Inspection Report Summary
Most inspections found no deficiencies, with routine annual and licensing visits showing compliance in areas such as staffing, infection control, medication storage, and resident rights. Several complaint investigations were unsubstantiated, including allegations about housekeeping, diet management, and theft. However, the facility had isolated deficiencies related to medication management in November 2023 and maintenance issues due to mold in one resident’s room in January 2025, both posing potential health risks but without enforcement actions or fines listed. The most recent report from January 14, 2025, noted a substantiated mold issue requiring air conditioning replacement but no other deficiencies. Overall, the facility’s record shows mostly compliance with some isolated concerns that do not indicate a worsening trend.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 105
Capacity: 200
Deficiencies: 1
Jan 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-12-11 regarding housekeeping services, facility cleanliness, passageway obstructions, malodorous smells, and mold presence in the facility.
Findings
Most allegations including lack of housekeeping services, facility cleanliness, passageway obstruction, and malodorous smells were found to be unsubstantiated based on observations, interviews with staff and residents, and facility tour. However, the allegation regarding mold in room #721 was substantiated as the air conditioning unit was replaced due to mold, posing a potential health and safety risk.
Complaint Details
The complaint investigation was triggered by allegations received on 2024-12-11 concerning housekeeping services, facility cleanliness, passageway obstructions, malodorous smells, and mold. The mold allegation was substantiated, while the others were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility did not comply with maintenance and operation requirements as the air conditioning in Room #721 was replaced due to mold, posing a potential health and safety risk to residents. | Type B |
Report Facts
Capacity: 200
Census: 105
Deficiencies cited: 1
Plan of Correction Due Date: Jan 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bennette Pena | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| David Sicairos | Licensing Program Manager | Oversaw the complaint investigation |
| Claudia Ruiz | Business Office Manager | Facility representative met during the investigation |
| Crystene Char | Administrator | Facility administrator named in the report related to findings |
Inspection Report
Census: 110
Capacity: 200
Deficiencies: 0
Oct 29, 2024
Visit Reason
The visit was a virtual office meeting to discuss the de-licensing of the 7th floor of the facility.
Findings
Discussions included separation of common areas between Assisted Living and Independent Living residents, ensuring approved fire clearance, submission of application for capacity decrease, and staffing separation. The licensee is not interested in operating as a Continuing Care Retirement Community (CCRC).
Report Facts
Capacity: 200
Census: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Crystene Char | Executive Director | Met during the virtual office meeting and discussed de-licensing |
| Marlene Nelson | Director of Regulatory Compliance | Met during the virtual office meeting and discussed de-licensing |
| Daniel Konishi | Licensing Program Analyst | Conducted the virtual office meeting |
| David Sicairos | Licensing Program Manager | Conducted the virtual office meeting |
| Fernando Fierros | Licensing Program Manager | Conducted the virtual office meeting |
Inspection Report
Annual Inspection
Census: 110
Capacity: 200
Deficiencies: 0
Oct 29, 2024
Visit Reason
The inspection was a subsequent annual inspection visit conducted as part of case management and annual continuation to assess compliance with regulatory requirements.
Findings
The inspection found that staff files were properly maintained with current certifications and screenings, resident files were complete with required documentation, resident rights were posted and included in files, and the facility had adequate disaster preparedness and physical plant safety measures. Food service and medication storage were compliant with regulations.
Report Facts
Hot water temperature: 105.4
Hot water temperature: 106.6
Hot water temperature: 105.1
Hot water temperature: 107
Hot water temperature: 106.1
Hot water temperature: 111.5
Hot water temperature: 109.4
Hot water temperature: 113.5
Resident files reviewed: 11
Staff files reviewed: 10
Food supplies: 2
Food supplies: 7
Medication records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Reyes | Licensing Program Analyst | Conducted the annual inspection visit and reviewed compliance |
| Crystene Char | Administrator | Facility administrator met with Licensing Program Analyst during inspection |
| Fernando Fierros | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 110
Capacity: 200
Deficiencies: 0
Oct 24, 2024
Visit Reason
Licensing Program Analysts conducted the required annual inspection to evaluate compliance with regulatory requirements at West Park Senior Living Facility.
