Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not confirmed. The facility had isolated issues related to resident elopement due to malfunctioning egress doors and supervision lapses, with the most recent report on October 22, 2025, citing a deficiency for inadequate supervision after a resident left the memory care unit unassisted, resulting in a civil penalty. Previous reports noted problems with food safety, medication record maintenance, and accessible cleaning supplies, but these were addressed promptly. There is a mixed pattern with some improvement seen after earlier deficiencies, though recent findings show ongoing challenges with supervision and door alarms. No fines beyond the immediate civil penalty were listed in the available reports.
An unannounced case management visit was conducted to follow up on an incident report regarding a resident who eloped from the facility.
Findings
The resident with neurocognitive disorder left the memory care unit unassisted and was found 0.4 miles away from the facility. Staff did not hear door alarms, and the resident has a history of exit-seeking behavior. An immediate civil penalty was issued for absence of supervision.
Complaint Details
The visit was complaint-related due to an incident report of a resident eloping. The resident was found outside the facility 0.4 miles away. The complaint was substantiated with findings of inadequate supervision.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Failure to provide care, supervision, and services that meet individual needs, resulting in a resident eloping from the facility.
Type A
Report Facts
Civil penalty amount: 500Distance resident eloped: 0.4Plan of Correction due date: Oct 23, 2025
Employees Mentioned
Name
Title
Context
Michael Fountain
Administrator
Met with Licensing Program Analyst during inspection and reviewed report.
Manuel Monter
Licensing Program Analyst
Conducted the unannounced case management visit and authored the report.
An unannounced case management visit was conducted in response to an incident report stating that a resident had eloped from the facility on October 15, 2025.
Findings
The resident was found outside the community and safely returned with no visible injuries. The Licensing Program Analyst interviewed staff, reviewed schedules and care plans, and determined that further investigation is required.
Complaint Details
The visit was triggered by a complaint/incident report regarding a resident eloping from the facility. The incident was substantiated by the facility's report and further investigation was deemed necessary.
Report Facts
Census: 85Total Capacity: 112
Employees Mentioned
Name
Title
Context
Brianne Merritt
Business Office Director
Met with Licensing Program Analyst during the visit and reviewed the report
The inspection was an unannounced annual required 1-year inspection conducted to evaluate compliance with regulations at the facility.
Findings
The inspection found no deficiencies; resident files and medication records were complete, fire safety equipment and emergency plans were in place and functional, and environmental conditions such as temperatures and food storage met standards.
Report Facts
Resident files reviewed: 4Resident medications reviewed: 4Staff files reviewed: 4Fire extinguisher last service date: Jun 28, 2024Emergency drill frequency: 1Hot water temperature range: 111Kitchen refrigerator temperature: 26Kitchen freezer temperature: 0Walk-in refrigerator temperature: 36Walk-in freezer temperature: 0Food supply duration: 2Food supply duration: 7
Employees Mentioned
Name
Title
Context
Jolie Higgins
Executive Director
Met with Licensing Program Analyst during inspection and reviewed report
Ria Hernandez
Resident Services Director
Met with Licensing Program Analyst during inspection and reviewed report
The visit was an unannounced required 1-year annual inspection of the facility conducted by the Licensing Program Analyst.
Findings
The inspection found no deficiencies cited under California Code of Regulations, Title 22, but advisory notes were provided. Some egress doors in the memory care area were in disrepair and did not alarm, and the facility took immediate corrective actions while scheduling repairs. Medication record discrepancies were corrected promptly. Staff training and emergency preparedness were reviewed and found adequate.
Report Facts
Fire extinguisher last serviced: May 30, 2023First Aid certification course scheduled: Feb 26, 2024Fire drills conducted: 3Resident files reviewed in memory care: 4Residents using oxygen with physician order: 3Residents using half rails with physician order: 2Resident files reviewed in assisted living: 4Residents interviewed: 5Staff records reviewed: 6Staff with First Aid Certification: 1Resident apartments toured in memory care: 6Resident apartments toured in assisted living: 6
Employees Mentioned
Name
Title
Context
Jolie Higgins
Executive Director
Met with Licensing Program Analyst during inspection and reviewed report
The inspection was conducted as an unannounced complaint investigation following a complaint received on 09/11/2023 alleging that staff did not allow a resident to have visitors.
