Inspection Reports for Westmont at San Miguel Ranch
2325 Proctor Valley Rd, Chula Vista, CA 91914, United States, CA, 91914
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with several complaint investigations unsubstantiated. The most recent report from February 20, 2025, was clean with no deficiencies cited during the annual inspection. Earlier reports showed some isolated issues, including substantiated neglect causing resident injuries in September 2024 that resulted in a $500 fine, and medication administration delays due to staffing shortages in December 2023. Other deficiencies involved documentation errors and communication lapses, but these were generally minor or technical in nature. The facility’s record shows improvement over time, with the latest inspections free of violations and no ongoing enforcement actions.
Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 89
Capacity: 105
Deficiencies: 0
Mar 10, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident was charged for services not rendered.
Findings
The investigation included a tour, interviews, and detailed records review. It was found that the resident's level of care had significantly changed over time, and billing statements accurately reflected the care provided. There was insufficient evidence to support the allegation, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged that Resident R1 was charged for a level of care increase on December 20, 2023, without a documented change in medical condition. The investigation reviewed medical records, service plans, and billing statements from May 16, 2022, through June 1, 2024, and found the charges were accurate and supported by documented changes in condition. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Census: 89
Total Capacity: 105
Billing periods reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Ellen Arguello | Business Office Director | Interviewed during the investigation and exit interview |
Inspection Report
Annual Inspection
Census: 80
Capacity: 105
Deficiencies: 0
Feb 20, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, sanitary, and in good repair with compliant hot water temperature, safe food storage, proper medication labeling and storage, and all required safety equipment present. No deficiencies were cited during the inspection.
Report Facts
Capacity: 105
Census: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Zepeda | Administrator | Met with Licensing Program Analyst during inspection |
| Alyssa Ramirez | Licensing Program Analyst | Conducted the unannounced required annual inspection |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 105
Deficiencies: 0
Oct 17, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that facility staff was intoxicated with alcohol while caring for and supervising residents.
Findings
The investigation found that the staff member in question did not provide care or supervision of residents and there was no evidence of intoxication while on duty. Conflicting statements and lack of witnesses led to the allegation being unsubstantiated. No deficiencies were cited.
Complaint Details
The complaint alleged that a staff member was intoxicated while caring for residents. The investigation included records review, staff and resident interviews, and an outside source interview. The allegation was found unsubstantiated as evidence did not meet the preponderance of evidence standard.
Report Facts
Complaint Control Number: 08-AS-20240515104136
Facility Capacity: 105
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Ramirez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jessica Zepeda | Administrator | Facility administrator met during investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 105
Deficiencies: 0
Oct 17, 2024
Visit Reason
The visit was conducted in response to the licensee’s self-reported death of Resident #1, which was received on 2024-09-20. The resident passed away on 2024-09-09.
Findings
During the visit, a health and safety check was conducted with no safety concerns found. Pertinent care records were reviewed and staff interviewed. No deficiencies were observed or cited during the visit.
Complaint Details
The visit was complaint-related due to a self-reported death of a resident. No deficiencies or violations were found during the investigation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Zepeda | Administrator | Met with during the inspection and involved in the exit interview. |
| Alyssa Ramirez | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 105
Deficiencies: 1
Sep 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of neglect resulting in resident injuries, dehydration, pneumonia, and medication errors at Westmont at San Miguel Ranch.
Findings
The investigation substantiated neglect resulting in a resident sustaining injuries from multiple falls, posing immediate health and safety risks. Neglect allegations related to dehydration and pneumonia were unsubstantiated, as was the allegation of medication errors. A $500 civil penalty was assessed and a plan of correction was agreed upon.
