Inspection Report Summary
Most inspections found no deficiencies, including the most recent report from April 28, 2025, which was a complaint investigation that found all allegations unsubstantiated. The facility had one substantiated complaint in March 2023 involving admission to the memory care unit without prior consent and required appraisal, resulting in two cited deficiencies, but no fines or enforcement actions were listed. Other complaint investigations, including those related to resident respect and medication management, were unsubstantiated. Annual inspections from 2021 through 2025 were consistently clean, with only minor advisory notes such as a failed fire inspection in mid-2024 that was scheduled for repair. This pattern suggests the facility has maintained or improved compliance over time, with isolated issues addressed promptly.
Deficiencies per Year
4
3
2
1
0
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Capacity: 334
Deficiencies: 0
Apr 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-03-10 regarding admission without consent to the memory care unit, interference with resident visitors and sleep, restriction of resident movement, and improper medication dispensing.
Findings
The investigation included resident file reviews, facility tours, and interviews. The allegations were found to be unsubstantiated due to insufficient evidence to prove or refute the claims. Residents were observed to move freely and take naps as desired, visitation restrictions were based on resident consent, and medication management was confirmed to be handled by the facility since 2023.
Complaint Details
The complaint involved multiple allegations including unauthorized admission to memory care, interference with visitors and sleep, restricted movement, and medication dispensing issues. The investigation found no preponderance of evidence to substantiate these allegations, resulting in an unsubstantiated determination.
Report Facts
Facility capacity: 334
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation report |
| Joel Goldfain | Met with Licensing Program Analyst during the investigation | |
| Deborah Infield | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 198
Capacity: 334
Deficiencies: 0
Apr 7, 2025
Visit Reason
An unannounced annual inspection was conducted, including an inspection for the expanded memory care unit.
Findings
The facility was observed to be in good repair with all required components for licensing. No deficiencies were cited during the inspection. Resident and staff files were complete, medications were properly documented and administered, and facility areas were clean and properly furnished.
Report Facts
Resident files reviewed: 8
Staff files reviewed: 8
Water temperature range: 114.8-116.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Vanegas | Licensing Program Analyst | Conducted the inspection and authored the report |
| Deborah Infield | Administrator | Facility administrator met during inspection and participated in exit interview |
Inspection Report
Annual Inspection
Census: 174
Capacity: 300
Deficiencies: 0
Jul 30, 2024
Visit Reason
The inspection was an unannounced Required 1-Year annual evaluation using the CARE Inspection Tool conducted by the Licensing Program Analyst.
Findings
The facility was found to be operating within license conditions and limitations, clean and sanitary, with no deficiencies cited. An Advisory Note was issued due to the facility not passing the quarterly fire inspection conducted on June 17, 2024, with follow-up repairs scheduled.
Report Facts
Fire inspection date: Jun 17, 2024
Fire extinguisher service date: Aug 15, 2023
Emergency evacuation drill date: Apr 9, 2024
Hot water temperature range: 107.6-116.6
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the inspection and met with the Administrator |
| Deborah Infield | Administrator | Facility Administrator met during inspection and named in report |
Inspection Report
Complaint Investigation
Census: 191
Capacity: 300
Deficiencies: 2
Mar 15, 2023
Visit Reason
An unannounced complaint investigation was conducted due to allegations that the facility did not complete a reappraisal prior to admission to the memory care unit and admitted residents without prior consent from the residents and/or their authorized representatives.
Findings
The investigation substantiated that the facility admitted Resident 1 to the memory care unit prior to completing the required pre-admission appraisal and prior to obtaining consent from the resident's conservator. Resident 1 was admitted six days before verbal and written consent was obtained. Resident 2 was admitted with proper consent. Deficiencies were cited per Title 22 regulations.
