Inspection Reports for Westmont of Brentwood
450 John Muir Pkwy, Brentwood, CA 94513, United States, CA, 94513
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. However, the facility has had some substantiated issues over time, primarily related to medication management, staffing adequacy, and resident supervision. Notably, the most recent report from July 17, 2025, was clean with no deficiencies found during complaint investigations. Past serious findings included failures to administer medications properly, inadequate supervision leading to resident injury and wandering, and delayed incident reporting, but these issues appear to have been addressed with corrective actions and staff retraining. The overall pattern suggests improvement in recent inspections, with no new deficiencies cited in the latest visits.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
75% occupied
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 116
Capacity: 155
Deficiencies: 0
Date: Jul 17, 2025
Visit Reason
The visit was an unannounced complaint investigation to address allegations that staff did not respond to a resident's call button in a timely manner and left a resident in a soiled diaper for a long period of time.
Complaint Details
The complaint alleged that staff did not respond timely to a resident's call button and left the resident in a soiled diaper for a long period. The complaint was found to be unfounded and dismissed.
Findings
The investigation found the allegations to be unfounded based on documentation and record review, determining that the facility ensured the resident received an appropriate level of care. No deficiencies were issued.
Report Facts
Capacity: 155
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martin Vega | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
| Eduardo Rangel | Administrator | Facility administrator met during inspection |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 155
Deficiencies: 0
Date: Jul 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including insufficient staffing, lack of an Activities Director, unsanitary resident bathrooms, resident assault, delayed medical services, and neglect resulting in injury.
Complaint Details
The complaint investigation was triggered by allegations that the facility did not have enough staff, lacked an Activities Director, had unsanitary resident bathrooms, a resident assaulted another resident, the facility did not seek medical services timely, and neglect/lack of supervision resulted in injury. All allegations were found unsubstantiated or unfounded.
Findings
The investigation found all allegations to be unsubstantiated or unfounded based on record review, interviews, and facility tour. No deficiencies were issued and the allegations were dismissed.
Report Facts
Capacity: 155
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martin Vega | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Eduardo Rangel | Administrator | Facility administrator met during the investigation |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 115
Capacity: 155
Deficiencies: 0
Date: Jul 10, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be clean, in good repair, and free of fire hazards. Food storage and temperatures were adequate, resident rooms were properly furnished and safe, medications and chemicals were securely stored, and staff and resident files were up to date. No immediate hazards or deficiencies were noted in the narrative.
Report Facts
Facility capacity: 155
Census: 115
Food storage temperatures: 43
Food storage temperatures: -6
Hot water temperatures: 111.3
Hot water temperatures: 107.4
Hot water temperatures: 110.8
Hot water temperatures: 105.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eddie Rangel | Administrator / Executive Director | Met with Licensing Program Analyst during inspection |
| Martin Vega | Licensing Program Analyst | Conducted the inspection |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 115
Capacity: 155
Deficiencies: 0
Date: Feb 21, 2025
Visit Reason
The visit was an unannounced Case Management inspection conducted by the Licensing Program Analyst to serve a Decision and Order excluding a staff member from the facility and to ensure compliance with personnel reporting requirements.
Findings
No deficiencies were observed or cited during the visit. The Licensing Program Analyst served a Decision and Order excluding Staff 1 from the facility and instructed the Executive Director to update personnel records accordingly.
Report Facts
Capacity: 155
Census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eduardo Rangel | Executive Director | Met with Licensing Program Analyst during the inspection and was informed about the exclusion order for Staff 1 |
| Martin Vega | Licensing Program Analyst | Conducted the unannounced Case Management visit and served the Decision and Order |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 155
Deficiencies: 0
Date: Jan 28, 2025
Visit Reason
The visit was an unannounced Case Management visit conducted to follow up on an incident report submitted on 12/17/2024 regarding a client being out of medication for 6 days.
Complaint Details
The complaint involved Client #1 being out of medication for 6 days. The incident was substantiated and addressed with corrective actions including staff retraining and monitoring.
Findings
The facility took immediate and appropriate action by disciplining and retraining the medication technician involved, notifying the client's physician, and placing the client under observation with no issues observed. No deficiencies were cited.
Report Facts
Incident report date: Dec 17, 2024
Medication lapse duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eduardo Rangel | Administrator / Executive Director | Met with Licensing Program Analyst during visit and provided information on corrective actions |
| Martin Vega | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Brenda Chan | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 155
Deficiencies: 0
Date: Jan 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-10-29 alleging that staff do not ensure privacy while providing personal care to residents.