Complaint Details
The complaint investigation was substantiated for neglect causing resident injury. Neglect allegations related to dehydration and pneumonia, and medication administration allegations were unsubstantiated. The investigation included review of records, interviews with staff, residents, and family, and examination of medical documentation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1 was free from neglect, resulting in injuries and posing immediate health, safety, and personal rights risks. | Type A |
Report Facts
Resident falls: 12
Resident falls unwitnessed: 7
Civil penalty: 500
Facility capacity: 105
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Zepeda | Executive Director | Met with during the investigation and involved in plan of correction. |
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation. |
| Randal Newton | Administrator | Facility administrator named in the report header. |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 105
Deficiencies: 0
Aug 27, 2024
Visit Reason
The visit was conducted in response to the licensee’s self-reported death of Resident #1, which was received by the CCLD San Diego Regional Office on 2024-08-26. The resident passed away on 2024-08-19.
Findings
During the unannounced Case Management - Incident visit, a health and safety check was conducted with no safety concerns found. Pertinent care records were reviewed and no deficiencies were observed or cited.
Complaint Details
The visit was complaint-related due to the self-reported death of Resident #1. No deficiencies or violations were found during the investigation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Zepeda | Executive Director | Met with during the visit and involved in the exit interview. |
| Alyssa Ramirez | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 105
Deficiencies: 0
May 22, 2024
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that a resident's care plan did not accurately represent the care provided.
Findings
The investigation included interviews, record reviews, and a virtual tour. It was found that the resident had concerns about insurance reimbursements and care plan services, but there was no evidence that the care plan was inaccurate. The allegation was unsubstantiated.
Complaint Details
The complaint alleged that Resident 1's care plan did not accurately represent the care provided. The investigation did not find sufficient evidence to substantiate this allegation, and it was determined to be unsubstantiated.
Report Facts
Complaint Control Number: 08-AS-20210212154050
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becky Kennedy | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Ellen Argullo | Business Office Manager | Met with the investigator during the visit and participated in the exit interview. |
| Randal Newton | Administrator | Named as facility administrator. |
| Icela Estrada | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 105
Deficiencies: 0
May 21, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff mismanaged a resident's medication.
Findings
The investigation found that the allegation was unsubstantiated. Staff were aware that residents have the right to refuse medication and do not force medication administration. Documentation showed that the resident spit out medication and staff properly recorded refusal. No deficiencies were cited.
Complaint Details
The complaint alleged that a resident was not receiving medication due to spitting it out and staff not attempting to re-administer. Interviews and records review showed staff followed protocol respecting resident refusal and no medication orders allowed multiple attempts. The allegation was unsubstantiated.
Report Facts
Capacity: 105
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jessica Zepeda | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Michael Sokolowski | Administrator | Facility administrator named in the report |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 76
Capacity: 105
Deficiencies: 0
May 15, 2024
Visit Reason
An unannounced Case Management visit was conducted to review the facility's use of delayed-egress doors in its secured memory care area and to verify fire safety approval and updated floor plans.
Findings
No deficiencies were observed or cited during the visit. The facility's updated floor plan and use of delayed-egress doors were approved by the local fire marshal and properly posted.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Zepeda | Executive Director | Met with Licensing Program Analyst during the inspection and exit interview. |
| George Hayes | Maintenance Director | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 105
Deficiencies: 1
Apr 26, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not meet a resident's incontinence care needs.
Findings
The investigation substantiated that Resident 1 requested incontinence care at 9:17 PM but did not receive care for over six hours, as the care need was not properly communicated between shifts. The resident was left in soiled clothing for an excessive period, posing a potential risk to health.
Complaint Details
The complaint was substantiated. Resident 1 requested incontinence care which was not provided for approximately six hours due to failure in shift-to-shift communication and staff availability.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide basic services including personal assistance and care as needed by the resident, resulting in a six-hour delay in care delivery. | Type B |
Report Facts
Residents present during inspection: 63
Total licensed capacity: 105
Delay in care: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becky Kennedy | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jessica Zepeda | Executive Director | Facility representative met during investigation and exit interview |
| Randal Newton | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 105
Deficiencies: 0
Mar 27, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not communicate with the responsible party regarding fee increases for a resident's care plan.
