Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations unsubstantiated. The facility’s most recent report from September 4, 2025, was clean with no deficiencies cited. Earlier reports included some substantiated complaints related to missed medications due to ordering and follow-up failures, and a serious incident in January 2025 where inadequate supervision led to a resident’s death, resulting in a $500 fine and pending additional penalties. Other issues involved food service violations and medication errors, but these were isolated and addressed with staff retraining and corrective actions. The trend shows improvement, as the latest annual inspection was free of deficiencies after previous findings.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
63% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 107
Capacity: 170
Deficiencies: 0
Date: Sep 4, 2025
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements.
Findings
The facility was inspected physically including resident units, common areas, and safety equipment. Record reviews of resident and staff files were conducted. No deficiencies were cited during this inspection.
Report Facts
Residents files reviewed: 5
Staff files reviewed: 5
Fire drill frequency: 4
Hot water temperature range: 108-118
Licensed capacity: 170
Current census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elena Cuevas | Administrator | Facility Administrator met during inspection and exit interview. |
| Arvin Villanueva | Licensing Program Analyst | Conducted the annual inspection visit. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 170
Deficiencies: 2
Date: Aug 5, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted due to allegations that facility staff did not ensure that a resident was administered their medication as prescribed and that staff did not respond to call bells in a timely manner.
Complaint Details
The complaint was substantiated regarding missed medication administration due to failure in ordering and follow-up. The complaint about untimely response to call bells was unsubstantiated after interviews and record review.
Findings
The investigation substantiated the allegation that a resident missed medication on 02/04/2025 due to failure in medication ordering and follow-up by staff. The allegation regarding untimely response to call bells was unsubstantiated based on staff and resident interviews and call log review.
Deficiencies (2)
The licensee did not assist residents with self-administered medications as needed, resulting in a missed medication for resident R1.
The licensee did not obtain medication as prescribed resulting in a missed dosage, posing potential health, safety, and personal rights risks.
Report Facts
Census: 108
Total Capacity: 170
Call bell response time: 9
Call bell response time: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Elena Cuevas | Facility Designated Administrator | Met with Licensing Program Analyst during investigation and interview |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 170
Deficiencies: 0
Date: Jul 28, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not properly safeguard the outdoor patio area of the facility for residents.
Complaint Details
The complaint alleged that facility staff failed to properly safeguard the outdoor patio areas for residents. After observations, interviews, and tours, the allegations were found to be unsubstantiated.
Findings
The investigation found that the patio furniture was in good repair and sturdy, and interviews with residents and family members did not support the allegation. The department found the allegations to be unsubstantiated with no deficiencies observed or cited.
Report Facts
Capacity: 170
Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elena Cuevas | Facility Designated Administrator | Met with Licensing Program Analysts during the complaint investigation |
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Arvin Villanueva | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 170
Deficiencies: 0
Date: Jul 28, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-05-29 regarding staff assistance to residents to prevent falls and the condition of a resident bathroom door.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not assisting residents timely to prevent falls and a bathroom door in disrepair. Interviews and observations did not support these claims.
Findings
The investigation found insufficient evidence to substantiate the allegations that staff did not assist residents in a timely manner to prevent falls and that the resident bathroom door was in disrepair. No deficiencies were observed or cited.
Report Facts
Capacity: 170
Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elena Cuevas | Facility Designated Administrator | Met with Licensing Program Analysts during the complaint investigation |
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Rios | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Arvin Villanueva | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 170
Deficiencies: 0
Date: Jul 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff did not ensure reporting requirements were met for a resident in care.
Complaint Details
The complaint alleged that staff failed to meet reporting requirements for a resident. The investigation found no evidence of a fall or injury requiring notification to the Department. The allegation was unsubstantiated.
Findings
The investigation included interviews and record reviews and found insufficient evidence to support the allegation. There was no fall or injury requiring reporting, and the allegation was unsubstantiated. No deficiencies were cited.
Report Facts
Capacity: 170
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elena Cuevas | Executive Director/Administrator | Interviewed regarding the incident involving resident R1 |
| Arvin Villanueva | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 170
Deficiencies: 0
Date: Jul 28, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-05-15 alleging that a resident was injured by a motorized cart while in care.