Complaint Details
The complaint alleged that staff do not ensure privacy while providing personal care to residents. The investigation included interviews with three staff members, two of whom stated the allegations did not occur. The allegations were determined to be unsubstantiated.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur, resulting in the allegations being unsubstantiated.
Report Facts
Complaint Control Number: 24
Complaint Control Number Suffix: 20241029140334
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martin Vega | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Eduardo Rangel | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 155
Deficiencies: 1
Date: Oct 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-07-05 regarding multiple allegations against facility staff practices.
Complaint Details
The complaint investigation was unannounced and addressed multiple allegations including medication errors, supervision of children, communication with authorized representatives, hygiene issues, and safeguarding resident property. Only the allegation regarding safeguarding resident property was substantiated; others were unsubstantiated.
Findings
The investigation found one allegation substantiated regarding failure to safeguard resident property, specifically a lost hearing aid not reimbursed to the resident. All other allegations, including medication dispensing, supervision, communication, hygiene, and cleanliness, were found unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
The facility failed to provide a replacement or monetary refund to resident when lost hearing aid for resident 1 while resided at the facility in June 2024, which poses health and safety risk to persons in care.
Report Facts
Capacity: 155
Census: 103
Plan of Correction Due Date: Oct 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Eduardo Rangel | Administrator | Facility administrator met during investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 155
Deficiencies: 1
Date: Sep 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2024-06-05 regarding infection control, facility odor, and resident laundry cleanliness.
Complaint Details
The complaint investigation was unannounced and conducted due to allegations that staff did not meet infection control requirements, the facility was malodorous, and staff did not ensure residents had clean laundry. The infection control and laundry allegations were unsubstantiated, while the failure to sanitize the resident room was substantiated.
Findings
The investigation found one substantiated allegation that staff failed to ensure the R1 room was sanitized after a resident left for the hospital, posing potential health and safety risks. Two other allegations regarding infection control and laundry cleanliness were unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
Facility failed to ensure resident room was cleaned and disinfected until 05/31/2024 after resident left on 05/13/2024, posing potential health, safety, and personal rights risk.
Report Facts
Census: 110
Total Capacity: 155
Deficiency Type: 1
Plan of Correction Due Date: Sep 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Brenda Chan | Licensing Program Manager | Oversaw the complaint investigation |
| Eduardo Rangel | Administrator | Facility administrator involved in interviews and findings discussion |
Inspection Report
Annual Inspection
Census: 107
Capacity: 155
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean, in good repair, and compliant with safety and health standards. No deficiencies were issued during this inspection.
Report Facts
Facility capacity: 155
Census: 107
Refrigerator temperature: 43
Freezer temperature: -6
Hot water temperature: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eddie Rangel | Administrator / Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Vadim Gorban | Licensing Program Analyst | Conducted the inspection |
| Brenda Chan | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 155
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2024-03-21 regarding allegations that staff did not follow infection control practices and reporting requirements.
Complaint Details
Allegations of staff not following infection control practices and reporting requirements were investigated and found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included a review of facility files, staff interviews, and observations. No evidence was found to substantiate the allegations, and the complaint was determined to be unsubstantiated.
Report Facts
Capacity: 155
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eddie Rangel | Administrator | Met with Licensing Program Analyst during the investigation and discussed findings |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 155
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2024-01-26 regarding multiple allegations about staff performance and facility monitoring.
Complaint Details
The complaint included allegations that staff did not ensure residents received contracted services, did not dispense medication as prescribed, did not assist residents timely with care needs, and did not adequately monitor facility entrance doors. All allegations were found to be unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations, including failure to provide contracted services, medication dispensing errors, timely assistance with care needs, and monitoring of facility entrance doors. No deficiencies were cited during the visit.
Report Facts
Capacity: 155
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eddie Rangel | Administrator | Met with Licensing Program Analyst during investigation and discussed findings |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 155
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that facility staff did not prevent the spread of scabies among residents and staff.
Complaint Details
Allegation: Facility staff did not prevent spread of scabies amongst residents and staff. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found no evidence that staff or residents contracted scabies. Based on interviews and records review, the allegation was unsubstantiated and no deficiencies were cited during the visit.
Report Facts
Capacity: 155
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eddie Rangel | Administrator | Met with Licensing Program Analyst during the investigation and discussed findings |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 155
Deficiencies: 0
Date: Mar 22, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2024-02-21 regarding facility door locks.