Findings
The investigation found that the facility did not schedule meetings for every change in care level pricing but provided written notice within two business days. The allegation that the responsible party was not notified of fee increases was unsubstantiated, and no deficiencies were cited.
Complaint Details
The complaint alleged that staff did not communicate with the responsible party of fee increases for a resident's care plan. The investigation included records review and interviews with staff, clients, and outside agencies. It was found that the responsible party did not receive notification of the increase, but documentation showed that changes to the service plan were emailed to the responsible party on 12/20/2023. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 08-AS-20240112134103
Capacity: 105
Census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Ramirez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Eva Amorim | Resident Services Director | Met with Licensing Program Analyst during investigation and exit interview |
| Michael Sokolowski | Administrator | Facility administrator named in the report |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 105
Deficiencies: 0
Jan 30, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations including failure to provide food, incontinence care, medication administration, falsification of documents, failure to follow care plans, hazardous item accessibility, temperature maintenance, and reporting requirements.
Findings
The investigation found no substantiated evidence to support the allegations. Interviews and observations did not corroborate claims of neglect or improper care, and the facility addressed some concerns such as securing the salon door. Records requested were not readily available, but overall, the allegations were unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to provide food, incontinence care, medication administration, falsification of documents, failure to follow care plans, hazardous item accessibility, temperature maintenance, and failure to follow reporting requirements. Interviews and observations did not support these allegations, and no preponderance of evidence was found.
Report Facts
Capacity: 105
Census: 69
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Sokolowski | Executive Director | Facility representative met during investigation |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 71
Capacity: 105
Deficiencies: 1
Jan 19, 2024
Visit Reason
The inspection visit was an unannounced continuation of a Required Annual Inspection to evaluate compliance with licensing regulations at the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with compliant environmental conditions and safety equipment. One deficiency was cited for failure to obtain written fire authority approval for delayed-egress doors used in the secured memory care area.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee utilized delayed egress devices on exterior doors without ensuring fire clearance included approval of delayed egress devices, posing a potential safety risk. | Type B |
Report Facts
Residents in care: 71
Licensed capacity: 105
Deficiencies cited: 1
Plan of Correction due date: Feb 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Sokolowski | Executive Director | Met with during inspection and participated in exit interview |
| Liliana Silveira | Licensing Program Analyst | Conducted inspection and authored report |
| Denise Powell | Supervisor | Supervisor overseeing licensing evaluation |
Inspection Report
Annual Inspection
Census: 71
Capacity: 105
Deficiencies: 0
Jan 16, 2024
Visit Reason
An unannounced required annual inspection was conducted to review the facility's compliance with licensing regulations.
Findings
No deficiencies were cited during the visit. Due to time constraints, a return visit is needed to complete the annual inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Sokolowski | Executive Director | Met with Licensing Program Analysts during the inspection and participated in the exit interview. |
| Eva Amorim | Resident Services Director | Participated in discussion of the purpose of the visit with Licensing Program Analysts. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 105
Deficiencies: 0
Dec 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 09/20/2023 regarding insufficient staff to respond to residents' call buttons timely.
Findings
The investigation included interviews with residents and staff and records review. Most residents reported timely staff response to call buttons, with one resident reporting untimely response of about 20 minutes. No injuries were reported due to staff response delays. Incident reports showed no major injuries related to untimely call responses. The allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged insufficient staff to respond to residents' call buttons timely, potentially causing injuries. The investigation found no substantiation of the allegation.
Report Facts
Residents with call button delays over 30 minutes: 5
Capacity: 105
Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Sokolowski | Executive Director | Met with Licensing Program Analyst during investigation and discussed findings |
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 105
Deficiencies: 1
Dec 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff did not meet training requirements and did not provide medications as prescribed.
Findings
The investigation found the allegation that staff did not meet training requirements to be unsubstantiated, as records showed proper training for medication administration staff. However, the allegation that staff did not provide medications as prescribed was substantiated, with evidence that medications were administered late due to staffing shortages and use of agency staff unfamiliar with the facility.