Complaint Details
The complaint allegation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
The investigation found that the resident denied being injured by the motorized cart, and there was insufficient evidence to substantiate the allegation. No deficiencies were observed or cited during the visit.
Report Facts
Complaint Control Number: 27
Capacity: 170
Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elena Cuevas | Facility Designated Administrator | Met during the investigation and interviewed regarding the complaint |
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation |
| Arvin Villanueva | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 170
Deficiencies: 0
Date: Jul 28, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-02-27 alleging that staff did not safeguard a resident's personal property.
Complaint Details
The complaint allegation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
The investigation found insufficient evidence to substantiate the allegation that facility staff did not safeguard the resident's personal property. No deficiencies were observed or cited during the visit.
Report Facts
Complaint Control Number: 27-AS-20250227142527
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation |
| Elena Cuevas | Facility Designated Administrator | Met with investigators during the complaint visit |
| Lisa Rios | Licensing Program Manager | Named in report as Licensing Program Manager |
| Arvin Villanueva | Licensing Program Analyst | Assisted in conducting the complaint visit |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 170
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not ensure that a resident's grooming needs were met.
Complaint Details
The complaint alleged that staff did not ensure that resident R1's grooming needs, specifically toenail management, were met. The allegation was unsubstantiated based on interviews and record reviews.
Findings
The investigation found that the resident was independent in grooming and self-care prior to hospice care and had opted out of podiatry services. Facility staff are not permitted to clip toenails, but arranged grooming services for the resident after hospice enrollment. The allegation was unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 170
Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elana Cuevas | Executive Director/Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Arvin Villanueva | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 170
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff do not keep the facility clean and sanitary.
Complaint Details
The complaint was unsubstantiated based on the investigation findings and evidence provided.
Findings
The investigation found no unsanitary conditions or foul odors during the visit, and video evidence showed housekeeping promptly addressing the reported stain. Therefore, the allegation was unsubstantiated.
Report Facts
Capacity: 170
Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the complaint investigation |
| Elena Cuevas | Administrator | Met with Licensing Program Analyst and provided information during the investigation |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 170
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
An unannounced complaint investigation was conducted based on allegations received on 2025-06-13 regarding elevator operation, fire safety requirements, and response to the residents council.
Complaint Details
The complaint investigation was unsubstantiated, meaning the allegations may have happened or are valid, but there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found the allegations unsubstantiated after reviewing elevator maintenance documents, permits, and resident council communications, concluding there was insufficient evidence to prove the violations occurred.
Report Facts
Capacity: 170
Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the complaint investigation |
| Elena Cuevas | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 170
Deficiencies: 2
Date: Mar 13, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff were not providing basic food services to a resident and that the facility was overcharging a resident.
Complaint Details
The complaint was substantiated. Allegations included failure to provide basic food services and overcharging a resident. The resident was charged for additional meals despite being in Assisted Living where meals should be included. The administrator refused to sign the report and plans to appeal the citations.
Findings
The investigation substantiated that the facility staff were not providing basic food services as required, specifically charging a resident for a third meal despite the resident living in the Assisted Living program where three meals should be included. The facility was also found to be overcharging the resident by charging for additional meals beyond the core service fee, contrary to regulations.
Deficiencies (2)
Basic services shall at a minimum include three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity, as specified in Section 87555, General Food Service Requirements.
General Food Service Requirements: Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day.
Report Facts
Census: 109
Total Capacity: 170
Additional meal charge: 12
Additional meals charge: 72
Rent: 3200
Care services charge: 280
Plan of Correction Due Date: Mar 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arvin Villanueva | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Elana Cuevas | Administrator | Facility administrator interviewed during investigation and named in findings |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 170
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that facility staff were not awake when residents required overnight assistance.
Complaint Details
The allegation that facility staff are not awake or unavailable during overnight hours was deemed unsubstantiated based on interviews, record reviews, and staffing schedules.
Findings
The investigation, including interviews and record reviews, found no evidence to substantiate the allegation. Staff perform random night checks, call light response times average 7 to 9 minutes, and adequate staffing is maintained during overnight shifts.