Findings
The facility is approved for 81 ambulatory and 119 non-ambulatory residents, including 10 bedridden residents, and has an approved hospice waiver for 15 residents. The facility has an Infection Control Plan in place and is adhering to staffing requirements. Due to time constraints, the inspection was not fully completed and will be continued at a later date.
Report Facts
Approved ambulatory residents: 81
Approved non-ambulatory residents: 119
Approved bedridden residents: 10
Hospice waiver residents: 15
CARE Tool domains to complete: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Reyes | Licensing Program Analyst | Conducted the required annual inspection |
| Crystene Char | Administrator | Met with Licensing Program Analyst during inspection and discussed visit purpose |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 200
Deficiencies: 0
Jun 18, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff were not following residents' physicians' orders for special diets and that residents' money was stolen due to lack of supervision.
Findings
The investigation found that 6 of 7 residents reported having choices and appropriate special diet accommodations, and no written physician order for a specific diet was found. Regarding the allegation of stolen money, interviews revealed no evidence to support the claim, with most residents and staff denying any theft incidents. Therefore, both allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not following special diet orders and residents' money being stolen due to lack of supervision. Interviews and evidence did not support these claims.
Report Facts
Capacity: 200
Census: 102
Number of residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Crystene Char | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Annual Inspection
Census: 112
Capacity: 200
Deficiencies: 0
Nov 30, 2023
Visit Reason
The inspection was a subsequent annual inspection visit conducted as part of case management and annual continuation to assess compliance with regulatory requirements.
Findings
The facility was found to have operational safety equipment including carbon monoxide detectors and fire extinguishers, proper hot water temperatures, adequate food supplies and storage, and secure medication storage with electronic documentation. No deficiencies or violations were explicitly noted in the report.
Report Facts
Hot water temperature readings: 109
Hot water temperature readings: 106.1
Hot water temperature readings: 106
Hot water temperature readings: 109.6
Hot water temperature readings: 110
Hot water temperature readings: 108
Hot water temperature readings: 107
Hot water temperature readings: 107
Hot water temperature readings: 109.1
Hot water temperature readings: 108
Fire extinguisher last service date: Feb 21, 2023
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the annual inspection visit and reviewed medication |
| Crystene Char | Facility representative met during inspection and received report and appeal rights |
Inspection Report
Annual Inspection
Census: 112
Capacity: 200
Deficiencies: 0
Nov 28, 2023
Visit Reason
The inspection was a required annual unannounced visit to evaluate compliance with licensing regulations at the facility.
Findings
The facility was found to have an Infection Control Plan in place, was adhering to staffing requirements, and maintained personnel and resident records appropriately. Some domains such as Physical Plant & Environment Safety, Food Service, and Health Related Services/Incidental Medical Services remain pending.
Report Facts
Hospice waiver residents: 15
Bedridden residents capacity: 10
Ambulatory residents capacity: 81
Non-ambulatory residents capacity: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the required annual inspection |
| Tony Vasallo | Supervisor | Supervisor overseeing the inspection |
| Claudia Ruiz | Facility representative met during inspection | |
| Crystene Char | Facility representative present during inspection and exit interview |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 200
Deficiencies: 1
Nov 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 09/20/2023 alleging that facility staff mismanaged a resident's medication.
Findings
The investigation substantiated the allegation that the facility failed to administer medications according to doctor's orders due to a discrepancy between the doctor's order and the medication label for Hydralazine, posing a health and safety hazard.
