Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were without reasonable basis. However, there have been some isolated issues, including a substantiated complaint in October 2024 where the facility failed to provide adequate supervision, resulting in inappropriate contact between residents. The most recent report from September 26, 2025, was clean with no deficiencies found during a complaint investigation about vehicle safety. A citation was issued in June 2025 for failing to submit a timely incident report after a resident’s fall, but no fines or enforcement actions were listed in the available reports. Overall, the facility’s record shows mostly compliance with some minor and isolated deficiencies, and the latest inspection suggests improvement in maintaining standards.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 95
Capacity: 104
Deficiencies: 0
Sep 26, 2025
Visit Reason
The visit was conducted as an unannounced complaint investigation following a complaint received on 2025-08-06 alleging that facility transportation vehicles used to transport residents were not maintained in a safe operational condition.
Findings
The investigation included interviews with the Executive Director, drivers, staff, and residents, as well as inspection of the facility vehicles. The Department found that the allegation was unfounded, with no evidence of unsafe vehicle conditions or accidents, and both vehicles were well maintained and clean.
Complaint Details
The complaint alleged that facility transportation vehicles were not maintained in a safe operational condition. The investigation found the allegation to be unfounded, meaning it was false or without reasonable basis.
Report Facts
Facility capacity: 104
Census: 95
Complaint received date: Aug 6, 2025
Number of staff interviewed: 4
Number of residents interviewed: 4
Years driver 2 employed: 7
Flat tire incident timeframe: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marife Duewel | Executive Director | Interviewed regarding vehicle maintenance and complaint |
| Steve Chang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Chihhsien Chang | Licensing Program Analyst | Conducted investigation and signed report |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 83
Capacity: 104
Deficiencies: 1
Jun 17, 2025
Visit Reason
The visit was an unannounced case management visit to deliver an amended LIC9099 and LIC9099D report which were incorrectly issued on 2025-03-06 and should have been a case management visit.
Findings
The facility failed to submit an incident report within 7 days for a resident (R1) who had a fall resulting in a fracture on 2025-02-27. A citation was issued for this failure to report, posing a potential health and safety risk to persons in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit incident report within 7 days for resident R1's fall resulting in fracture. | Type B |
Report Facts
Plan of Correction Due Date: Jun 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marife Duewel | Administrator | Met during the inspection and involved in discussion about incident report |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced case management visit and initial investigation |
| Chihhsien Chang | Licensing Program Analyst | Created and signed the report |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 104
Deficiencies: 0
May 30, 2025
Visit Reason
The visit was conducted as an unannounced complaint investigation following an allegation that a resident sustained a fracture due to lack of care from staff.
Findings
The investigation found the allegation unsubstantiated based on observations, records reviewed, and interviews conducted. The facility had implemented measures including 1:1 24x7 caregiver monitoring for the resident after the initial incident. No deficiencies or citations were noted during the investigation.
Complaint Details
The complaint alleged that a resident sustained a fracture due to lack of care from staff. The investigation included interviews with the Executive Director, staff, private caregivers, and the resident, as well as review of resident records and observations. The allegation was found unsubstantiated.
Report Facts
Capacity: 104
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marife Durewel | Executive Director | Interviewed during the investigation and named in findings |
| Steve Chang | Licensing Program Analyst | Conducted the investigation visit and delivered findings |
Inspection Report
Annual Inspection
Census: 85
Capacity: 104
Deficiencies: 0
Nov 20, 2024
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements at the facility.
Findings
The inspection found the facility generally compliant with no citations noted. The administrator certificate was expired but had been renewed. Safety features such as locked medication rooms, functioning fire extinguishers, and tested carbon monoxide detectors were observed. Emergency call response and exit door alarms were tested and found operational.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Fire extinguisher service date: Jan 24, 2024
Emergency drill date: Aug 30, 2024
Emergency call response time (minutes): 8
Room temperature (F): 70
Hot water temperature (F): 107
Facility capacity: 104
Current census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marife Duewel | Administrator | Met with Licensing Program Analyst during inspection |
| Roselily Cacas | Assist Living Director | Met with Licensing Program Analyst during inspection |
| Steve Chang | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 104
Deficiencies: 1
Oct 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was inappropriately touched by another resident due to neglect and lack of supervision.