Report Facts
Call light response time (minutes): 7
Call light response time (minutes): 9
Census: 107
Total capacity: 170
Call light response time (minutes): 8.5
Staff scheduled per night shift: 2
Staff scheduled per night shift: 2
Med tech scheduled per night shift: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elena Cuevas | Executive Director/Administrator | Met with Licensing Program Analyst and provided information on staffing and call light response times |
| Arvin Villanueva | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 170
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following an allegation that residents missed medications.
Complaint Details
The complaint alleged that residents missed medications. The allegation was found to be unfounded, meaning it was false or without reasonable basis, and the complaint was dismissed.
Findings
The investigation found no evidence that residents missed medications. Based on interviews, documentation, and review of records, the allegation was determined to be unfounded and no deficiencies were cited.
Report Facts
Estimated Days of Completion: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Elana Cuevas | Executive Director | Met with Licensing Program Analyst during investigation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 170
Deficiencies: 1
Date: Jan 16, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that lack of care and supervision resulted in a resident's death.
Complaint Details
The complaint was substantiated. The allegation was that lack of care and supervision resulted in resident death. The investigation included interviews, record reviews, and video footage analysis. The facility had a COVID outbreak impacting supervision. Staffing shortages and communication failures were noted. Immediate civil penalty of $500 was issued with additional penalties pending.
Findings
The investigation substantiated that the facility failed to provide adequate care and supervision to resident R1, who was left unattended outside in direct sunlight and extreme heat, resulting in heat stroke, severe injuries, and death. Contributing factors included staffing shortages, procedural failures such as lack of shift crossover, and delayed resident checks.
Deficiencies (1)
Failure to ensure staff provided care and supervision to R1, who was left unattended outside with direct exposure to sun and heat, sustaining heat-related injuries and heat stroke resulting in death.
Report Facts
Civil penalty: 500
Resident core temperature: 105.3
Resident burns percentage: 23
Resident burns percentage: 25
Outdoor temperature: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elana Cuevas | Administrator/Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Arvin Villanueva | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 170
Deficiencies: 1
Date: Dec 3, 2024
Visit Reason
The visit was an unannounced case management inspection conducted due to a self-reported incident on 2024-11-22 where Memory Care residents did not receive their scheduled morning medications due to staffing shortages.
Complaint Details
The visit was complaint-related due to a self-reported incident where Memory Care residents missed morning medications. The facility promptly notified residents' responsible parties, hospices, and physicians, monitored residents for 48 hours with no adverse effects observed, and implemented corrective actions.
Findings
The facility failed to ensure that Memory Care residents received their prescribed morning medications because of the absence of qualified medication technicians. The facility took corrective actions including notifying responsible parties, monitoring residents, providing staff training, hiring additional staff, and implementing a staffing plan to prevent recurrence.
Deficiencies (1)
The facility did not ensure enough qualified staff to assist with residents' medication as scheduled, posing an immediate threat to residents' health, safety, and personal rights.
Report Facts
Census: 122
Total Capacity: 170
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elana Cuevas | Administrator | Met during inspection and involved in incident response |
| Arvin Villanueva | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 105
Capacity: 170
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
The visit was an unannounced required annual inspection conducted to ensure compliance with Title 22 regulations and assess the facility's physical plan, resident care, and safety measures.
Findings
The facility was generally found to be in compliance with regulations regarding cleanliness, safety, medication storage, and emergency preparedness. However, a deficiency was cited for housing 2 residents who became bedridden in units not fire cleared for bedridden residents, posing an immediate health and safety risk.
Deficiencies (1)
Two residents became bedridden and were living in units not fire cleared for bedridden residents, posing an immediate health, safety, or personal rights risk.
Report Facts
Residents in care not fire cleared for bedridden status: 2
Resident files reviewed: 6
Staff files reviewed: 6
Hospice residents approval: 25
Bedridden residents fire clearance: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elana Cuevas | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Arvin Villanueva | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Stephen Richardson | Licensing Program Manager | Supervised the inspection. |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 170
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
The inspection was an unannounced case management incident inspection triggered by an incident report received on 2024-07-02 regarding a medication error involving resident R1.