Complaint Details
The complaint alleged that staff did not ensure facility door locks were in good repair. The allegation was unsubstantiated after investigation.
Findings
The investigation found that the facility door locks were in good repair based on observations and interviews with staff, the administrator, and residents. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 155
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eddie Rangel | Administrator | Met with Licensing Program Analyst during investigation and discussed findings |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 155
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2023-12-12 alleging that staff did not dispense medication to a resident in a timely manner.
Complaint Details
The complaint alleged that staff did not dispense medication to a resident in a timely manner. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included a review of facility records and interviews with staff and the Administrator. Medication administration to the resident was found to be as prescribed, and there was insufficient evidence to prove the alleged violation. Therefore, the complaint was unsubstantiated.
Report Facts
Capacity: 155
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eddie Rangel | Administrator | Met with Licensing Program Analyst during the investigation and discussed findings |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 155
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2023-11-30 alleging that staff did not seek medical attention for residents with scabies.
Complaint Details
The complaint alleged that staff did not seek medical attention for residents with scabies. The investigation found the allegation unsubstantiated.
Findings
The investigation included a facility tour, record review, and staff interviews. The facility addressed scabies by notifying medical personnel and administering medication to affected residents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 155
Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eddie Rangel | Administrator | Met with Licensing Program Analyst during the investigation and discussed findings |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
Inspection Report
Census: 87
Capacity: 155
Deficiencies: 4
Date: Feb 21, 2024
Visit Reason
A scheduled informal meeting was conducted via teleconference to discuss recently identified issues associated with the operation of the facility and to provide support on the subject matter.
Findings
The meeting addressed deficiencies related to facility staffing, care and supervision, medications, and reporting requirements. The Executive Director agreed to develop a written plan of action to ensure compliance by 02/26/2024, with potential increased monitoring or administrative action if not completed.
Deficiencies (4)
Facility staffing issues
Care and supervision deficiencies
Medication-related deficiencies
Reporting requirements deficiencies
Report Facts
Compliance deadline: Feb 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eduardo Rangel | Executive Director | Agreed to develop plan of action to address deficiencies |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 155
Deficiencies: 2
Date: Feb 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including sharing of hygiene products and clothes, disclosure of personal information, inadequate supervision, mishandling of medications, and failure to properly report incidents involving residents.
Complaint Details
The complaint investigation was initiated based on allegations received on 11/03/2023. Some allegations such as sharing hygiene products, sharing clothes, disclosure of personal information, and inadequate supervision were found unsubstantiated. The allegations of mishandling medications and failure to properly report incidents were substantiated.
Findings
The investigation found some allegations unsubstantiated due to lack of preponderance of evidence, while the allegations regarding mishandling of medications and failure to properly report incidents were substantiated. Deficiencies were cited related to failure to administer medications as prescribed and failure to submit timely reports to the licensing agency.
Deficiencies (2)
Facility failed to administer medications as prescribed and according to physician directions, posing an immediate risk to health and safety to residents in care.
Facility failed to provide a report to Licensing Agency following Title 22 regulations in a timely manner, posing potential risk to health and safety to residents in care.
Report Facts
Capacity: 155
Census: 73
Deficiencies cited: 2
Plan of Correction Due Date: Feb 2, 2024
Plan of Correction Due Date: Feb 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brenda Chan | Licensing Program Manager | Oversaw the licensing program and signed the report |
| Eddie Rangel | Administrator | Facility administrator met during the investigation and involved in findings discussion |
| Patrick Frazier | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 155
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-11-06 regarding staff not responding to resident assistance and making inappropriate comments in the presence of residents.
Complaint Details
The complaint involved allegations that staff did not respond to resident assistance and made inappropriate comments in the presence of residents. The investigation concluded the allegations were unsubstantiated.
Findings
The investigation included a facility tour, record review, and interviews with staff and the administrator. The allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove the violations occurred.
Report Facts
Capacity: 155
Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eddie Rangel | Administrator | Met with Licensing Program Analyst during the investigation and discussed findings |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 155
Deficiencies: 0
Date: Nov 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-15 alleging that the facility does not have an administrator.
Complaint Details
Complaint was found to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis. The complaint was dismissed.
Findings
The investigation found the complaint to be unfounded after reviewing the facility file, interviewing the administrator and staff, and touring the facility. The allegation that the facility does not have an administrator was determined to be false and without reasonable basis.
