Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. The facility’s most recent report from October 3, 2025, had no deficiencies and showed no health or safety issues. Earlier reports included a few isolated deficiencies, such as failure to maintain documentation of missing personal property in December 2024, inadequate hot water temperatures in January 2025, and not reporting a scabies outbreak to the local health officer in February 2025. The main themes among deficiencies involved documentation, environmental maintenance, and infection control reporting, but none posed immediate jeopardy or resulted in fines or license actions. The overall trend suggests improvement, with the latest inspections consistently clean and no recent substantiated complaints.
A case management incident visit was conducted to follow up on an incident report received by Community Care Licensing on October 1, 2025, submitted by the Executive Director Carmen Galicia.
Findings
During the inspection, no health or safety issues were observed in the facility or Resident 1's room. No deficiencies were cited at this time.
The inspection was conducted as an unannounced complaint investigation following a complaint received on May 20, 2025, alleging staff interference with the resident council and failure to safeguard residents' personal belongings.
Findings
The investigation found the allegations of staff interfering with the resident council and not safeguarding residents' personal belongings to be unsubstantiated. Interviews with residents and staff, observations, and record reviews did not support the claims. No deficiencies were cited.
Complaint Details
The complaint alleged that facility staff interfered with the resident council by stealing and copying meeting minutes and retaliating against residents, and that staff did not safeguard residents' personal belongings. The investigation included interviews with residents and staff, document reviews, and observations. The allegations were determined to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 152Census: 109Residents interviewed: 8Residents agreeing staff never spoke inappropriately: 7Residents confirming no staff interference with resident council: 5Facility staff interviewed: 7
Employees Mentioned
Name
Title
Context
Michael Tea
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Alisa Ortiz
Licensing Program Manager
Oversaw the complaint investigation
Carmen Galicia
Executive Director
Facility representative who assisted during the investigation and exit interview
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on May 21, 2025, alleging inadequate medication assistance, untimely response to resident calls, and failure to safeguard residents' personal belongings.
Findings
The investigation found that although some residents reported occasional delays in medication administration and response times, and concerns about safeguarding personal belongings, there was insufficient evidence to substantiate the allegations. Staff were observed to respond within adequate timeframes, and protocols for safeguarding belongings were followed. The allegations were determined to be unsubstantiated or unfounded, and no deficiencies were cited.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Michael Tea. Allegations included inadequate medication assistance, untimely response to resident calls, and failure to safeguard personal belongings. The investigation included interviews with residents and staff, review of call logs, and observations. The allegations were determined to be unsubstantiated or unfounded based on evidence and interviews.
Report Facts
Capacity: 152Census: 109Complaint received date: May 21, 2025Visit start time: 1300Visit end time: 1700Residents interviewed: 8
Employees Mentioned
Name
Title
Context
Michael Tea
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Carmen Galicia
Executive Director
Facility representative who assisted during the visit and exit interview
Sharon Perez
Wellness Coordinator
Interviewed regarding medication administration and safeguarding of belongings
An unannounced complaint investigation visit was conducted in response to allegations that staff were mismanaging residents' medications and not ensuring residents' rooms were clean and sanitized.
Findings
The investigation found no evidence to substantiate the allegations. Medication administration records and interviews confirmed medications were given as prescribed, and the facility's housekeeping practices were generally satisfactory with no observed cleanliness issues in the resident's room.
Complaint Details
The complaint investigation was unsubstantiated based on observations, interviews, and record reviews. Allegations included medication mismanagement and inadequate room sanitation, but evidence did not support these claims.
Report Facts
Residents interviewed: 11Residents agreeing medication given as prescribed: 9Residents satisfied with room cleanliness: 8
Employees Mentioned
Name
Title
Context
Michael Tea
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Carmen Galicia
Executive Director
Facility representative who met with the investigator and participated in the exit interview
Brittainy Prieto
Wellness Director
Provided information regarding resident care and family communications
Daniel Guerrero
Maintenance Director
Provided information about housekeeping and room inspections
The inspection was conducted as a case management follow-up visit triggered by a co-complaint report received on April 8, 2025, alleging that the facility was not changing residents' sheets on a regular weekly basis.
Findings
Based on observations, interviews with staff and residents, and review of linen supply invoices, the allegation that the facility was not changing residents' sheets weekly was determined to be unsubstantiated. No deficiencies were cited during this visit.
Complaint Details
The complaint alleged that the facility was not changing residents' sheets on a regular weekly basis. After investigation, including interviews with the Executive Director, staff, and residents, and review of linen supply invoices, the complaint was determined to be unsubstantiated.
The inspection was an unannounced annual required inspection conducted to evaluate compliance with licensing regulations.
Findings
The inspection found no deficiencies in the areas inspected. Resident files, staff files, physical plant, fire safety, medication storage, and resident care were all in compliance with regulations.
