Inspection Report Summary
Most inspections found no deficiencies, including the most recent reports from July 11, 2025, which were both complaint investigations with no substantiated violations. Earlier investigations identified several deficiencies related mainly to resident safety, personal rights, infection control, and communication issues. Notable findings included staff handling a resident roughly causing bruises, falsification of COVID-19 test documents, failure to follow COVID-19 guidance, mold in the facility, and delays in incident reporting and record updates. While some complaints were substantiated, many others were unsubstantiated, and the facility has taken corrective actions such as staff termination and training. The pattern shows improvement over time, with the latest inspections free of deficiencies after addressing prior issues.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 63
Capacity: 85
Deficiencies: 0
Jul 11, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 06/23/2022 alleging multiple concerns including unexplained bruising, unmet care needs, inadequate hygiene supplies, lack of medical care, unclean resident room, and failure to safeguard resident's personal information.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The resident had unexplained bruising but records showed no complaints or physical issues related to the bruises. Care needs and hygiene supplies were addressed according to records and staff interviews. Medical care was provided including podiatrist visits. Room cleanliness was on a rotating schedule and personal information disclosure was unsubstantiated due to lack of corroborating evidence.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included unexplained bruising, unmet care needs, inadequate hygiene supplies, failure to ensure medical care, unclean resident room, and failure to safeguard resident's personal information. Interviews, record reviews, and facility tours did not confirm violations.
Report Facts
Capacity: 85
Census: 63
Complaint received date: Jun 23, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Nora Garza | Administrator | Facility administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 85
Deficiencies: 0
Jul 11, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of physical abuse to a resident by staff.
Findings
The investigation included a facility visit, records review, and interviews. The evidence did not meet the preponderance of the evidence standard to prove physical abuse by staff, and the allegations were deemed unsubstantiated.
Complaint Details
Complaint alleged physical abuse to Resident #1 by Staff #1 resulting in injuries. Investigation found that Resident #1 was agitated and sustained bruises and skin tears possibly related to an incident involving Staff #1, but it was unknown if the injuries were caused by staff. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 8
Facility Capacity: 85
Census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
| Nara Garza | Administrator | Facility Administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 85
Deficiencies: 1
Jun 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-02-15 alleging that facility staff handled a resident roughly resulting in bruises and that the licensee did not follow the resident's plan of care.
Findings
The investigation substantiated that staff member S1 handled Resident #1 roughly, causing bruising and skin tears, and that the licensee failed to report the incident to the licensing agency. A deficiency was cited for failure to protect residents from physical abuse. A plan of correction was developed including termination of S1 and staff training. Another allegation that the licensee did not follow the resident's plan of care was found to be unsubstantiated based on records and interviews showing that more care was provided than outlined in the care plan.
Complaint Details
The complaint alleged that facility staff handled Resident #1 roughly resulting in bruises due to an altercation between Resident #1 and Staff #1. The allegation was substantiated. Another complaint alleged the licensee did not follow the resident's plan of care regarding standby assistance for showering; this was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff handled resident roughly resulting in bruises, violating Additional Personal Rights of Residents to be free from physical abuse. | Type A |
Report Facts
Capacity: 85
Census: 63
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Nora Garza | Administrator | Facility administrator met during investigation and exit interview |
| Jose Collado Jr | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 85
Deficiencies: 3
Jun 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2022-02-10 alleging that the licensee staff did not follow COVID-19 guidance, the facility was in disrepair, staff spoke inappropriately to residents, staff did not meet resident's needs including incontinence needs, and staff retaliated against a resident.
Findings
The investigation substantiated allegations that the licensee staff failed to follow COVID-19 guidance, the facility was in disrepair with mold issues in room #106, and staff spoke inappropriately to a resident. The allegation that staff retaliated against a resident and did not meet resident's needs was unsubstantiated. Three Type B deficiencies were cited related to buildings and grounds, personal rights, and infection control.