Report Facts
Capacity: 155
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Fowler | Business Office Director | Met with Licensing Program Analyst during the investigation |
| Patrick Frazier | Administrator | Notified of licensing visit and interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 155
Deficiencies: 0
Date: Sep 28, 2023
Visit Reason
Unannounced visit/investigation of a complaint received on 2023-07-05 regarding facility disrepair and room temperature maintenance.
Complaint Details
Allegations included facility disrepair and staff not ensuring a resident's room was maintained at a comfortable temperature. Both allegations were found unsubstantiated.
Findings
The investigation found the allegations unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 155
Census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jennifer Fowler | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 155
Deficiencies: 2
Date: Sep 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/11/2023 regarding facility alarm disrepair, resident injuries due to staff neglect, and failure to prevent resident wandering.
Complaint Details
The complaint investigation was initiated based on allegations received on 07/11/2023. The allegation regarding the facility alarm was unsubstantiated. The allegations that a resident sustained injuries due to staff neglect and that staff did not prevent the resident from wandering were substantiated. The resident was found outside with a skin tear and was unsupervised during the night. Relevant California Code of Regulations and Health and Safety Codes were cited.
Findings
The allegation that the facility alarm was in disrepair was found unsubstantiated after testing and review. However, two allegations were substantiated: a resident sustained injuries due to staff neglect, and staff failed to prevent the resident from wandering outside the facility unsupervised, posing immediate health and safety risks.
Deficiencies (2)
Failure to provide adequate care and supervision, resulting in a resident being found outside unsupervised with injuries.
Failure to provide safety measures to address wandering behavior, allowing a resident to leave the facility unsupervised at night.
Report Facts
Capacity: 155
Census: 102
Deficiencies cited: 2
Plan of Correction Due Dates: Type A deficiency due 09/29/2023, Type B deficiency due 10/16/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Fowler | Administrator | Met with Licensing Program Analyst to discuss findings |
| Vadim Gorban | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 113
Capacity: 155
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
An unannounced Case Management visit was conducted following a report to Licensing on 7/24/23.
Findings
No deficiencies were cited during this Case Management visit. The Licensing Program Analyst toured the facility, reviewed resident files, interviewed staff and administrator, and attempted to interview residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik V. Schuk | Administrator | Met with Licensing Program Analyst during the visit. |
| Vadim Gorban | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Brenda Chan | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 155
Deficiencies: 1
Date: Jul 18, 2023
Visit Reason
The visit was a case management incident investigation regarding an incident involving resident R1 that occurred on 2023-06-14 and was not reported until 2023-06-26.
Complaint Details
The visit was complaint-related, investigating an incident involving resident R1. The incident was substantiated as the licensee did not report the incident timely, posing potential risks to residents.
Findings
The Licensing Program Analyst found that the facility failed to report the incident involving resident R1 within the required timeframe, posing potential health, safety, and personal rights risks to residents in care.
Deficiencies (1)
Failure to submit a written report to the licensing agency and responsible person within seven days of the incident involving resident R1, as required by reporting regulations.
Report Facts
Census: 112
Total Capacity: 155
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik V. Schuk | Administrator | Met with Licensing Program Analyst during visit and provided personnel report |
| Vadim Gorban | Licensing Program Analyst | Conducted the case management visit and investigation |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 155
Deficiencies: 1
Date: Jul 5, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation following a complaint received on 04/04/2023 alleging that facility staff did not dispense medication as prescribed.
Complaint Details
The complaint alleging that facility staff did not dispense medication as prescribed was substantiated based on the preponderance of evidence standard.
Findings
The investigation found that facility staff failed to give medication as prescribed to a resident, which was substantiated based on interviews, observations, and record reviews. This posed an immediate health and safety risk to the resident.
Deficiencies (1)
Facility staff failed to give medication as prescribed and resident missed medications, which poses an immediate Health and Safety risk to the resident in care.
Report Facts
Capacity: 155
Census: 140
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation visit |
| Michelle Gonzalez | Residential Services Director | Met with Licensing Program Analyst during investigation and discussed allegation findings |
| Erik V. Schuk | Administrator | Facility administrator not available during investigation |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 155
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-04-04 alleging that facility staff did not assist a resident in a timely manner.
Complaint Details
The allegation that facility staff did not assist a resident in a timely manner was investigated and found unsubstantiated.
Findings
The investigation, including observation, records review, and interviews, found the allegation unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.
Report Facts
Capacity: 155
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Gonzalez | Resident Services Director | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| Erik V. Schuk | Administrator | Named as facility administrator; not available during the investigation |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 155
Deficiencies: 0
Date: Jun 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints alleging inadequate staffing and improper handling of residents' medications at the facility.
