Inspection Report Summary
Most inspections found deficiencies, though several complaint investigations were unsubstantiated. The most recent report from February 20, 2025, was clean with no deficiencies, showing improvement since prior findings. Earlier issues included neglect leading to a resident’s stage 4 pressure ulcers, medication management problems, and lapses in resident supervision and timely medical care, some of which posed immediate health risks. Other deficiencies involved environmental cleanliness and incomplete medical assessments, but no fines or enforcement actions were listed in the available reports. The facility’s record shows a mix of substantiated and unsubstantiated complaints with recent progress toward compliance.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
81% occupied
Based on a February 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 67
Capacity: 83
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
An unannounced visit was conducted for the facility’s annual inspection to evaluate compliance with California Code of Regulations, Title 22.
Findings
The inspection found no deficiencies. The facility was clean, well-maintained, and compliant with safety regulations including fire extinguisher, smoke alarms, carbon monoxide detector, and disaster drills. Resident and staff files, hospice care plans, and emergency plans were reviewed and found satisfactory.
Report Facts
Residents on hospice: 6
Resident files reviewed: 7
Staff files reviewed: 7
Hospice care plans reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Perez | Executive Director | Met during inspection and exit interview |
| Sarah Hurt | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 83
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that a resident sustained stage 4 pressure ulcers due to neglect.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The resident sustained stage 4 pressure ulcers due to neglect.
Findings
The investigation substantiated the allegation that a resident developed stage 4 pressure ulcers due to neglect. Records showed the resident had redness and an open sore on 07/14/2024 and was admitted to the hospital with a stage 4 wound on 07/17/2024.
Deficiencies (1)
Failure to develop and implement a plan for incidental medical and dental care, including arranging appropriate medical care for residents, as evidenced by a resident's stage 4 wound.
Report Facts
Capacity: 83
Census: 68
Deficiencies cited: 1
Plan of Correction Due Date: Dec 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maria Perez | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Brenda Chan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 83
Deficiencies: 1
Date: Nov 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-04-26 regarding failure to seek timely medical attention, inadequate resident care, unlawful eviction, and medication administration issues.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Sarah Hurt. Allegations included failure to seek medical attention timely, inadequate resident care, unlawful eviction, and failure to ensure medication administration. Only the medication administration allegation was substantiated; others were unsubstantiated.
Findings
The investigation found one allegation substantiated: facility staff did not ensure that a resident was taking prescribed medications, citing a deficiency under Title 22 regulations. Other allegations including failure to seek timely medical attention, inadequate care, and unlawful eviction were unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
Facility failed to assist residents with self-administered medications as needed, posing a potential health, safety, or personal rights risk due to medications found unsecured in resident's bedroom.
Report Facts
Capacity: 83
Census: 73
Deficiencies cited: 1
Plan of Correction Due Date: Dec 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Carter | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 83
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
Unannounced visit/investigation of a complaint alleging that staff did not follow a resident's physician's order regarding medications.
Complaint Details
The complaint was found to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis. The complaint was dismissed after investigation.
Findings
The investigation found that the medication in question was given per the physician's orders and that the complaint was unfounded. No deficiencies were cited.
Report Facts
Capacity: 83
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Carter | Administrator | Facility administrator met during the investigation |
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 83
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-29 alleging that a resident sustained an unexplained injury in care.
Complaint Details
The complaint alleged that a resident sustained an unexplained injury in care. The allegation was unsubstantiated after investigation.
Findings
The investigation found that Resident 1 did sustain an unexplained injury on 2023-08-14 and the facility sought timely medical care. However, there was no preponderance of evidence to prove the alleged violation occurred, and the allegation was unsubstantiated. No deficiencies were cited.
Report Facts
Complaint Control Number: 24
Capacity: 83
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Carter | Administrator | Met with Licensing Program Analysts during the investigation and named in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 83
Deficiencies: 0
Date: Jan 12, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations received on 07/27/2023 regarding resident safety and care during electrical outages and safeguarding of personal belongings.