Complaint Details
The complaint investigation was substantiated for allegations that licensee staff did not follow COVID-19 guidance, the facility was in disrepair, and staff spoke inappropriately to residents. The allegations that staff did not meet resident's needs, including incontinence needs, and that staff retaliated against a resident were unsubstantiated.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility was not clean, safe, sanitary, and in good repair; mold was present in room #106 posing a health and safety risk. | Type B |
| Staff used intimidating language towards a resident, violating personal rights. | Type B |
| Licensee did not ensure staff followed COVID-19 infection control guidance. | Type B |
Report Facts
Deficiencies cited: 3
Capacity: 85
Census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Jose Collado Jr | Administrator | Facility Administrator at the time of inspection. |
| Nora Garza | Administrator | Met with Licensing Program Analyst during the inspection and received the report. |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 85
Deficiencies: 1
Jun 5, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following multiple allegations received in February 2022 regarding medication assistance, billing discrepancies, transportation, housekeeping, dining services, and communication responsiveness at Villa Lorena facility.
Findings
The investigation substantiated that the licensee failed to respond promptly and appropriately to residents' communication requests, resulting in one cited deficiency. Other allegations including medication assistance, billing for unprovided items, transportation, housekeeping, and dining services were found unsubstantiated based on interviews, records review, and observations.
Complaint Details
The complaint investigation was triggered by allegations that the licensee did not assist a resident with medication administration, charged residents for items never provided, failed to provide itemized statements, did not meet transportation, housekeeping, and dining needs, and did not respond to residents' communication requests. The communication allegation was substantiated; others were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have communications to the licensee from residents' representatives answered promptly and appropriately, violating CCR 87468.1(a)(9). | Type B |
Report Facts
Capacity: 85
Census: 63
Deficiencies cited: 1
Plan of Correction due date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation |
| Nora Garza | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 85
Deficiencies: 3
Jun 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility did not provide records to a resident's responsible party, did not notify the responsible party of an incident, and did not update the resident's records.
Findings
The investigation substantiated the allegations, finding that the licensee staff failed to provide prompt access to records, did not notify the resident's responsible party of an incident within seven days, and did not update the resident's records to reflect the incident. Three deficiencies were cited related to these failures.
Complaint Details
The complaint was substantiated. The allegations included failure to provide records to the resident's responsible party, failure to notify the responsible party of an incident, and failure to update the resident's records. Evidence included record reviews, interviews, and written correspondence. The facility was cited for three deficiencies and developed a plan of correction.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Licensee did not provide prompt access to review records in 1 of 63 persons in care, posing a potential Personal Rights risk. | Type B |
| Licensee did not submit a written incident report to the licensing agency and the person responsible within seven days of the occurrence. | Type B |
| Licensee did not update resident records to include continuing record of illness, injury, or medical care impacting the resident's ability to function in 1 of 63 persons in care. | Type B |
Report Facts
Deficiencies cited: 3
Resident census: 63
Total capacity: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Nora Garza | Administrator | Facility administrator met during the investigation and exit interview. |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 85
Deficiencies: 1
Jun 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-03-18 alleging staff falsified documents and failed to notify an authorized representative of a change of condition.
Findings
The investigation substantiated that staff falsified a COVID-19 RT-PCR test document for Resident #1, posing a potential personal rights risk. The allegation that staff did not notify the authorized representative of Resident #1's change of condition was found to be unsubstantiated due to lack of documentation and contradictory evidence.
Complaint Details
The complaint investigation was substantiated for the allegation of staff falsifying documents related to COVID-19 test results for Resident #1. The allegation that staff did not notify the authorized representative of a change of condition was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the services provided by the facility. Based on interviews and record reviews, the licensee staff falsified documents for COVID-19 results for Resident #1, posing a potential personal rights risk to all residents in care. | Type B |
Report Facts
Capacity: 85
Census: 63
Deficiency Type B: 1
Plan of Correction Due Date: Jun 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nora Garza | Administrator | Facility administrator met with during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 85
Deficiencies: 0
Apr 24, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the licensee did not allow a resident to have visitors and did not safeguard the resident's belongings.
Findings
The investigation found no preponderance of evidence to prove the alleged violations occurred. The allegation that the licensee denied visitors to the resident was unsubstantiated, as was the allegation that the licensee failed to safeguard the resident's belongings.
Complaint Details
The complaint alleged that the licensee did not allow Resident #1 visitors and did not safeguard Resident #1's belongings. The investigation included interviews, record reviews, and observations. The allegations were found to be unsubstantiated.