Complaint Details
The complaint investigation was unsubstantiated for both allegations: 1) Facility does not have adequate staff to meet the needs of the residents, and 2) Facility staff are not properly handling resident's medications.
Findings
The investigation found both allegations unsubstantiated based on observations, interviews, record reviews, and facility tours. There was no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 155
Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Schuk | Administrator | Met with Licensing Program Analyst during investigation and named in findings discussion |
| Vadim Gorban | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 102
Capacity: 155
Deficiencies: 0
Date: Mar 21, 2023
Visit Reason
The visit was conducted as a follow-up to an incident reported to the department on 03/01/2023, specifically to verify details related to the incident and facility actions.
Findings
The Licensing Program Analyst visited the facility, followed infection prevention protocols, and attempted to interview a resident with dementia who was unable to confirm the return of a missing ring. The resident's family confirmed the ring was returned and kept in their possession. The facility terminated an employee (S1) related to the incident and disassociated them from the facility roster.
Report Facts
Facility capacity: 155
Resident census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik V. Schuk | Administrator | Named as facility administrator and involved in the incident follow-up |
| Jennifer Fowler | Assistance Administrator | Met with Licensing Program Analyst and signed the exit interview report |
| Vadim Gorban | Licensing Program Analyst | Conducted the follow-up visit and investigation |
Inspection Report
Follow-Up
Census: 93
Capacity: 155
Deficiencies: 1
Date: Oct 13, 2022
Visit Reason
The visit was an unannounced Case Management follow-up to an incident report submitted regarding a hospice resident who received a discontinued medication.
Complaint Details
The visit was triggered by a complaint regarding a hospice resident receiving a discontinued medication on 09/13/2022.
Findings
A deficiency was cited for failure to assist residents with self-administered medications as required, specifically for administering a discontinued medication to a resident, posing an immediate health and safety risk. A civil penalty of $250 was assessed for a repeat violation.
Deficiencies (1)
Facility staff administered a medication to a resident that had been discontinued, violating requirements for assisting residents with self-administered medications.
Report Facts
Civil penalty amount: 250
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik V. Schuk | Administrator | Met with Licensing Program Analyst during visit and involved in plan of correction |
| Alexandria Walton | Licensing Program Analyst | Conducted the unannounced Case Management visit and cited deficiency |
| Melinda Hoffmann | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Follow-Up
Census: 91
Capacity: 155
Deficiencies: 2
Date: Oct 3, 2022
Visit Reason
The visit was an unannounced case management follow-up to an incident report regarding a medication error where staff administered the same medication twice to a resident, and to investigate multiple falls of another resident that were not reported to the licensing agency.
Complaint Details
The visit was triggered by a complaint investigation following an incident report of a medication error and unreported multiple falls of a resident. The investigation number is #24-AS-20220729113420.
Findings
Deficiencies were found related to failure to assist residents properly with self-administered medications and failure to report multiple falls of a resident to the licensing agency, posing immediate health and safety risks.
Deficiencies (2)
Staff administered two of the same medication to resident R1, violating requirements for assistance with self-administered medications.
The facility failed to report multiple falls of resident R1 to the Fresno Community Care Licensing Office within the required timeframe.
Report Facts
Deficiencies cited: 2
Capacity: 155
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Schuk | Administrator | Met with Licensing Program Analyst during the visit and acknowledged receipt of report and appeal rights. |
| Alexandria Walton | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| Melinda Hoffmann | Licensing Program Manager | Supervisor overseeing the licensing program and deficiencies. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 155
Deficiencies: 1
Date: Oct 3, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff did not respond timely to an egress alarm, resulting in a resident exiting memory care, falling, and sustaining an injury.
Complaint Details
The complaint was substantiated based on interviews and records review. Staff did not respond timely to the egress alarm, resulting in a resident exiting memory care, falling, and sustaining an injury.
Findings
The investigation found that staff failed to respond to the egress alarm for approximately 34 minutes, leading to a resident leaving the facility undetected and sustaining a head injury. The allegation was substantiated and a deficiency was cited related to insufficient staff supervision and care.
Deficiencies (1)
Failure to ensure resident's needs were met when resident was able to leave the facility undetected resulting in a fall outside the facility, posing an immediate health and safety risk.