Complaint Details
The complaint included allegations that staff did not ensure a safe environment during electrical outages, left a resident on the floor for an extended period, did not respond to resident pendents, and failed to safeguard residents' personal belongings. Each allegation was investigated and found unsubstantiated. An additional allegation regarding inadequate oxygen supply was found unfounded.
Findings
All allegations were investigated and found to be unsubstantiated or unfounded due to lack of preponderance of evidence. No deficiencies were cited per Title 22 Regulations.
Report Facts
Capacity: 83
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Maria Perez | Business Office Director | Met with Licensing Program Analyst during investigation and exit interview |
| Joy Carter | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 73
Capacity: 83
Deficiencies: 4
Date: Dec 5, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted by Licensing Program Analysts to evaluate compliance with regulatory requirements.
Findings
The facility was generally clean and in good repair with adequate food supply and safety equipment operational. However, deficiencies were noted including black discoloration on the kitchen ice machine, soda machine needing cleaning, incomplete first aid kits, and four memory care residents lacking current updated medical assessments.
Deficiencies (4)
Kitchen ice machine has black discoloration on the top inside.
Facility soda machine inside the kitchen needs cleaning.
First aid kits located throughout the facility are not all complete.
Four memory care residents did not have current updated medical assessments as required.
Report Facts
Residents on hospice: 11
Plan of Correction Due Date: Dec 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Perez | Office Manager | Met with Licensing Program Analysts during inspection and exit interview |
| Joy Carter | Administrator | Administrator's certification expiration noted; responsible for plan of correction |
| Sarah Hurt | Licensing Program Analyst | Conducted inspection and signed report |
| Lisa Salazar | Licensing Program Analyst | Conducted inspection |
| Brenda Chan | Licensing Program Manager | Supervisor of licensing evaluation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 83
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not provide proper notification of a rate increase.
Complaint Details
The complaint alleged improper notification of rate increase. The complaint was investigated and found to be unfounded based on interviews and record review.
Findings
The investigation found that the facility initially sent letters with incorrect rate increase amounts and effective dates, but corrected these errors with subsequent letters. No resident paid any increased amount before the corrected notification. The complaint was found to be unfounded and dismissed.
Report Facts
Capacity: 83
Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Carter | Administrator | Met during the investigation and named in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 83
Deficiencies: 0
Date: Oct 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-06-13 regarding lack of planned activities, failure of staff and kitchen staff to perform hand hygiene, and failure of staff to bathe residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of planned activities, staff not performing hand hygiene, and staff not bathing residents. Evidence did not support these allegations.
Findings
All allegations were found to be unsubstantiated based on observations, interviews, and documentation reviewed. The facility had planned activities, staff training on hand hygiene was documented, and residents were being bathed as per logs and staff interviews. No deficiencies were cited per Title 22 regulations.
Report Facts
Capacity: 83
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Carter | Executive Director | Met with Licensing Program Analyst during inspection and named in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 83
Deficiencies: 2
Date: Oct 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 04/13/2023 regarding failure to seek timely medical attention, resident elopement due to lack of supervision, inadequate food supply, failure to assess residents prior to admission, call button accessibility, staff response to call buttons, and food service provision.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not seek timely medical attention for Resident 1 and that Resident 2 went AWOL due to lack of supervision. Other allegations were found to be unsubstantiated or unfounded.
Findings
Two allegations were substantiated: failure to seek timely medical attention for Resident 1 and lack of supervision leading to Resident 2 eloping from the facility. Other allegations including inadequate food supply, failure to assess residents prior to admission, call button accessibility, staff response to call buttons, and food service provision were found to be unsubstantiated or unfounded based on interviews and record reviews.
Deficiencies (2)
Resident 1 had a documented ongoing cough for several days without medical treatment, posing an immediate health, safety, or personal rights risk to residents in care.