Complaint Details
The complaint investigation was triggered by allegations received on 10/02/2023 regarding staff training deficiencies and medication administration issues. The training allegation was unsubstantiated. The medication administration allegation was substantiated due to late medication delivery confirmed by residents and staff interviews.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not provide the residents their medications as prescribed, at the appropriate timeframe, posing a potential health risk to 4 of 71 residents in care. | Type B |
Report Facts
Capacity: 105
Census: 71
Residents affected: 4
Plan of Correction Due Date: Dec 22, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Sokolowski | Executive Director | Met with during inspection and involved in exit interview |
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 105
Deficiencies: 0
Sep 22, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were inappropriately restraining residents in care, specifically the use of 17 bed rails as restraints.
Findings
The investigation found that residents used bed rails as assistive support mechanisms, not as restraints. All 17 residents had physician-approved orders for half-bed rails, and no evidence supported the allegation of inappropriate restraint. The complaint was deemed unsubstantiated.
Complaint Details
The complaint alleged inappropriate restraint of residents using bed rails. Interviews, record reviews, and observations found no concerns or evidence of restraint use. The allegation was unsubstantiated.
Report Facts
Number of bed rails alleged as restraint: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Sokolowski | Executive Director | Met with during investigation and exit interview |
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 105
Deficiencies: 0
Sep 18, 2023
Visit Reason
The visit was an unannounced complaint investigation and case management visit in response to an Incident Report regarding missing money reported by a resident.
Findings
The facility conducted an internal investigation which was inconclusive as the money was not found. The resident was reimbursed for the lost/stolen money. No deficiencies were issued during this visit.
Complaint Details
The complaint involved a resident reporting missing money totaling $100 in various bills. Staff confirmed the money was previously in the resident's belongings. Attempts to report to police were unsuccessful due to the amount being under $10,000 and the resident chose not to pursue further.
Report Facts
Resident reported missing money: 100
Facility capacity: 105
Census: 78
Hospice approved beds: 12
Non-ambulatory residents allowed: 105
Bedridden residents allowed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Sokolowski | Executive Director | Met during the visit and involved in the internal investigation |
| Carmen Lopez | Licensing Program Analyst | Conducted the unannounced complaint investigation and case management visit |
| Denise Powell | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 105
Deficiencies: 1
Sep 18, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/14/2023 regarding the facility's failure to obtain residents' Physician's Reports prior to admission and failure to safeguard a resident's personal belongings.
Findings
The investigation substantiated that the facility did not obtain Physician's Reports prior to admission for two residents, posing a potential health risk. The allegation regarding failure to safeguard a resident's personal belongings was unsubstantiated based on interviews and observations.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility failed to obtain residents' Physician's Reports prior to admission. The allegation that the facility did not safeguard a resident's personal belongings was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not obtain residents' Physician's Report prior to admission for two residents. | Type B |
Report Facts
Capacity: 105
Census: 78
Deficiencies cited: 1
Plan of Correction Due Date: Oct 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Sokolowski | Executive Director | Named in findings and exit interview |
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 105
Deficiencies: 0
Sep 14, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff placed bedridden residents on the second floor of the facility.
Findings
The investigation found insufficient evidence to substantiate the allegation. Records showed no residents medically assessed as bedridden on the second floor, and the allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff placed bedridden residents on the second floor. The investigation included interviews, records review, and observations. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 105
Bedridden residents allowed on ground floor: 12
Residents in question: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Sokolowski | Executive Director | Interviewed during investigation and exit interview |
| Brittany Blaul | Resident Service Director | Met during investigation |
Inspection Report
Capacity: 105
Deficiencies: 0
Sep 14, 2023
Visit Reason
Licensing Program Analyst Carmen Lopez conducted an unannounced visit to deliver complaint findings and concurrently conducted a case management visit.