Report Facts
Response time to egress alarm (minutes): 34
Census: 91
Total Capacity: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Erik Schuk | Administrator | Met with Licensing Program Analyst during the investigation and received report and plan of correction. |
Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 0
Date: Aug 8, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-05-13 regarding resident care and facility conditions.
Complaint Details
The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
Based on observation, record review, and interviews, all allegations including foul odors, unkempt bathrooms, unattended residents, transportation issues, medication management, and failure to seek medical care were found to be unsubstantiated. No deficiencies were issued during the inspection.
Report Facts
Facility capacity: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik Schuk | Administrator | Met with Licensing Program Analyst during investigation and received exit interview |
| Alexandria Walton | Licensing Program Analyst | Conducted complaint investigation visit |
| Melinda Hoffmann | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 88
Capacity: 155
Deficiencies: 2
Date: Jul 28, 2022
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst Walton to evaluate compliance with regulatory requirements at the facility.
Findings
The facility was generally compliant with safety and infection control measures, including clear pathways, use of facial coverings, and sanitation practices. However, deficiencies were cited for medications and knives being accessible to residents in room 134, posing immediate health and safety risks.
Deficiencies (2)
Medications in room 134 were accessible to residents, violating safe and locked storage requirements.
A small container of knives in room 134 was accessible to residents, violating storage safety requirements.
Report Facts
Capacity: 155
Census: 88
Plan of Correction Due Date: Jul 29, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erik V. Schuk | Administrator | Met with Licensing Program Analyst during inspection and involved in Plan of Correction |
| Alexandria Walton | Licensing Program Analyst | Conducted the inspection and authored the report |
| Melinda Hoffmann | Licensing Program Manager | Supervised the inspection process |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 155
Deficiencies: 1
Date: May 9, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-04-08 regarding staff fraudulently signing medication administration records, mismanagement of resident medications, and delayed response to resident calls for assistance.
Complaint Details
The complaint investigation was substantiated for the allegation that staff fraudulently signed medication administration records. The allegations of staff mismanaging medications and delayed response to resident calls were previously cited and addressed with a Plan of Correction. Other allegations related to trash, meal service, and cleanliness were unsubstantiated.
Findings
The allegation that staff fraudulently signed medication administration records was substantiated based on interviews and record reviews, revealing that medications were signed off as given prior to actual administration, posing an immediate health and safety risk. Other allegations regarding trash maintenance, meal service, and floor cleanliness were found to be unsubstantiated.
Deficiencies (1)
87207 False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. Based on interviews and record review, S1 made false/misleading statements when S1 initialed that medications were administered to residents when S1 did not administer medications. This poses an immediate health and safety risk to residents in care.
Report Facts
Capacity: 155
Census: 79
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Administrator | Met with during inspection and involved in Plan of Correction discussion |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melinda Hoffmann | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Follow-Up
Census: 76
Capacity: 155
Deficiencies: 1
Date: May 2, 2022
Visit Reason
The inspection was conducted as a follow-up to an incident reported on 2022-04-18 regarding a medication administration error where medications prepared for a resident were not administered but documented as given.
Findings
The facility was found deficient for failing to ensure all residents were assisted with self-administered medications as needed, posing an immediate health and safety risk. A deficiency was issued under California Code Regulations, Title 22, Division 6.
Deficiencies (1)
Failure to assist residents with self-administered medications as needed, posing an immediate health and safety risk.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Administrator | Met with Licensing Program Analyst during inspection and involved in Plan of Correction |
| Alexandria Walton | Licensing Program Analyst | Conducted the inspection and authored the report |
| Melinda Hoffmann | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 75
Capacity: 155
Deficiencies: 1
Date: Apr 13, 2022
Visit Reason
The visit was an unannounced Case Management - Deficiencies Inspection to follow up on 6 incident reports that were not submitted to the Fresno CCL office within 7 days of occurrence.
Findings
A deficiency was cited for failure to submit written incident reports within seven days of occurrence, as evidenced by 6 incident reports submitted late. A Plan of Correction was reviewed and developed with the Administrator.
Deficiencies (1)
Failure to furnish written incident reports within seven days of occurrence as evidenced by 6 incident reports submitted after the 7-day time frame.
Report Facts
Incident reports submitted late: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Administrator | Met with Licensing Program Analyst during inspection and involved in Plan of Correction |
| Alexandria Walton | Licensing Program Analyst | Conducted the inspection and signed the report |
| Melinda Hoffmann | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 155
Deficiencies: 1
Date: Apr 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-11-30 regarding residents' showering needs not being met and other allegations.