Complaint Details
The visit was complaint-related, triggered by an incident report of a medication error. The incident was substantiated as the medication error was confirmed. The staff member responsible was retrained and removed from medication duties.
Findings
The investigation confirmed that resident R1 was mistakenly given eye drops intended for another resident by staff member S1. The incident was reported timely, no adverse effects were noted, and S1 was removed from medication duties and retrained. A deficiency was cited for failure to comply with medical care regulations.
Deficiencies (1)
Licensee did not comply with medical care regulations as staff member S1 administered eye drops prescribed for another resident to R1, posing potential health and safety risks.
Report Facts
Plan of Correction (POC) Due Date: Sep 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elana Cuevas | Executive Director | Met with Licensing Program Analyst during inspection and involved in interview regarding medication error |
| Arvin Villanueva | Licensing Program Analyst | Conducted the case management incident inspection |
| Stephen Richardson | Licensing Program Manager | Named as supervisor and licensing program manager in the report |
Inspection Report
Census: 85
Capacity: 170
Deficiencies: 1
Date: Dec 21, 2023
Visit Reason
The visit was an unannounced case management inspection conducted to review recent incident reports regarding resident falls at the facility.
Findings
The inspection found that seven of eight reviewed falls were unwitnessed, and the facility has implemented a fall prevention protocol including frequent resident checks, therapy programs, medication evaluations, and fall pendants. A deficiency was cited for late submission of a death report beyond the required seven-day timeframe, posing a potential health and safety risk.
Deficiencies (1)
A death report was submitted to the Department past the seven days requirement, which poses/posed a potential health, safety or personal rights risk to persons in care.
Report Facts
Resident falls reviewed: 8
Unwitnessed falls: 7
Deficiency citations: 1
Fine amount: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arvin Villanueva | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
| Elena Cuevas | Administrator | Facility administrator interviewed during the visit |
| Rochelle Factor | Regional Health and Wellness Director | Facility director interviewed regarding falls and protocols |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 170
Deficiencies: 1
Date: Nov 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations that staff were not following medical professional's orders, a resident sustained severe burn, and the facility did not ensure staff were trained to meet residents' needs.
Complaint Details
The complaint investigation was substantiated regarding failure to follow medical professional's orders related to sunscreen application and medication administration for Resident 1. Other allegations, including resident sustaining severe burn and staff training deficiencies, were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the facility did not consistently follow physician orders for Resident 1, particularly regarding sunscreen application, posing an immediate health and safety risk. Some allegations were substantiated, including failure to follow medical orders, while others, such as staff training adequacy and prolonged sun exposure, were unsubstantiated due to insufficient evidence.
Deficiencies (1)
Licensee did not ensure Resident 1's physician orders were followed, posing an immediate health, safety, or personal rights risk to residents in care.
Report Facts
Capacity: 170
Census: 78
Deficiency count: 1
Plan of Correction due date: Nov 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation process |
| Luna Garcia | Business Office Manager | Met with Licensing Program Analyst during the investigation |
| Casey Simon | Administrator | Facility administrator mentioned in the report |
Inspection Report
Census: 58
Capacity: 170
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The visit was an unannounced case management visit to evaluate the facility and discuss the licensee's plan to incorporate a chicken coop in the garden area of the memory care unit as a resident activity.
Findings
No health or safety issues were observed related to the chicken coop or the facility. No deficiencies were cited during this visit.
Report Facts
Number of chickens: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Casey Simon | Administrator | Met with Licensing Program Analyst during the case management visit |
| Christina Valerio | Licensing Program Analyst | Conducted the unannounced case management visit |
| Stephen Richardson | Licensing Program Manager | Named in the report header |
Inspection Report
Annual Inspection
Census: 58
Capacity: 170
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct an annual inspection to ensure compliance with Title 22 regulations.
Findings
The facility was found to be clean, organized, and free from debris with no health and safety concerns observed. Resident files and staff files were current and up to date. No deficiencies were observed during the inspection.
