufficient documentation and failure to notify the responsible party in a timely manner, leading to missed doses.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement a plan for incidental medical and dental care, including assisting residents with self-administered medications as needed, resulting in missed medication doses for resident R1. | Type A |
Report Facts
Facility capacity: 80
Deficiency citation: 1
Plan of Correction due date: Dec 18, 2024
Training proof due date: Dec 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met during investigation and exit interview |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Gao Yang | Memory Care Director | Interviewed during investigation |
| Jennifer Haney | Health & Wellness Director | Interviewed during investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 80
Deficiencies: 0
Oct 1, 2024
Visit Reason
The visit was an unannounced Case Management - Other visit to follow up on a SOC341 report dated 7/23/24 and an incident report regarding a suspected physical abuse incident that occurred on 7/17/24 at 3am.
Findings
The facility conducted an internal investigation which was unsubstantiated. Staff training on elder abuse/mandated reporting was conducted on 7/24/24. Staff member S1 resigned due to dissatisfaction with the facility's response. No deficiencies were cited during the inspection.
Complaint Details
The complaint involved a suspected physical abuse incident where staff member S1 pushed resident R1 during an attempt to redirect them. The facility contacted law enforcement and conducted a skin assessment with no injuries found. The internal investigation was unsubstantiated.
Report Facts
Incident date: Jul 17, 2024
Report date: Jul 23, 2024
Staff resignation date: Jul 25, 2024
Staff training date: Jul 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Executive Director | Met during inspection and involved in incident reporting |
| Marisol Cuadra | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 64
Capacity: 80
Deficiencies: 0
May 21, 2024
Visit Reason
The inspection was a Required - 1 Year unannounced visit conducted to evaluate the facility's compliance with licensing regulations and operational plans.
Findings
The facility was found to be clean, orderly, and compliant with regulatory requirements including infection control, emergency preparedness, staff training, and medication storage. No deficiencies were cited during the visit.
Report Facts
Hospice care waiver residents: 13
Resident records reviewed: 8
Staff records reviewed: 7
Emergency drill frequency: 3
Hot water temperature: 119
Shelter in place emergency supply duration: 72
Fire clearance capacity: 80
Bedridden residents included in fire clearance: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Jose Moreno | Maintenance Director | Accompanied Licensing Program Analyst during facility tour |
| Dina Alviso | Licensing Program Analyst | Conducted the inspection visit |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 80
Deficiencies: 0
Mar 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to an allegation that staff were not following physicians' orders.
Findings
The investigation found that medication orders were provided as prescribed by the physician. Although there was differing information regarding the allegation, no evidence supported a violation. The allegation was determined to be unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that staff were not following physicians' orders. The investigation included review of resident records, medication administration records, care plans, and interviews. The allegation was found unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 80
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with Licensing Program Analyst during complaint investigation and exit interview |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 1
Jan 31, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted due to an allegation that staff were not changing a resident timely.
Findings
The investigation substantiated the allegation that staff were not changing the resident timely. It was found that some facility caregivers stopped checking on the resident, mistakenly believing the resident's private companion was providing incontinent care, which is the responsibility of the facility staff.
Complaint Details
The complaint alleging that staff were not changing the resident timely was substantiated based on interviews and record reviews. A citation was issued under CCR 87625 for managed incontinence care violations.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered; failure to ensure incontinent residents are checked during known incontinent periods including night; failure to keep incontinent residents clean and dry and facility free of odors. | Type B |
Report Facts
Facility capacity: 80
Plan of Correction due date: Feb 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortes | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Jennifer Haney | Health & Wellness Director | Provided statements regarding facility caregiver responsibilities for incontinent care |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 2
Sep 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations that staff were not ensuring residents received medications timely, call buttons were not operable or answered timely, and concerns about laundry services and resident safety.
Findings
The investigation substantiated that the facility failed to refill resident medications timely and did not respond promptly to resident call bells, resulting in citations and a civil penalty. Allegations regarding unsanitary laundry services, residents left in soiled items, and unsafe environment were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations related to medication delays and call bell response times. The allegations regarding unsanitary laundry services, residents left in soiled items, and unsafe environment were unsubstantiated due to lack of evidence.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not refill resident's medication in a timely manner, requiring responsible party to purchase medication. | Type A |
| Staff did not respond timely to resident call bell/pendant, with delays of 24 and 25 minutes documented. | Type B |
Report Facts
Capacity: 80
Call bell response delay: 24
Call bell response delay: 25
Civil penalty amount: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Maria Cortes | Administrator | Facility administrator met during inspection and exit interview |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 1
Aug 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations including staff not following physician's orders regarding medications, facility not following the Admission's Agreement, staff yelling at residents, and staff not responding to residents' requests for assistance in a timely manner.
Findings
The investigation found that the allegations regarding staff not following physician's orders and the facility not following the Admission's Agreement were unfounded. The allegation that staff yelled at residents was unsubstantiated. However, the allegation that staff did not respond to residents' requests for assistance in a timely manner was substantiated, with evidence that a resident waited approximately an hour for assistance after requesting help from staff.