Report Facts
Capacity: 85
Census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nora Garza | Administrator / Executive Director | Facility representative met during the investigation and exit interview |
| Denise Powell | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 63
Capacity: 85
Deficiencies: 0
Apr 24, 2025
Visit Reason
The inspection was an unannounced annual one-year inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be in compliance with all licensing requirements with no deficiencies cited. The environment was safe, sanitary, and well-maintained, with sufficient staff and proper care provided to residents.
Report Facts
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the inspection and authored the report |
| Nora Garza | Executive Director | Facility representative who accompanied the inspection and acknowledged receipt of the report |
Inspection Report
Annual Inspection
Capacity: 85
Deficiencies: 0
Mar 20, 2025
Visit Reason
Licensing Program Analyst Amy Rodgers conducted an unannounced visit to commence a Required Annual Inspection of the facility.
Findings
During the visit, the facility was toured, client records were reviewed, and staff and clients were interviewed. No deficiencies were cited during the visit, but a return visit is needed to complete the annual inspection due to time constraints.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the unannounced annual inspection visit. |
| Nora Garza | Administrator | Met with Licensing Program Analyst during the inspection and participated in the exit interview. |
| Maureen C. Manxon | Administrator/Director | Named as facility Administrator/Director in the report header. |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 85
Deficiencies: 0
Oct 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2024-10-07 regarding improper resident care placement, lack of supervision resulting in elopement, and failure to meet personal care needs.
Findings
The investigation found that residents with dementia were properly assessed and cared for, supervision and safety measures such as delayed egress alarms were in place and functioning, and personal care needs including bathing were met. The allegations were deemed unsubstantiated due to inconsistent statements and lack of corroborating evidence.
Complaint Details
The complaint involved allegations that the licensee did not ensure proper care placement for residents, lack of supervision led to resident elopement, and personal care needs were unmet resulting in residents smelling bad. The investigation included interviews, record reviews, and multiple facility visits. The allegations were found unsubstantiated.
Report Facts
Capacity: 85
Census: 65
Number of residents with dementia: 4
Number of facility tours: 4
Number of visits for bathing observation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and facility visits |
| Maureen Manzon | Resident Service Director | Facility representative met during the investigation and exit interview |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 85
Deficiencies: 0
Oct 24, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by multiple allegations received on 2024-08-20 concerning hot water availability, staffing sufficiency, doorway obstruction, alarm disrepair, administrator availability, staff training, supervision, and resident elopement at the facility.
Findings
The investigation found all allegations unsubstantiated after facility tours, staff interviews, record reviews, and observations. Showers delivered compliant hot water, staffing levels were adequate, no obstructions were found, alarms were operational, staff training was documented, administrator availability was sufficient, and the facility followed proper elopement procedures.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of hot water in showers, insufficient staffing, doorway obstruction, alarm disrepair, inadequate administrator presence, insufficient staff training, lack of supervision causing resident elopement. Investigation revealed no evidence to support these claims.
Report Facts
Facility capacity: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maureen Manzon | Resident Service Director | Met with Licensing Program Analyst during the investigation and received report |
| Jose Collado Jr | Administrator | Facility Administrator mentioned in allegations regarding availability |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 85
Deficiencies: 0
Oct 1, 2024
Visit Reason
The visit was conducted in response to an Incident Report received on 2024-09-27 regarding a staff member who left the property and did not return.
Findings
The investigation included gathering evidence and interviews with staff and the licensee. No deficiencies were cited or observed during the visit.
Complaint Details
The complaint involved Staff #1 leaving the property and not returning. The staff member no longer works at the facility. The complaint was investigated and no deficiencies were found.
Report Facts
Capacity: 85
Census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Maureen Manzon | Resident Service Director | Met with Licensing Program Analyst during the visit |
| Lorraine Black | Licensee | Licensee involved in the investigation and received the report |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 85
Deficiencies: 0
Aug 28, 2024
Visit Reason
The visit was conducted as an unannounced Case Management - Incident inspection in response to a self-submitted LIC624 Incident Report regarding a resident who went AWOL from the facility on 2024-08-18.