Report Facts
Residents on hospice: 12Resident files reviewed: 11Staff files reviewed: 7Water temperature range: 108.3-109.4
Employees Mentioned
Name
Title
Context
Michael Tea
Licensing Program Analyst
Conducted the inspection and authored the report
Lakhena Lor
Business Office Manager
Assisted with the inspection and participated in the exit interview
Kenya Carlton
Executive Director (filling in)
Filling in for Executive Director during the inspection
An unannounced complaint investigation visit was conducted to investigate allegations of a scabies infestation, improper medication administration, and failure to follow the Infection Control Plan at the facility.
Findings
The investigation found that only one resident was diagnosed with scabies and there was no evidence of an infestation. Medication administration was found to be properly managed and documented. The facility followed infection control protocols promptly when scabies was suspected. Overall, the allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations of scabies infestation, medication mismanagement, and infection control plan noncompliance.
Report Facts
Capacity: 152Census: 108
Employees Mentioned
Name
Title
Context
Michael Tea
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Carmen Galicia
Executive Director
Facility representative who assisted during the visit and exit interview
Brittainy Prieto
Health and Wellness Director
Interviewed regarding scabies cases and medication management
A case management visit was conducted to follow up on a co-complaint report received by Community Care Licensing on January 16, 2025, submitted by Orange County Health Agency regarding a scabies outbreak and failure to report to the local health officer/agency.
Findings
The facility was cited for failure to report an infection outbreak to the local health officer as required by Title 22 Division 6 of the California Code of Regulations, posing a potential health and safety risk to residents.
Complaint Details
The visit was complaint-related based on a report of a scabies outbreak and failure to report infection control issues to the local health officer. The complaint was submitted by Orange County Health Agency and investigated by Community Care Licensing.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to report epidemic outbreaks, such as the scabies outbreak, to the local health officer within 24 hours as required.
Type B
Report Facts
Capacity: 152Census: 108Plan of Correction Due Date: Mar 12, 2025
Employees Mentioned
Name
Title
Context
Michael Tea
Licensing Program Analyst
Conducted the case management visit and cited the deficiency
Carmen Galicia
Executive Director
Met with Licensing Program Analyst during the visit and participated in exit interview
The inspection was a case management incident visit conducted to follow up on an incident report received by Community Care Licensing on January 24, 2025.
Findings
During the inspection, no health or safety issues were observed, the facility was clean and organized, and no deficiencies were cited at this time.
Employees Mentioned
Name
Title
Context
Michael Tea
Licensing Program Analyst
Conducted the case management incident visit.
Carmen Galicia
Executive Director
Assisted with the visit and participated in the exit interview.
Brittainy Prieto
Health and Wellness Director, LVN
Submitted the incident report prompting the visit.
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on November 18, 2024, including mismanagement of resident medication, presence of bedbugs, failure to provide a copy of the admission agreement, and lack of hot water in restrooms and sinks.
Findings
The investigation found the allegations of medication mismanagement and bedbugs to be unsubstantiated due to conflicting evidence. The allegation that the facility did not provide a copy of the admission agreement was unfounded. However, the allegation that restrooms and sinks did not have hot water was substantiated, with hot water temperatures tested below the required minimum, posing a potential health risk.
Complaint Details
The complaint investigation addressed multiple allegations: 1) Facility mismanaged resident's medication - unsubstantiated; 2) Facility has bedbugs - unsubstantiated; 3) Facility did not provide resident with a copy of the admission agreement - unfounded; 4) Facility's restrooms and sinks do not have hot water - substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
87303 Maintenance and Operation (e)(2) Faucets used by residents for personal care shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement was not met as evidence by hot water tested between 91.2 to 102.3 degrees Fahrenheit, posing a potential health, safety or personal rights risk to persons in care.
Type B
Report Facts
Hot water temperature range: 91.2Hot water temperature range: 102.3Facility capacity: 152Resident census: 111Plan of Correction due date: 2025
Employees Mentioned
Name
Title
Context
Alvaro Ramirez Jr.
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Sheila Santos
Licensing Program Manager
Oversaw the complaint investigation
Carmen Galicia
Executive Director
Facility representative met during the investigation and exit interviews
An unannounced complaint investigation visit was conducted in response to allegations received on October 11, 2024, concerning privacy violations, uncomfortable accommodations due to air fresheners, retaliation against residents, and untimely response to the facility call system.
Findings
The investigation found conflicting information regarding the allegations. Some residents and staff confirmed or denied the complaints, and document reviews supported staff training and policies protecting resident rights. Due to insufficient evidence, all allegations were deemed unsubstantiated, and no citations were issued.
Complaint Details
The complaint investigation was unsubstantiated due to conflicting information and lack of preponderance of evidence to prove or refute the allegations.
Report Facts
Capacity: 152Census: 111Call system response time: 5Call system response time: 35Resident reported call response time: 24Resident reported call response time: 30Call system test response time: 6Call system test response time: 25
Employees Mentioned
Name
Title
Context
Alvaro Ramirez Jr.