Complaint Details
The complaint investigation was triggered by multiple allegations including staff not following physician's orders, facility not following Admission's Agreement, staff yelling at residents, and staff not responding timely to residents' requests. The allegation of staff not responding timely was substantiated; others were unsubstantiated or unfounded.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to respond to residents' requests for assistance in a timely manner, resulting in a resident waiting an hour for medication technician assistance. | Type B |
Report Facts
Capacity: 80
Citation Section: 87468.2
Plan of Correction Due Date: Aug 18, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortez | Administrator | Met with Licensing Program Analyst during investigation and involved in findings |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Limberg | Administrator | Named as facility administrator |
Inspection Report
Annual Inspection
Capacity: 80
Deficiencies: 4
Jun 8, 2023
Visit Reason
Continuation of the required annual inspection visit to evaluate compliance with licensing regulations and facility operations.
Findings
The facility was generally clean and orderly with proper emergency and infection control plans in place. However, several deficiencies were cited including unlocked beauty salon with accessible poisons, hot water temperature out of regulatory range, uncovered food items, and a resident lacking an updated medical assessment.
Severity Breakdown
Type A: 3
Type B: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| One resident lacked an updated medical assessment as required for residents with dementia. | Type B |
| Beauty salon in assisted living was unlocked with poisons, chemicals, and toxins accessible to residents. | Type A |
| Hot water temperature controls did not maintain water temperature between 105°F and 120°F as required. | Type A |
| Two large boxes of lentils and a large box of rice were opened and not covered or stored appropriately to prevent contamination. | Type A |
Report Facts
Capacity: 80
Number of staff records reviewed: 5
Number of resident records reviewed: 5
Number of fire extinguishers: 22
Number of stairwells: 2
Number of residents approved for hospice care waiver: 13
Hot water temperatures observed: Measured temperatures were 122°F, 121.5°F, and 123.4°F, exceeding regulatory limits
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Cortez | Administrator | Met with Licensing Program Analyst during inspection |
| Dina Alviso | Licensing Program Analyst | Conducted the inspection and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 80
Deficiencies: 0
Apr 28, 2023
Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint received on 2023-01-24 alleging multiple issues including improper toileting assistance, rough handling of residents, failure to follow physician orders for bathing, inappropriate speech to residents, and unmet dietary needs.
Findings
The investigation found no substantiation for the allegations after reviewing resident and staff records and conducting interviews. Residents were found to be receiving appropriate toileting, bathing, and dietary care, and staff were trained and respectful. No deficiencies were cited during the visit.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 3
Facility capacity: 80
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Hope DeBenedetti | Licensing Program Manager | Oversaw the complaint investigation |
| Eugenia Smith | Interim Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 80
Deficiencies: 0
Apr 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that the facility did not have an acting administrator in charge and that the facility was in disrepair.
Findings
The investigation found no evidence to support the allegations. The facility had an Interim Administrator in place, and the elevator incident was addressed appropriately with repairs completed. The facility was not found to be in disrepair. The complaint was determined to be unfounded.
Complaint Details
The complaint control number 21-AS-20230420164901 involved allegations that the facility lacked an acting administrator and was in disrepair. The investigation concluded these allegations were unfounded, meaning they were false or without reasonable basis.
Report Facts
Facility capacity: 80
Census: 62
Elevator outage date: Apr 14, 2023
Elevator repair completion date: Apr 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation |
| Eugenia Smith | Interim Administrator | Interviewed regarding administrator coverage and elevator incident |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 80
Deficiencies: 1
Oct 14, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that facility sink faucets do not deliver hot water.
Findings
The investigation substantiated the allegation that the facility's sink faucets did not consistently deliver hot water due to intermittent hot water issues affecting specific units. A professional plumber identified a faulty tempering valve that needs replacement, which is currently on order. The hot water temperature was found to be within regulatory limits during the inspection.
Complaint Details
The complaint was substantiated based on interviews, record reviews, and observations. The allegation was that facility sink faucets do not deliver hot water. The facility had prior incidents in February and September 2022 and a current issue reported on October 10, 2022. The hot water issue was ongoing but being addressed with plumbing repairs.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain water supplies and plumbing fixtures so that faucets used by residents deliver hot water within the temperature range of 105°F to 120°F. | Type B |
Report Facts
Facility Capacity: 80
Census: 59
Citation Number: 87303
Plan of Correction Due Date: Oct 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dina Alviso | Licensing Program Analyst | Conducted the complaint inspection and investigation |
| Stephanie Limberg | Administrator | Facility administrator met during inspection and involved in addressing the hot water issue |
| Hope DeBenedetti | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 80
Deficiencies: 2
Oct 14, 2022
Visit Reason
The case management inspection was conducted to review several resident incident reports, specifically focusing on medication errors.
Findings
Two incident reports were reviewed involving medication errors where staff did not provide the correct medication dosage or medication, resulting in health and safety risks and personal rights violations to residents. A citation was issued for failure to assist residents with self-administered medications as required.