Complaint Details
The complaint was substantiated. It was alleged that the facility failed to administer medications according to doctor's orders, specifically regarding the administration of Hydralazine to resident R1. The investigation found that the doctor's order and medication label were not identical, leading to refusal to provide an additional half tablet as requested by the resident.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Doctor’s order dated 5/16/23 for Hydralazine dosage does not match the label dosage on the bottle dispensed on 07/23/23. The doctor’s order is for 1 tablet by mouth 3 times per day and label reads: Take 1 tablet by mouth 3 times per day. Ok to take extra one-half tablet if SHIP is above 150. Both the doctor’s order and the label should mirror each other. This posed/poses a health and safety hazard to persons in care. | Type A |
Report Facts
Capacity: 200
Census: 118
Plan of Correction Due Date: Dec 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Hicks | Licensing Program Manager | Named in relation to the complaint investigation report |
| Crystene Char | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 200
Deficiencies: 0
May 4, 2023
Visit Reason
Licensing Program Analyst Mora conducted a collateral visit to interview the Executive Director and Business Office Manager as part of a complaint investigation (complaint control #28-AS-20220421101842).
Findings
The visit consisted of interviews with facility leadership and was completed after the interviews ended. An exit interview was held and a copy of the report was provided.
Complaint Details
Complaint investigation visit related to complaint control #28-AS-20220421101842; no substantiation status stated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Irby | Executive Director | Interviewed during the complaint investigation visit. |
Inspection Report
Census: 113
Capacity: 200
Deficiencies: 1
Apr 13, 2023
Visit Reason
The visit was an unannounced case management inspection focused on deficiencies related to the facility's failure to comply with reporting requirements.
Findings
The facility failed to report incidents within the required seven-day timeframe, including a resident self-injury and a death report submitted without the resident's name. No immediate health or safety hazards were observed during the visit, but the reporting delays pose a health and safety risk to residents.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit required reports to the licensing agency within seven days of incidents, including a resident self-injury and a death report missing resident information. | Type B |
Report Facts
Capacity: 200
Census: 113
Plan of Correction Due Date: Apr 20, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Irby | Administrator | Met during the inspection and discussed the purpose of the visit |
| Lisa Hicks | Supervisor | Named as supervisor in the report |
| Alberto Lopez | Licensing Evaluator | Conducted the inspection and signed the report |
Inspection Report
Census: 116
Capacity: 200
Deficiencies: 0
Mar 27, 2023
Visit Reason
An unannounced case management visit was conducted stemming from an initial 10-day complaint visit dated 07/22/21. The visit involved obtaining current staff and resident rosters and planning further file reviews to confirm change in licensee.
Findings
The Licensing Program Analysts requested and obtained current staff and resident rosters from West Park Senior Living. Further file reviews and possible additional visits are planned to confirm the change in licensee and collect more documents and interviews.
Complaint Details
The visit was related to a complaint originally filed against Atria Rancho Park and assigned control number 28-AS-20210721085127. The case management visit stems from the initial complaint investigation.
Report Facts
Facility capacity: 200
Census: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the unannounced case management visit and requested documents |
| Erik Zaragoza | Licensing Program Analyst | Conducted the unannounced case management visit and requested documents |
| Lori Irby | Administrator | Facility administrator met during the visit |
Inspection Report
Original Licensing
Census: 117
Capacity: 200
Deficiencies: 0
Jul 8, 2022
Visit Reason
The visit was conducted as a pre-licensing evaluation for an initial license application submitted on 2022-03-14 for a Residential Care Facility for the Elderly serving age 60 and over.
Findings
The facility was found to be in substantial compliance with applicable laws and regulations during the pre-licensing inspection. No items of noncompliance were observed. The facility was well-equipped, clean, and safe with operational safety systems and adequate furnishings.
Report Facts
Capacity: 200
Census: 117
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Irby | Administrator | Facility administrator met during the inspection |
| Kruz Long | Licensing Program Analyst | Conducted the pre-licensing evaluation visit |
| Fernando Fierros | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Original Licensing
Census: 119
Capacity: 200
Deficiencies: 0
Apr 22, 2022
Visit Reason
The visit was conducted as a Component II evaluation by the Community Care Licensing analyst via telephone to verify the applicant and administrator's understanding of licensing requirements and facility operation for initial licensing.
Findings
The applicant and administrator successfully completed Component II, confirming understanding of facility operation, staff qualifications, program policies, and other licensing requirements. No deficiencies or violations were noted in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Irby | Administrator | Named as participant and administrator in the Component II licensing evaluation |
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