Report Facts
Resident files reviewed: 6
Staff files reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Casey Simon | Administrator | Met with Licensing Program Analyst during inspection |
| Monica Cardenas | Memory Care Director | Accompanied Licensing Program Analyst during Memory Care area tour |
| Christina Valerio | Licensing Program Analyst | Conducted the annual inspection |
| Stephen Richardson | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 170
Deficiencies: 1
Date: Feb 7, 2023
Visit Reason
The visit was an unannounced case management inspection triggered by an incident report involving a staff member accidentally allowing a resident with dementia to leave the memory care unit unassisted, posing a safety risk.
Complaint Details
The visit was complaint-related due to an incident where a staff member accidentally let a resident with dementia leave the memory care unit unassisted. The resident was missing for 50 minutes before being returned safely. The complaint was substantiated with a deficiency cited.
Findings
The investigation found that staff were not properly trained to prevent a resident from wandering out of the facility, resulting in a cited deficiency. The resident was returned safely and staff received immediate in-service training. A second incident involving a resident's change of condition was also reviewed with no further issues.
Deficiencies (1)
Staff (S1) was not properly trained to ensure that 1 out of 24 memory care residents were kept safe from wandering out of the facility, posing an immediate health and safety risk.
Report Facts
Residents in memory care unit: 24
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Maurer | Administrator | Met with Licensing Program Analyst during the visit and provided information about the incidents and staff training |
| Christina Valerio | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 66
Capacity: 170
Deficiencies: 0
Date: Aug 31, 2022
Visit Reason
The inspection was an unannounced required annual visit conducted to evaluate the facility's compliance with licensing regulations.
Findings
The Licensing Program Analyst toured the facility, observed safety measures and resident activities, and found no deficiencies or violations during the inspection.
Report Facts
Licensed capacity: 170
Current census: 66
Administrator certificate expiration: 2023
Hot water temperature: 119.3
Facility temperature: 75
Hospice waiver beds: 25
Non-ambulatory beds: 170
Bedridden beds: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Maurer | Administrator | Met with Licensing Program Analyst during inspection |
| Christina L Garcia | Alternate Administrator | Administrator certificate expiration noted |
| Jamie Ivey Canady | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 170
Deficiencies: 0
Date: Aug 25, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-05-23 regarding overcharging residents, dietary needs, food service adequacy, front door disrepair, notice of door code changes, and housekeeping services.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included overcharging residents, inadequate dietary and food services, front door disrepair, lack of notice for door code changes, and unmet housekeeping needs. The department found no evidence to prove the alleged violations occurred.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Records and interviews showed that residents were not overcharged, dietary needs were met with quarterly audits and dietitian-approved menus, the front door was operational with proper notification of gate code changes, and housekeeping needs were met despite occasional short staffing.
Report Facts
Facility capacity: 170
Resident census: 54
Audit score: 99
Number of housekeeping staff: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Maurer | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 52
Capacity: 170
Deficiencies: 0
Date: Mar 11, 2022
Visit Reason
The inspection visit was an unannounced case management visit conducted to follow up on incident reports sent to the department in December 2021 regarding medications and incidents involving two residents.
Findings
No health or safety concerns were observed during the visit, and the facility was found to be in compliance with Title 22 regulations. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Maurer | Administrator/Executive Director | Met with Licensing Program Analyst to discuss incident reports and follow-up actions. |
| Christina Valerio | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 40
Capacity: 170
Deficiencies: 0
Date: Jul 9, 2021
Visit Reason
The visit was a required, unannounced annual inspection conducted to evaluate compliance with licensing regulations and ensure the safety and well-being of residents.
Findings
No deficiencies were observed or cited during the inspection. The facility met all regulatory requirements including safety systems, medication storage, and environmental conditions.
Report Facts
Capacity: 170
Census: 40
Hospice waiver capacity: 25
Hospice residents: 2
Temperature inside facility: 75
Hot water temperature: 118.3
2-day perishables observed: 2
7-day non-perishables observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Maurer | Administrator | Met with Licensing Program Analyst during inspection |
| Camille Marcello | Business Office Director | Assisted with the inspection visit |
| Victoria Brown | Licensing Program Analyst | Conducted the inspection |
| Cristina Wong | Program Clinical Consultant | Assisted with the inspection |
| Stephen Richardson | Licensing Program Manager | Named in report |
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