Findings
The facility was provided additional guidance for hospice care for terminally ill residents and reappraisals for residents with changes in condition. The facility will closely monitor residents and ensure compliance with their approved license. Technical assistance was issued.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Sokolowski | Executive Director | Met during the visit and participated in the exit interview. |
| Brittany Blaul | Resident Service Director | Met during the visit. |
| Carmen Lopez | Licensing Program Analyst | Conducted the unannounced visit and delivered complaint findings. |
| Denise Powell | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 105
Deficiencies: 1
Sep 6, 2023
Visit Reason
Licensing Program Analyst Carmen Lopez conducted an unannounced visit to open a complaint investigation submitted on August 29, 2023, and to conduct a case management visit for review of resident records.
Findings
The facility did not keep resident #1's Physician’s Report (LIC602) updated, resulting in a technical violation issued to the facility.
Complaint Details
Complaint investigation initiated based on a complaint submitted on August 29, 2023. The facility was found to have a technical violation related to outdated resident documentation.
Deficiencies (1)
| Description |
|---|
| Facility did not keep resident #1's Physician’s Report (LIC602) updated. |
Report Facts
Capacity: 105
Census: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Sokolowski | Executive Director | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Brittany Blaul | Resident Service Director | Participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 105
Deficiencies: 1
Apr 12, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report regarding a resident who was briefly absent without leave (AWOL) from the secured memory care neighborhood.
Findings
The investigation found that a staff member (S2) did not have the necessary training to recognize the resident as a memory care resident, which contributed to the resident's AWOL incident. The facility conducted an internal investigation, implemented corrective measures including staff training and a missing resident drill, and cited one deficiency related to personnel competency.
Complaint Details
The visit was complaint-related, triggered by an incident report of a resident briefly leaving the secured memory care neighborhood unassisted. The complaint was substantiated by evidence showing staff incompetency contributed to the incident.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel (S2) was not competent to provide the services necessary to meet the needs of 1 of 81 residents (R1), posing a potential safety risk. | Type B |
Report Facts
Deficiencies cited: 1
Resident count: 81
Facility capacity: 105
Time resident was outside: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Rossi | Director of Operations | Met during visit and participated in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 105
Deficiencies: 1
Mar 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 03/03/2023 regarding lack of supervision resulting in resident elopement and concerns about personal hygiene products being accessible to an at-risk resident.
Findings
The investigation substantiated the allegation that lack of supervision resulted in resident elopement due to staff not following the absentee notification plan, posing a safety risk to one resident. Another allegation regarding personal hygiene products being accessible to an at-risk resident was unsubstantiated as evidence showed the resident was not at risk.
Complaint Details
The complaint investigation was substantiated for lack of supervision resulting in resident elopement. The allegation regarding personal hygiene products being accessible to an at-risk resident was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with the absentee notification plan after an exit door alarm went off, posing a potential safety risk to one resident. | Type B |
Report Facts
Deficiencies cited: 1
Resident census: 67
Facility capacity: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hamilton | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Patrick Frazier | Operations Specialist | Met with Licensing Program Analyst during the investigation and exit interview |
| Maria Rossi | Administrator | Facility administrator named in the report |
Inspection Report
Follow-Up
Census: 80
Capacity: 105
Deficiencies: 0
Sep 29, 2022
Visit Reason
The visit was a Case Management follow-up on an incident reported to Community Care Licensing on August 19, 2022.
Findings
During the visit, no violations were observed. Records were requested and reviewed, and an exit interview was conducted with the Resident Services Director.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dominick Orana | Resident Services Director | Met with during the visit and involved in the exit interview. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 105
Deficiencies: 0
Sep 29, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation following an allegation received on 07/27/2022 that the facility did not treat a bed bug infestation.
Findings
The investigation included a tour, staff and outside interviews, and records review, which found no evidence of bed bug infestation or failure to treat. The allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that since June 23, 2022, a resident had visible skin irritations and itching from bed bug bites, and that the facility failed to take action despite multiple reports. The investigation found no signs of bed bugs, confirmed active pest control contracts with regular inspections, and that residents with skin symptoms received medical treatment. The allegation was unsubstantiated.