Complaint Details
The visit was complaint-related focusing on medication errors. The citation was issued based on substantiated incidents of medication errors posing health and safety risks.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement a plan for incidental medical and dental care that ensures assistance with self-administered medications as needed. | Type A |
| Two incidents of medication errors where staff did not provide correct medication dosage and/or correct medication to residents. | Type A |
Report Facts
Deficiencies cited: 2
Plan of Correction Due Date: Oct 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during inspection and involved in findings related to medication errors |
| Dina Alviso | Licensing Program Analyst | Conducted the case management inspection and cited deficiencies |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 52
Capacity: 80
Deficiencies: 2
Mar 8, 2022
Visit Reason
The inspection was a required 1-year unannounced visit focused on infection control procedures and practices at the facility.
Findings
The facility was generally clean, orderly, and well-supplied with hygiene products and PPE. However, deficiencies were found related to improper food storage and unsecured personal medications in the dementia care unit.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Food items were not stored properly, including lack of labeling and presence of old dated items, risking food safety and quality. | Type A |
| Personal medications belonging to a staff person were found unsecured on an activity cart in the dementia care unit, along with nail polish remover and hand sanitizer. | Type A |
Report Facts
Residents in care: 52
Licensed capacity: 80
Hospice care waiver residents: 13
Cream dressing containers: 7
Deficiencies cited: 2
Plan of Correction due date: Mar 9, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during inspection and involved in addressing deficiencies |
| Dina Alviso | Licensing Program Analyst | Conducted the inspection and authored the report |
| Carla Martinez | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Capacity: 80
Deficiencies: 0
May 25, 2021
Visit Reason
Annual required inspection focused on infection control procedures and practices at the facility.
Findings
The facility was found to be clean, orderly, and at a comfortable temperature with proper infection control measures including COVID mitigation plan, resident and staff screening, sanitizer availability, and PPE supply. No citations were issued during this inspection.
Report Facts
Hospice care waiver residents: 13
Licensed capacity: 80
Bedridden residents: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met during inspection and mentioned in infection control practices |
| Dina Alviso | Licensing Program Analyst | Conducted the annual inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report header |
Inspection Report
Capacity: 80
Deficiencies: 0
May 25, 2021
Visit Reason
The inspection was a case management visit related to legal/non-compliance issues, continuing from prior inspections on 4/29/21 and 4/30/21, to ensure the facility's compliance with health and safety regulations and probation order terms.
Findings
The Licensing Program Analyst reviewed emergency preparedness training files for staff and disaster leaders, finding that staff had the required training. Technical assistance was provided to improve documentation and tracking of training records. No citations were issued.
Report Facts
Emergency preparedness training files reviewed: 13
Facility capacity: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during inspection and involved in findings |
| Dina Alviso | Licensing Program Analyst | Conducted the case management inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report header |
Inspection Report
Capacity: 80
Deficiencies: 1
Apr 30, 2021
Visit Reason
The inspection was a case management legal/non-compliance visit conducted via tele-video to ensure compliance with the stipulation, waiver, and order in place related to license revocation stayed under probation conditions.
Findings
The facility was found to be generally compliant with posting requirements and emergency plans, but deficiencies were noted regarding staff lacking required emergency disaster and disaster leader training as mandated by the stipulation order. Emergency preparedness measures such as evacuation drills, emergency supplies, and communication systems were observed and reviewed.
Deficiencies (1)
| Description |
|---|
| Staff lacked the required emergency disaster training and disaster leader training as required by the stipulation order. |
Report Facts
Capacity: 80
Staff files reviewed: 10
Evacuation drills per year: 2
Last evacuation drill date: 202102
Hot water temperature range: 111.2
Hot water temperature range: 119.6
Probation period: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during inspection and discussed emergency preparedness |
| Dina Alviso | Licensing Program Analyst | Conducted the case management legal/non-compliance inspection |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 61
Capacity: 80
Deficiencies: 0
Apr 29, 2021
Visit Reason
The inspection was a case management- Legal/Non-compliance visit conducted to ensure compliance with the stipulation, waiver, and order in place related to license revocation stayed for 2 years with probation period effective 8/7/19 to 8/7/21.
Findings
The Licensing Program Analyst conducted a physical plant inspection via tele-video visit and observed no deficiencies. All fire extinguishers were charged and tagged, exits unobstructed, elevator inspected, sufficient food and water supply, hot water temperatures within range, safety features like grab bars and non-slip flooring present, evacuation chairs and generators observed, medication room and toxins securely stored. No deficiencies were cited during this inspection.
Report Facts
Water supply volume: 400
Hot water temperature: 112.4
Hot water temperature: 116.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during inspection |
| Dina Alviso | Licensing Program Analyst | Conducted the case management- Legal/Non-compliance inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 0
Jan 13, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff failed to properly assist a resident with medications.
Findings
The investigation found that the resident was unable to manage their own medications safely and was placed on the facility's medication program with agreement from the responsible party. The allegation was determined to be unfounded, with no deficiencies cited during the visit.
Complaint Details
The complaint allegation that staff failed to properly assist the resident with medications was investigated and found to be unfounded.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Limberg | Administrator | Met with Licensing Program Analyst during the investigation and involved in medication assistance finding. |
| Dina Alviso | Licensing Program Analyst | Conducted the complaint investigation. |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
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