Facility did not provide Care and Supervision for Resident 2 as he left the facility on 04/17/2022 which poses an immediate health, safety, or personal rights risk to residents in care.
Report Facts
Capacity: 83
Census: 76
Deficiencies cited: 2
Plan of Correction Due Dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Carter | Administrator | Named in findings related to medical care and supervision deficiencies |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brenda Chan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 77
Capacity: 83
Deficiencies: 1
Date: Sep 5, 2023
Visit Reason
Licensing Program Analyst Sarah Hurt conducted an unannounced facility visit to conduct a Case Management visit and met with the facility Administrator Joy Carter to explain the purpose of the visit.
Findings
A deficiency was cited for a violation of Title 22 regulations regarding the personal rights of residents. Specifically, Resident 1 was observed fully exposed to other residents in a common area, posing a potential health, safety, or personal rights risk.
Deficiencies (1)
Resident 1 was fully exposed to residents in common area which poses a potential health, safety, or personal rights risk to residents in care.
Report Facts
Plan of Correction Due Date: Sep 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Carter | Administrator | Met with Licensing Program Analyst during the visit and named in findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced facility visit and cited deficiencies |
| Brenda Chan | Licensing Program Manager | Supervisor named in report |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 83
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2023-01-11 regarding staff not enforcing public health guidelines.
Complaint Details
The complaint alleged staff were not enforcing public health guidelines. The allegation was substantiated based on interviews and records showing failure to notify visitors of a COVID outbreak.
Findings
The investigation substantiated that the facility did not enforce public health guidelines properly, specifically failing to notify visitors of a COVID-19 outbreak on December 20, 2022, despite having visitor logs. The facility reported COVID positive residents to responsible parties but did not notify visitors.
Deficiencies (1)
Failure to report the COVID outbreak on December 20, 2022 to State Licensing or facility visitors within required timeframes, posing a potential health, safety, or personal rights risk to residents.
Report Facts
Capacity: 83
Census: 68
Plan of Correction Due Date: Feb 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Carter | Administrator | Named in relation to the complaint investigation and findings |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Oversaw the complaint investigation |
| Caitia Fajardo | Resident Care Director | Interviewed during investigation regarding notification procedures |
Inspection Report
Original Licensing
Census: 63
Capacity: 83
Deficiencies: 0
Date: Apr 9, 2022
Visit Reason
The visit was an unannounced Post Licensing inspection conducted to evaluate compliance with licensing requirements following the facility's initial licensing.
Findings
The inspection found no deficiencies. The facility met all regulatory requirements including safety measures, medication storage, food supplies, and first aid kit contents.
Report Facts
Residents receiving hospice care: 9
Rooms toured: 11
Evacuation chairs: 3
Temperature inside facility: 74
Hot water temperature: 107.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Carter | Administrator | Administrator present during the inspection and named in the report |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection visit |
| Henrietta Acevedo | LVN Health & Wellness Director | Met with Licensing Program Analyst and assisted with the visit |
| Sandra Ealy | Sales & Marketing Director | Met with Licensing Program Analyst and assisted with the visit |
Inspection Report
Original Licensing
Census: 59
Capacity: 83
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
An unannounced pre-licensing inspection was conducted for a change of ownership at the facility.
Findings
The facility was observed to be in good repair with appropriate safety measures, clean and furnished resident rooms, and proper food storage. No issues were noted, and the facility was deemed ready to be licensed pending final approval by the Central Applications Bureau.
Report Facts
Fire clearance capacity: 61
Fire clearance capacity: 22
Water temperature range: 107.4
Water temperature range: 114.3
Refrigerator temperature: 32
Freezer temperature: 0
Kitchen water temperature: 105.4
Number of resident files reviewed: 5
Number of staff files reviewed: 5
Administrator experience: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joy Carter | Administrator | Met with Licensing Program Analyst during inspection and noted as facility administrator |
| Anna Bui | Licensing Program Analyst | Conducted the unannounced pre-licensing inspection |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on report |
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