Report Facts
Residents with symptoms: 6
Residents treated for scabies: 2
Residents treated for dry skin/eczema: 4
Pest control inspections: 3
Facility capacity: 105
Census: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| John Rante | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Dominick Orana | Resident Services Director | Met with during the investigation and exit interview |
| William Byrne, III | Executive Director | Met with during the investigation |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 105
Deficiencies: 0
Sep 16, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of neglect contributing to the death of a resident (Resident 1) on 07/18/2020.
Findings
The investigation included record reviews and interviews with staff, responsible persons, and outside sources. No evidence of neglect or lapse in staff response was found, and the allegation of neglect contributing to the resident's death was unsubstantiated.
Complaint Details
The complaint alleged neglect contributing to the death of Resident 1. The investigation found no supporting evidence of neglect, and the allegation was unsubstantiated.
Report Facts
Capacity: 105
Census: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation |
| William Byrne | Executive Director (Interim) | Met with Licensing Program Analyst during the investigation |
Inspection Report
Census: 87
Capacity: 105
Deficiencies: 0
May 26, 2022
Visit Reason
The Department conducted an announced Case Management visit to provide technical assistance and to evaluate the facility's COVID-19 screening, testing, and disinfection processes and the staff’s use of personal protective equipment.
Findings
During the visit, the Licensing Program Analyst and Healthcare Associated Infection nurses toured the facility, interacted with staff, and interviewed the administrator. No deficiencies were cited on this date.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randal Newton | Executive Director | Interviewed during the visit and participated in the exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the announced Case Management visit. |
| Elizar Perez | Nurse Contractor | Accompanied the Licensing Program Analyst during the visit. |
| Robert Montanillo | Nurse Contractor | Accompanied the Licensing Program Analyst during the visit. |
Inspection Report
Census: 81
Capacity: 126
Deficiencies: 0
Mar 25, 2022
Visit Reason
An unannounced case management visit was conducted due to a request to change the facility capacity.
Findings
The Licensing Program Analyst toured the facility, observed residents in care, and found the facility layout consistent with the current sketch. No immediate health or safety concerns were observed.
Report Facts
Capacity decrease request: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randal Newton | Administrator | Administrator present during the visit and participated in exit interview |
| Kristiana Lopez | Business Office Director | Greeted Licensing Program Analyst and discussed purpose of visit |
| Rebecca Ruiz | Licensing Program Analyst | Conducted the unannounced case management visit |
| Lizzette Tellez | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 81
Capacity: 126
Deficiencies: 0
Mar 25, 2022
Visit Reason
An unannounced required 1-year visit was conducted to evaluate the facility's compliance with licensing requirements and infection control measures.
Findings
No deficiencies were cited or observed during the inspection. The Licensing Program Analyst provided technical assistance and evaluated the facility's COVID-19 Mitigation Plan including disinfection, testing, vaccination, screening protocols, and PPE use.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randal Newton | Administrator | Named as the facility administrator present during the inspection and exit interview. |
| Kristiana Lopez | Business Office Director | Met by Licensing Program Analyst and explained the purpose of the visit. |
| Rebecca Ruiz | Licensing Program Analyst | Conducted the inspection and evaluation. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 126
Deficiencies: 0
May 13, 2021
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility was in disrepair with a dishwasher not working properly and that the facility was not kept clean.
Findings
The investigation found that the dishwasher was in working order despite requiring some repair about a month prior, and the kitchen floors and drains were observed to be clean with no noticeable food or debris. The complaint was determined to be unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included the dishwasher not working properly and the facility not being kept clean. Observations and interviews did not support these claims.
Report Facts
Capacity: 126
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Kennedy | Licensing Program Analyst | Conducted the complaint investigation |
| Randal Newton | Executive Director | Facility representative met during the investigation |
| Rebecca Hedgecock | Licensing Program Manager | Named in report as Licensing Program Manager |
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