Complaint Details
The complaint investigation was substantiated. It was found that Resident 1 was admitted to the memory care unit prior to completion of the required pre-admission appraisal and prior to obtaining consent from the resident's conservator. Resident 2 was admitted with proper consent. The facility was cited for these deficiencies.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| 87457 Pre-Admission-General (c) Prior to admission a determination of the prospective resident’s suitability for admission including an appraisal of his/her individual service needs was not met as the reappraisal was completed after Resident 1 was admitted to the memory care unit. | Type B |
| 87457 Pre-Admission Appraisal-General (b) No person shall be admitted without his/her consent and agreement, or that of his/her responsible person, if any. Resident 1 was admitted six days prior to consent and verbal agreement by the POA. | Type B |
Report Facts
Capacity: 300
Census: 191
Deficiencies cited: 2
Plan of Correction Due Date: Mar 22, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Debbie Infield | Executive Director | Facility representative interviewed during investigation |
| Pamela Lowe | Health Services Director | Interviewed during investigation |
| Sheila Santos | Licensing Program Manager | Oversaw licensing program, named in report |
Inspection Report
Complaint Investigation
Census: 191
Capacity: 300
Deficiencies: 0
Feb 21, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff did not treat a resident with respect.
Findings
The investigation included interviews, record reviews, and a facility tour. Due to conflicting statements and lack of sufficient evidence, the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that facility staff did not treat a resident with respect. The investigation found conflicting statements between the resident and the Executive Director regarding the interaction, resulting in the allegation being unsubstantiated.
Report Facts
Facility capacity: 300
Resident census: 191
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Debbie Infield | Executive Director | Interviewed during the investigation and involved in the allegation |
Inspection Report
Complaint Investigation
Census: 182
Capacity: 300
Deficiencies: 0
Oct 10, 2022
Visit Reason
The visit was a Case Management - Incident to discuss a resident attempted suicide which occurred on 2022-10-09.
Findings
The Licensing Program Analyst toured the resident's apartment, interviewed staff and witnesses, and reviewed pertinent documentation including the resident's physician report and Admission Agreement. A follow-up visit will be conducted at a later date.
Complaint Details
The visit was triggered by a resident attempted suicide incident on 2022-10-09. No substantiation status is stated.
Report Facts
Licensed capacity: 138
Hospice waiver capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Tapia | Licensing Program Analyst | Conducted the Case Management - Incident visit |
| Nadine A. Roisman | Administrator | Participated in exit interview |
| Sheila Santos | Licensing Program Manager | Named in report header |
Inspection Report
Capacity: 300
Deficiencies: 0
Jun 8, 2022
Visit Reason
The visit was a Case Management - Incident visit conducted to discuss a missing 14 karat gold filigree band reported by a resident.
Findings
The investigation found no citations or deficiencies. The theft loss policy was followed, and a police report was filed. The resident did not complete the Client/Resident Personnel Property Report form.
Report Facts
Facility capacity: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Tapia | Licensing Program Analyst | Conducted the Case Management - Incident visit |
| Debbie Infield | Executive Director | Met with during exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 184
Capacity: 300
Deficiencies: 0
Jun 8, 2022
Visit Reason
Licensing Program Analyst Edward Tapia conducted an unannounced required annual inspection at the facility to evaluate compliance with licensing regulations.
Findings
No deficiencies were noted during the inspection and no citations were issued. Three advisories were issued related to minor observations such as missing hand washing signs in resident bathrooms and water temperature recommendations.
Report Facts
Capacity: 300
Census: 184
Non-ambulatory licensed capacity: 138
Hospice waiver capacity: 20
Food stock supply: 2
Food stock supply: 7
Inspection time: 232
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Tapia | Licensing Program Analyst | Conducted the inspection and made observations |
| Debbie Infield | Executive Director | Provided assistance during the inspection and participated in exit interview |
Inspection Report
Annual Inspection
Census: 193
Capacity: 300
Deficiencies: 0
Jun 21, 2021
Visit Reason
This unannounced inspection was conducted for the purpose of an Annual Inspection to evaluate the facility's compliance with regulations.
Findings
The inspection found no health and safety issues; the facility was clean, organized, and compliant with COVID-19 related policies and procedures. No deficiencies were cited during this inspection.
Report Facts
Staff present: 65
Supply duration: 2
Supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nadine A. Roisman | Administrator | Met with Licensing Program Analyst during inspection and discussed inspection purpose |
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and provided technical assistance |
| Marina Stanic | Licensing Program Manager | Named in report as Licensing Program Manager |
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