Findings
The investigation substantiated the allegation that the facility failed to provide necessary care and supervision, resulting in resident R1 wandering into resident R2's room and inappropriately touching R2. The facility lacked an effective action plan despite prior incidents and did not update R1's care plan accordingly.
Complaint Details
The complaint was substantiated. The allegation involved neglect and lack of supervision resulting in inappropriate touching between residents. The Department found sufficient evidence to substantiate the complaint after interviews, record reviews, and law enforcement reports.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not provide necessary care and supervision to resident R1, leading to R1 wandering into R2's room and inappropriately touching R2's private areas, posing a potential health, safety, or personal rights risk. | Type B |
Report Facts
Capacity: 104
Census: 86
Plan of Correction Due Date: Oct 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marrife Duewel | Executive Director | Met during investigation and provided statements regarding the incident and corrective actions |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced investigation visit |
| Chihhsien Chang | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Romeo Manzano | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 104
Deficiencies: 0
Oct 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-03-17 regarding food supplies, medication supervision, expired medications, insulin injections by unlicensed staff, and incomplete medication records.
Findings
The investigation found no evidence to support the allegations. The facility had sufficient non-perishable food during a power outage, staff properly supervised medication administration, no expired medications were found, insulin injections were administered by licensed nurses, and medication records were complete. All allegations were determined to be unfounded or unsubstantiated.
Complaint Details
The complaint included allegations that the facility did not have non-perishable foods for a minimum of a week, staff were not properly supervising residents during medication administration, residents' centrally stored medications were expired, residents were administered insulin injections by non-licensed staff, and medication records were incomplete. The investigation found these allegations to be unfounded or unsubstantiated.
Report Facts
Capacity: 104
Census: 77
Number of staff interviewed: 11
Number of residents interviewed: 6
Number of medications checked: 20
Number of residents' medication records checked: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marife Duewel | Executive Director | Met with during investigation and provided statements regarding food supplies and medication supervision |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| S1 | Resident Care Coordinator | Interviewed regarding insulin injection administration and nursing license status |
| S2 | Health and Wellness Director, LVN | Interviewed regarding insulin injection administration |
| Chihhsien Chang | Licensing Program Analyst | Conducted investigation and signed report |
| Romeo Manzano | Licensing Program Manager | Oversaw investigation and signed report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 104
Deficiencies: 0
Oct 18, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident sustained unexplained burn(s) while in care.
Findings
The investigation included interviews with the Executive Director and staff, review of medical documents, and environmental observations. The allegation was found to be unsubstantiated due to lack of preponderance of evidence to prove the burn(s) occurred as alleged.
Complaint Details
The complaint alleged that a resident sustained unexplained burn(s) while in care. The investigation found no evidence of burns caused by hot water, hot coffee, or electric blankets. The resident's right hand was paralyzed and had blisters, but the cause was undetermined and might be infection or allergy. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 26
Water temperature in resident's bathroom: 107
Water temperature in common bathroom: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chihhsien Chang | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Marife Duewel | Executive Director | Interviewed during investigation and exit interview |
| Romeo Manzano | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 104
Deficiencies: 0
Apr 7, 2023
Visit Reason
The visit was conducted as a case management incident investigation following receipt of an Incident Report on 2023-03-29 regarding inappropriate body contact between a client and a staff member at the facility.
Findings
Licensing Program Analysts conducted an unannounced visit, interviewed the administrator and one staff member, toured resident bedrooms, and reviewed resident physician reports and service plans. The administrator stated the facility will submit an action plan to prevent similar incidents.
Complaint Details
The visit was triggered by a complaint incident report alleging inappropriate body contact between a client and staff. The facility acknowledged the incident and plans to submit a corrective action plan.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marrife Duewel | Administrator | Met with during the visit and involved in discussion of the incident and corrective action plan. |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Trang Pham | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Romeo Manzano | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 104
Deficiencies: 0
Jan 31, 2023
Visit Reason
The visit was an unannounced case management incident investigation to physically inspect the safety of the facility and review the Plan of Action.