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Cristina Miller
Administrator
Facility administrator mentioned in the report
Ashanti Minor
Administrative Services Coordinator
Met with Licensing Program Analyst during the investigation
Carmen Galicia
Executive Director
Met with Licensing Program Analyst and participated in exit interview
Sheila Santos
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
The inspection was an unannounced visit to investigate complaints received on 2024-09-18 regarding staff not ensuring residents' personal property was safely secured, mail deliveries, and laundry handling.
Findings
Two allegations regarding mail delivery and laundry handling were found to be unsubstantiated due to insufficient evidence. One allegation regarding failure to maintain required documentation of missing personal property was substantiated, resulting in a Type B deficiency citation.
Complaint Details
The complaint investigation was triggered by allegations that staff did not ensure residents' personal property was safely secured, mail was not properly delivered to residents, and laundry was returned undamaged. The mail and laundry allegations were unsubstantiated, while the personal property documentation allegation was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to maintain required documentation of missing property including description, estimated value, date/time of theft or loss, and actions taken as required by Health and Safety Code section 1569.153(c).
Type B
Report Facts
Facility capacity: 152Plan of Correction due date: Jan 3, 2025
Employees Mentioned
Name
Title
Context
Kevin Saborit-Guasch
Licensing Program Analyst
Conducted the complaint investigation and unannounced visit
Sheila Santos
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
Cristina Miller
Administrator
Facility administrator present and assisted with the visit
An unannounced complaint investigation visit was conducted to follow up on multiple allegations received on 06/07/2024 regarding resident care and facility conditions at Westminster Terrace.
Findings
The investigation substantiated the allegation that residents were not being provided with clean linen, issuing a Type B citation. Other allegations including residents being left soiled, pest infestations, disrespectful treatment, unclean dining areas, and lack of call system access were found to be unsubstantiated.
Complaint Details
The complaint investigation was substantiated for the allegation regarding clean linen provision. Other allegations were unsubstantiated based on interviews, observations, and documentation.
Severity Breakdown
Type B: 1
Deficiencies (1)
Description
Severity
Failure to assure provision of clean linen as required by CCR 87307(a)(3)(C), evidenced by multiple living units having soiled, dirty, or absent linen.
Type B
Report Facts
Capacity: 152Census: 112Deficiency citation: 1Plan of Correction Due Date: Oct 2, 2024
Employees Mentioned
Name
Title
Context
Kevin Saborit-Guasch
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Sheila Santos
Licensing Program Manager
Oversaw the complaint investigation
Carmen Galicia
Executive Director
Facility representative present during inspection and assisted with investigation
Cristina Miller
Administrator
Facility administrator who provided documentation and information during investigation
An unannounced complaint investigation visit was conducted in response to allegations that residents are afraid to express themselves due to retaliation and that the facility is understaffed.
Findings
The investigation included interviews with residents and staff, a tour of the facility, and review of records. The allegations were not substantiated as resident and staff interviews did not corroborate the claims, and staffing levels were verified as adequate through staff schedules and observations.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents fearing retaliation and understaffing. Interviews with 7 residents and staff did not support these allegations. Staffing schedules confirmed adequate coverage. No preponderance of evidence was found to prove or refute the allegations.
Report Facts
Capacity: 152Census: 102Resident interviews: 7Staff interviews: 3Caregivers per shift: 4Med-tech hybrids per shift: 2Caregivers per night shift: 2Med-tech hybrids per night shift: 1
Employees Mentioned
Name
Title
Context
Celine De Perio
Licensing Program Analyst
Conducted the complaint investigation and authored the report
Carmen Galicia
Facility Administrator
Met with the Licensing Program Analyst during the investigation and exit interview
Inspection Report Original LicensingCensus: 55Capacity: 152Deficiencies: 0Feb 22, 2023
Visit Reason
The visit was conducted as a pre-licensing evaluation for an existing facility undergoing a Change of Ownership and applying to operate as a Residential Care For the Elderly (RCFE) with a capacity of 152 residents.
Findings
The facility was toured and found to be in compliance with regulatory requirements including adequate supplies, clean and hazard-free common areas, proper food storage, locked medication and toxin storage, and functional call systems. The facility is ready to be licensed.
The visit was an office evaluation conducted on February 9, 2023, involving a telephone interview with the applicant/administrator to verify identification and confirm understanding of California Code Title 22 regulations and facility operation requirements.
Findings
The applicant/administrator demonstrated understanding of licensing requirements including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness during the COMP II telephone interview.
Employees Mentioned
Name
Title
Context
Suzette Johnson
Administrator
Named as facility administrator participating in the COMP II interview
Erin Mahoney
Participant in COMP II telephone interview
Jude De La Concepcion
Licensing Program Manager
Named as Licensing Program Manager
Bethany Hunter
Licensing Program Analyst
Named as Licensing Program Analyst conducting the evaluation
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