Findings
The facility staff provided needed supervision leading up to the AWOL incident and followed the written Absentee Notification Plan. The resident was found safe and unharmed at the time of the visit. No deficiencies were cited or observed during the inspection.
Complaint Details
The complaint involved Resident #1 going AWOL on 2024-08-18. The incident was substantiated as staff followed the facility's Absentee Notification Plan and no deficiencies were found.
Report Facts
Facility capacity: 85
Resident census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joey Collado Jr. | Executive Director | Met with Licensing Program Analyst during the visit and involved in exit interview |
| Amy Rodgers | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Marie Lou Fikingas | Memory Care Director | Discussed the purpose of the visit with Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 85
Deficiencies: 2
Mar 26, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations including staff tampering with a resident's personal belongings, failure to provide safe equipment to a resident, and withholding of a resident's medical records.
Findings
The investigation substantiated that staff covered a resident's laptop camera without proper consent, violating personal rights, and that the resident's wander guard safety equipment was inoperable for approximately three days, posing a safety risk. The allegation that the facility withheld the resident's medical records was found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that staff tampered with a resident's personal belongings by covering the resident's laptop camera without proper consent and that the resident was not provided with safe equipment due to an inoperable wander guard bracelet. The allegation that the facility withheld the resident's medical records was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not accord dignity to 1 out of 71 residents when they covered the resident's laptop camera, posing a potential safety and/or personal rights issue. | Type B |
| Licensee did not ensure resident's safety equipment was operable for 1 out of 71 residents due to the wander guard being inoperable for approximately three days, posing a potential safety and/or personal rights issue. | Type B |
Report Facts
Resident count during inspection: 62
Total licensed capacity: 85
Days wander guard was inoperable: 3
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Collado Jr. | Executive Director | Named in findings related to covering resident's laptop camera and safety equipment issues. |
| Marie Lou Fikingas | Memory Care Director | Met during investigation and received report and licensee rights. |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation. |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Capacity: 85
Deficiencies: 0
Mar 26, 2024
Visit Reason
The investigation was conducted in response to a complaint alleging inadequate staffing to meet residents' needs and malodorous conditions in the memory care unit.
Findings
The investigation found sufficient staffing based on staff schedules, interviews, and resident feedback. The allegation of malodorous conditions was unsubstantiated as the memory care unit was clean and odor free, with occasional odors in the common area due to resident incontinence promptly addressed by staff.
Complaint Details
The complaint was unsubstantiated after investigation revealed inconsistent statements and insufficient evidence to support the allegations of inadequate staffing and malodorous conditions.
Report Facts
Capacity: 85
Staff caregivers in memory care unit: 4
Staff med techs in memory care unit: 1
Staff activity directors in memory care unit: 1
Staff leads in memory care unit: 1
Staff check interval: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Collado Jr. | Executive Director | Interviewed regarding staffing adequacy |
| Marie Lou Fikingas | Memory Care Director | Interviewed regarding staffing and facility conditions |
| Natasha Persaud | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 85
Deficiencies: 0
Mar 12, 2024
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations including resident elopement, staff not following resident's care plan, and staff not noticing resident's change in condition.
Findings
The investigation found no evidence to support the allegations. Interviews and record reviews showed the resident did not elope, staff followed the care plan, and staff appropriately responded to the resident's illness. All allegations were determined to be unsubstantiated.
Complaint Details
The complaint included allegations that a resident eloped, staff did not follow the resident's care plan, and staff did not notice a resident's change in condition. The investigation concluded these allegations were unsubstantiated due to lack of supporting evidence.
Report Facts
Capacity: 85
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Collado | Executive Director | Met during investigation and exit interview |
| Amy Salvador | Resident Service Director | Met during investigation and exit interview |
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Denise Powell | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 61
Capacity: 85
Deficiencies: 1
Feb 20, 2024
Visit Reason
The inspection was an unannounced required one-year inspection conducted to evaluate compliance with licensing regulations for the Villa Lorena Facility.
Findings
No deficiencies were cited during the visit; however, a technical violation was issued. The facility was found to be generally compliant with regulations, including proper food storage, medication management, and resident care.