Findings
The Licensing Program Analyst inspected the facility's main entrance door, lock, trimmed shrubs, bushes, and exterior lighting. Discussions were held regarding self-defense services and grief management for staff. No citations were issued based on the inspection, observations, interviews, and document reviews.
Complaint Details
The visit was triggered by a case management incident investigation; no citations or deficiencies were found.
Report Facts
Capacity: 104
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marife Duewel | Administrator | Met with Licensing Program Analyst during the inspection and discussed facility safety and staff services |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced case management incident investigation visit |
Inspection Report
Annual Inspection
Census: 79
Capacity: 104
Deficiencies: 0
Nov 18, 2022
Visit Reason
Licensing Program Analyst Steve Chang conducted an unannounced Annual Inspection visit to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be in compliance with no citations noted. Observations included proper infection control measures, secured medication storage, sufficient food and PPE supplies, and functional safety equipment.
Report Facts
Fire extinguisher service date: Dec 22, 2021
Room temperature: 72
Hot water temperature: 110
Food supply duration - perishable: 2
Food supply duration - nonperishable: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steve Chang | Licensing Program Analyst | Conducted the unannounced Annual Inspection visit |
| Marife Duewel | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 85
Capacity: 104
Deficiencies: 0
Oct 29, 2021
Visit Reason
An unannounced annual inspection visit was conducted to evaluate the facility's compliance with licensing requirements and infection control measures.
Findings
The inspection found the facility generally compliant with no deficiencies or allegations issued. Observations included proper infection control practices, sufficient PPE and food supplies, and functional safety equipment.
Report Facts
Room temperature: 73
Hot water temperature: 117
Capacity: 104
Census: 85
Perishable food supplies: 2
Nonperishable food supplies: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Merife Duewel | Administrator | Met with Licensing Program Analyst during inspection |
| Steve Chang | Licensing Program Analyst | Conducted the annual inspection visit |
| Romeo Manzano | Licensing Program Manager | Named in report header and footer |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 104
Deficiencies: 0
Oct 29, 2021
Visit Reason
The inspection visit was conducted as a complaint investigation following allegations received on 08/12/2021 that a resident was physically abused by facility staff.
Findings
Based on interviews with staff, residents, and a family member, as well as review of records, the Department found the allegations to be unfounded. Staff and family reported the resident has fragile skin and unpredictable behavior that could explain bruises and skin tears. No citations were issued.
Complaint Details
The complaint alleged physical abuse and rough handling of a resident by staff. The investigation included interviews with 6 staff members, 3 residents, and the resident's family member. All staff denied abuse and explained the resident's skin condition and behavior. The family member did not believe staff intentionally harmed the resident. The allegations were determined to be unfounded.
Report Facts
Facility capacity: 104
Resident census: 85
Staff interviewed: 6
Residents interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chihhsien Chang | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Ma. Felicitas V. Duewel | Administrator | Facility Administrator present during exit interview |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 104
Deficiencies: 0
Jun 3, 2021
Visit Reason
The visit was conducted to obtain additional information on an incident report received on 06/02/2021 regarding an alleged abuse towards a resident (R1).
Findings
Based on interviews, observations, and record reviews, the Department found the incident of alleged elder abuse to be unsubstantiated due to lack of preponderance of evidence. No citation was issued.
Complaint Details
The investigation was triggered by an alleged abuse incident reported on 06/02/2021 involving resident R1. The allegation was denied by staff and found unsubstantiated after investigation.
Report Facts
Capacity: 104
Census: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marife Duewel | Administrator | Met during investigation and exit interview |
| Steve Chang | Licensing Program Analyst | Conducted investigation |
| Romeo Manzano | Licensing Program Manager | Conducted investigation |
Inspection Report
Census: 78
Capacity: 104
Deficiencies: 0
May 27, 2021
Visit Reason
Licensing Program Analyst arrived unannounced to conduct a Case Management Visit regarding COVID-19 Prevention Measures.
Findings
The facility has been conducting staff surveillance testing twice per week and testing 25% of residents weekly since December 2020, with no positive COVID-19 cases reported. No citations were issued per California Code of Regulations Title 22.
Report Facts
Residents in Memory Care: 22
Staff testing frequency: 2
Resident testing percentage: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marife Duewel | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 104
Deficiencies: 0
Apr 7, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-10-23 regarding multiple allegations against the facility.