Complaint Details
The complaint investigation was substantiated for the allegation that residents' showering needs were not being met. Other allegations about ants, falls, and bruising were unsubstantiated due to insufficient evidence.
Findings
The allegation that residents' showering needs were not being met was substantiated based on staff interviews and review of shower records showing incomplete shower schedules. Other allegations regarding ants, falls due to lack of supervision, and bruising were found unsubstantiated due to lack of sufficient evidence.
Deficiencies (1)
Facility did not ensure residents were assisted with activities of daily living such as bathing as evidenced by facility shower logs and consistent staff statements, posing a potential health and safety risk.
Report Facts
Capacity: 155
Census: 75
Plan of Correction Due Date: May 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Pamela Hamilton | Administrator | Facility administrator involved in the investigation and exit interview |
| Melinda Hoffmann | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 155
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 2022-01-11 regarding multiple allegations about resident care and facility conditions.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not safeguarding resident's personal belongings, dirty resident's room, inadequate bedding, unmet hygiene needs, no hand soap in bathroom, and TV in disrepair. Interviews, observations, and record reviews did not support these allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations concerning safeguarding of personal belongings, cleanliness of resident's room, adequacy of bedding, hygiene needs, availability of hand soap, and condition of resident's TV. No deficiencies were issued during this inspection.
Report Facts
Capacity: 155
Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Pamela Hamilton | Administrator | Facility administrator met during investigation and exit interview |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 155
Deficiencies: 1
Date: Apr 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-02-03 regarding staff not responding timely to resident calls due to insufficient staffing and failure to provide appropriate transportation for residents.
Complaint Details
The complaint was substantiated for the allegation that staff do not respond timely to resident calls due to insufficient staffing. The allegation regarding failure to provide appropriate transportation was unsubstantiated.
Findings
The allegation that staff do not respond timely to resident calls due to insufficient staffing was substantiated based on observations and interviews, including an observed 27-minute delay in response to an emergency call. The allegation that the facility failed to provide appropriate transportation for residents was unsubstantiated due to lack of sufficient evidence.
Deficiencies (1)
Facility staff did not respond timely to residents' emergency call buttons, posing a potential health and safety risk.
Report Facts
Response time to emergency call: 27
Deficiency Plan of Correction Due Date: May 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including residents sustaining pressure injuries, staff leaving residents in soiled diapers for extended periods, inadequate food service, questionable death, and residents wandering away from the facility.
Complaint Details
The complaint investigation was triggered by allegations of multiple residents sustaining pressure injuries, staff neglect in hygiene and food service, questionable death, and residents wandering away. The findings were unsubstantiated or unfounded, meaning the allegations were not proven or were false.
Findings
The investigation found all allegations to be unsubstantiated or unfounded due to lack of preponderance of evidence or reasonable basis. No deficiencies were issued during the inspection.
Report Facts
Facility capacity: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
Unannounced visit/investigation of a complaint received on 2022-03-04 regarding allegations that staff failed to provide a comfortable environment for residents, the facility is in disrepair, and the facility is unkempt.
Complaint Details
The complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations did or did not occur.
Findings
Based on observation, record review, and interviews with residents and staff, the allegations were found to be unsubstantiated. No deficiencies were issued during this inspection.
Report Facts
Facility capacity: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Administrator | Met with Licensing Program Analyst during the investigation and named in the report |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 0
Date: Mar 9, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2021-11-29 regarding facility neglect, failure to observe changes in resident health, and unmet bathing needs.
Complaint Details
The complaint involved allegations of facility neglect resulting in a resident developing an infection, failure of staff to observe changes in resident's health condition, and unmet bathing needs. The investigation concluded these allegations were unsubstantiated.
Findings
Based on interviews and record reviews, the allegations were found to be unsubstantiated. No deficiencies were issued during this inspection.
Report Facts
Facility capacity: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Administrator | Met with Licensing Program Analyst during the investigation |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 101
Capacity: 155
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
An informal meeting was held to discuss recently identified issues associated with the operation of the facility, including recent deficiencies and staffing concerns.
Findings
The meeting focused on recent deficiencies and staffing concerns at the facility. The Department offered to submit a referral to the Technical Support Program to assist the facility in returning to substantial compliance, which was accepted by facility leadership.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Executive Director | Met with during the informal meeting discussing facility issues |
| Diane Navarro | Regional Director of Operations | Met with during the informal meeting discussing facility issues |
| Melinda Hoffmann | Licensing Program Manager | Present during the meeting and named in the report |
| Alexandria Walton | Licensing Program Analyst | Present during the meeting and named in the report |
| Sergiy Pidgirny | Licensing Program Manager | Present during the meeting and named in the report |
Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 1
Date: Nov 3, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 08/20/2021 alleging that staff were not wearing masks.