Deficiencies (1)
| Description |
|---|
| Technical violation issued related to delayed egress doors lacking appropriate signage. |
Report Facts
Capacity: 85
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Collado Jr. | Executive Director | Facility representative who granted entry and received the report |
| Amy Rodgers | Licensing Program Analyst | Conducted the inspection and authored the report |
| Denise Powell | Licensing Program Manager | Named in the report as overseeing licensing program |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 85
Deficiencies: 1
Nov 15, 2023
Visit Reason
The visit was conducted in response to two incident reports involving a resident, submitted by the licensee to the Community Care Licensing Division.
Findings
During the unannounced case management incident visit, the resident was found safe, pertinent records were reviewed, and staff interviewed. No deficiencies were cited, but one Technical Violation related to Reporting Requirements was issued.
Complaint Details
The visit was triggered by two incident reports involving Resident #1, which were self-submitted by the licensee. The resident was found safe and no substantiation of deficiencies was noted.
Deficiencies (1)
| Description |
|---|
| Technical Violation regarding Reporting Requirements |
Report Facts
Incident Reports: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joey Collado | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Amy Salvador | Resident Services Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Lizzette Tellez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 85
Deficiencies: 1
Jan 19, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not meet minimum qualifications, specifically regarding annual training hours.
Findings
The investigation substantiated that staff member S1 did not complete the required 20 hours of annual training for 2020 and 2021, posing a potential safety risk to all 67 residents in care. Staff files showed current background clearances and health screenings, but the training requirement was not met.
Complaint Details
The complaint alleged that staff did not meet minimum qualifications. The allegation was substantiated based on record review and interviews, confirming that staff member S1 lacked required annual training hours for 2020 and 2021.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff training requirements not met: S1 did not complete the 20 hours of annual training for 2020 and 2021 as required by CA Code of Regulations, Title 22, Section 1569.625(b)(2). | Type B |
Report Facts
Residents in care: 67
Total licensed capacity: 85
Deficiency count: 1
Plan of Correction due date: Feb 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Salvador | Resident Care Director | Interviewed during investigation and recipient of exit interview |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 65
Capacity: 85
Deficiencies: 0
Mar 21, 2022
Visit Reason
An unannounced required 1-year visit was conducted to evaluate the facility's compliance with licensing requirements, including infection control measures related to COVID-19.
Findings
The Licensing Program Analyst conducted a tour and review of the facility, observed clients in care, and evaluated the COVID-19 Mitigation Plan implementation. No deficiencies were cited or observed during this visit.
Report Facts
Capacity: 85
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Salvador | Resident Service Director | Met with Licensing Program Analyst during inspection |
| Joey Collado | Executive Director | Met with Licensing Program Analyst during inspection |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Monitoring
Census: 65
Capacity: 85
Deficiencies: 0
Mar 21, 2022
Visit Reason
Unannounced case management visit to follow up on incident reports at the facility.
Findings
No deficiencies were cited or observed during the visit. The Licensing Program Analyst observed clients in care and reviewed client records.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Salvador | Resident Services Director | Met during the visit and participated in the exit interview. |
| Joey Collado | Executive Director | Met during the visit and participated in the exit interview. |
| Rebecca A Ruiz | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 85
Deficiencies: 1
Sep 30, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility failed to address multiple falls resulting in minor injuries and lacked sufficient staffing to meet residents' needs.
Findings
The investigation substantiated that the facility failed to implement updated care plans or fall mitigation strategies for residents who experienced multiple falls resulting in minor injuries. However, the allegation that the facility lacked sufficient staffing was unsubstantiated based on staff interviews and records. Additionally, the facility failed to notify responsible parties of some incidents, which was also unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding failure to address multiple falls for residents R1 and R2 resulting in minor injuries. The allegations of insufficient staffing and failure to notify responsible parties of incidents were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The facility failed to implement a plan or identify staff objectives to mitigate falls for residents R1 and R2, posing a potential health and safety risk. | Type B |
Report Facts
Facility census: 72
Facility capacity: 85
Residents in memory care: 17
Staff on evening shifts: 3
Staff on evening shifts (increased): 4
Plan of Correction due date: Oct 25, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joey Collado | Administrator | Met during investigation and exit interview |
| Laarni Santiago | Licensing Program Analyst | Conducted the complaint investigation |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Beth Romeo | Resident Care Director | Interviewed during investigation |
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