Findings
The investigation found all allegations to be unfounded after interviews, record reviews, and observations. No deficiencies or citations were noted during the complaint investigation visit.
Complaint Details
The complaint included allegations of staff providing false information about a resident's health, presence of mold exacerbating resident health, residents having outdoor activities on poor air quality days, lack of special diet options on the menu, and foods not meeting recommended dietary allowances. The investigation found no evidence supporting these allegations.
Report Facts
Capacity: 104
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chihhsien Chang | Licensing Program Analyst | Conducted the complaint investigation and tele-visit |
| Marife Duewel | Administrator | Facility administrator interviewed during the investigation |
| Steve Chang | Licensing Program Analyst | Conducted complaint tele-visit to deliver investigation findings |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 104
Deficiencies: 0
Mar 30, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations received on 10/23/2020 regarding staff not assisting residents with feeding, staff not keeping residents safe from other residents, and staff unfamiliarity with the Emergency Disaster Plan.
Findings
The investigation found the allegations to be unsubstantiated based on observations, interviews, and records reviewed. Staff were found to be familiar with the Emergency Disaster Plan, residents were assisted with feeding though it may have appeared otherwise, and the facility had addressed aggressive resident behavior. No deficiencies or citations were noted during the investigation.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not assisting residents with feeding, staff not keeping residents safe from other residents, and staff unfamiliarity with the Emergency Disaster Plan. Interviews with staff and administration, as well as review of facility plans and records, did not substantiate these allegations.
Report Facts
Facility capacity: 104
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marife Duewel | Administrator | Interviewed regarding complaint allegations and facility operations |
| Chihhsien Chang | Licensing Program Analyst | Conducted the complaint investigation and tele-visit |
| Romeo Manzano | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 104
Deficiencies: 0
Mar 30, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of neglect/lack of care and supervision which resulted in the deaths of residents, received on 10/27/2020.
Findings
The investigation included interviews with residents, staff, and family members, review of residents' documents, and an unannounced facility visit. The Department found the allegation to be unsubstantiated with no deficiencies or citations noted during the investigation.
Complaint Details
The complaint alleged neglect/lack of care and supervision resulting in resident deaths. The investigation found the allegation unsubstantiated based on observations, records, and interviews.
Report Facts
Resident deaths related to COVID-19: 7
Total deceased residents: 12
Residents interviewed: 4
Staff interviewed: 7
Family members interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chihhsien Chang | Evaluator / Licensing Program Analyst | Conducted the complaint tele-visit and delivered investigation findings. |
| Romeo Manzano | Licensing Program Manager | Conducted the 10-day visit inspection/investigation and involved in the complaint investigation. |
| Marife Duewel | Administrator | Facility administrator met with during the investigation and exit interview. |
Inspection Report
Census: 77
Capacity: 104
Deficiencies: 2
Dec 17, 2020
Visit Reason
The inspection was a Case Management - Other type visit conducted as a technical assistance tele-inspection to review the facility's COVID-19 screening procedures and infection control practices.
Findings
The facility was found not to have an updated COVID-19 symptom screening questionnaire and failed to properly mark isolation rooms for COVID-19 positive residents, posing an immediate risk to resident health and safety. Recommendations and a deficiency citation were issued related to infection control and personal rights violations.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not protect the personal rights of residents due to failure to follow current screening guidelines for COVID-19 including asking complete symptom list, posing an immediate risk to health and safety. | Type A |
| Facility did not mark isolation rooms in a timely manner to protect residents and staff from entering COVID-19 positive rooms, posing an immediate risk to health and safety. | Type A |
Report Facts
Residents in Memory Care: 18
Residents in Assisted Living: 59
Deficiency count: 2
Plan of Correction due date: Dec 21, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marife Duewel | Administrator | Met with Licensing Program Analysts during inspection |
| Gladys Kuizon | Licensing Program Analyst | Conducted the inspection and signed the report |
| Steve Chang | Licensing Program Analyst | Conducted the inspection |
| Helen Shi | Program Clinical Consultant | Present during tele-inspection |
| Sarah Yip | Licensing Program Manager | Named as supervisor and manager on report |
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