Complaint Details
Complaint was substantiated. The complaint alleged staff were not wearing masks, which was confirmed during the investigation.
Findings
The investigation found that 3 out of 4 dining room staff were observed not wearing facial coverings or wearing them improperly, violating official government orders and posing a potential health and safety risk to residents.
Deficiencies (1)
Facility did not ensure staff are wearing facial coverings as mandated, with 3 out of 4 dining staff not wearing facial coverings during the lunch period.
Report Facts
Capacity: 155
Dining staff non-compliance: 3
Dining staff total: 4
Plan of Correction due date: Dec 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Pamela Hamilton | Executive Director | Met with Licensing Program Analyst during investigation |
| Olaf Becker | Resident Service Director | Met with Licensing Program Analyst during investigation |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 155
Deficiencies: 0
Date: Jul 14, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to an allegation that a resident sustained an unwitnessed fall resulting in fracture.
Complaint Details
The complaint was unsubstantiated; although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur.
Findings
The allegation was found to be unsubstantiated based on record review and staff interviews. No deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation and staff interviews. |
| Pamela Hamilton | Administrator | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Annual Inspection
Census: 109
Capacity: 155
Deficiencies: 0
Date: Jun 30, 2021
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with regulatory requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. Observations included proper infection control measures, secure medication storage, and no fire clearance issues.
Report Facts
Capacity: 155
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Administrator | Met with Licensing Program Analyst during inspection |
| Olaf Becker | Resident Services Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Census: 70
Capacity: 155
Deficiencies: 0
Date: May 6, 2021
Visit Reason
The inspection was an unannounced Case Management Inspection conducted by Licensing Program Analyst A. Walton to assess compliance and conduct resident interviews.
Findings
No deficiencies were issued during the inspection. Resident interviews were conducted and an exit interview was held with the Executive Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Executive Director | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 1
Date: Mar 23, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted due to an allegation of illegal eviction received on 10/01/2020.
Complaint Details
The complaint investigation was substantiated based on evidence that the facility did not follow proper eviction procedures for resident R1, including failure to conduct a second needs appraisal and failure to provide a 30-day eviction notice.
Findings
The investigation found that the facility failed to conduct a second needs and services appraisal for resident R1 and did not issue a 30-day eviction notice to R1 or the Responsible Party, substantiating the allegation of illegal eviction.
Deficiencies (1)
Failure to legally evict resident R1 by not conducting a reappraisal and not providing a thirty (30) day written eviction notice as required by California Code of Regulations, Title 22, Division 6, Section 87224(a)(4).
Report Facts
Capacity: 155
Plan of Correction Due Date: Apr 2, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Pamela Hamilton | Executive Director | Facility administrator involved in the investigation and exit interview |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 1
Date: Mar 23, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations that staff were not responding timely to resident needs and that the facility did not report changes in condition to a resident's physician.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not responding timely to resident needs due to insufficient staffing. The allegation that the facility did not report changes in condition to a resident's physician was unsubstantiated.
Findings
The allegation that staff were not responding timely to resident needs was substantiated based on interviews and record reviews indicating insufficient staffing. The allegation that the facility did not report changes in condition to a resident's physician was unsubstantiated with no deficiencies issued.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide the services necessary to meet resident needs, posing a potential health and safety risk.
Report Facts
Facility capacity: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hamilton | Executive Director | Named in relation to findings and interviews during the complaint investigation |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Capacity: 155
Deficiencies: 1
Date: Mar 23, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation received on 01/22/2021 that the facility was not meeting resident needs due to insufficient staffing.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard after staff interviews and record review confirmed insufficient staffing to meet resident needs.
Findings
The investigation found, based on staff interviews and record reviews, that the facility did not have sufficient personnel to meet resident needs, substantiating the allegation of insufficient staffing.
Deficiencies (1)
Facility did not ensure personnel was sufficient in numbers, qualifications, and competency to meet resident needs, posing a potential health and safety risk.
Report Facts
Total licensed capacity: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Pamela Hamilton | Executive Director | Facility representative interviewed during the investigation |
| Melinda Hoffmann | Licensing Program Manager | Named in the report as Licensing Program Manager |
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