Findings
The investigation found that the resident had a signed visitation list specifying who was allowed and not allowed to visit, and that the resident refused to see visitors. Based on interviews, record review, and observation, the allegation was unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that staff did not allow resident (R1) to have visitors. The allegation was found unsubstantiated after investigation, indicating insufficient evidence to prove the violation occurred.
Report Facts
Capacity: 112Census: 76
Employees Mentioned
Name
Title
Context
Christine Dolores
Licensing Program Analyst
Conducted the complaint investigation
Jolie Higgins
Executive Director
Met with Licensing Program Analyst during investigation and named in findings
An unannounced complaint investigation was conducted regarding allegations that staff were not responding to residents' call buttons in a timely manner, residents' dietary requests were not being met, and the facility failed to maintain residents' rooms in good repair.
Findings
After interviews, record reviews, and investigation, there was insufficient evidence to substantiate the allegations. The facility follows a pre-set menu and addresses special dietary needs, call system issues were related to an outdated signal system replaced in 2022, and maintenance work orders were completed timely based on priority.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included delayed response to call buttons, unmet dietary requests, and failure to maintain resident rooms. Interviews with staff and administrators, record reviews, and facility work orders showed no preponderance of evidence to prove the allegations occurred.
Report Facts
Complaint Control Number: 26-AS-20200825152249Capacity: 112Census: 76Call response time: 12Call system installation date: New call system installed on 5/25/2022Work order completion times: Work orders made on 08/09/2020 completed on 08/19/2020; 08/26/2020 completed on 08/27/2020; 08/27/2020 completed on 08/27/2020
Employees Mentioned
Name
Title
Context
Manuel Monter
Licensing Program Analyst
Conducted the complaint investigation
Jolie Higgins
Administrator
Met with Licensing Program Analysts during investigation
The inspection was an unannounced complaint investigation conducted in response to multiple allegations received on 10/07/2020 regarding staff response times to call buttons, issuance of refunds, and timely medical attention.
Findings
The investigation found insufficient evidence to substantiate the allegations regarding staff response times to call buttons, refund issuance, and timely medical attention. Interviews, observations, and record reviews indicated that the allegations were either unsubstantiated or unfounded, and no deficiencies were cited.
Complaint Details
The complaint included allegations that staff did not respond to call buttons in a timely manner, the facility did not issue a refund, and staff did not seek medical attention in a timely manner. The investigation concluded the allegations were unsubstantiated or unfounded based on interviews, observations, and record reviews.
Report Facts
Capacity: 112Census: 76Refund check date: Oct 30, 2020Refund check cashed date: Dec 1, 2020Call response time: 12
The visit was an unannounced complaint investigation triggered by an allegation that a resident sustained injuries while in care.
Findings
The investigation found no evidence that the resident's bruise was caused by staff negligence. Interviews and record reviews indicated the resident resisted care and was prone to bruising during transfers. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that a resident sustained injuries while in care. The investigation included interviews with staff and review of the resident's physician report and incident documentation. The allegation was found unsubstantiated due to lack of evidence showing staff caused the injury.
Report Facts
Complaint Control Number: 26-AS-20210506115407Capacity: 112Census: 76
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2022-04-25 that staff were not assisting a resident with incontinence needs.
Findings
Based on interviews with the Executive Director and Resident Service Director, and review of resident care plans and records, the allegation was found to be unsubstantiated due to insufficient evidence to prove the violation occurred. No citations were issued.
Complaint Details
The complaint alleged that staff were not assisting a resident with incontinence needs. The investigation included interviews and record reviews. The finding was unsubstantiated, indicating no preponderance of evidence to confirm the allegation.
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-07-20 regarding the facility lacking a director, activities director, and staff not assisting residents with making phone calls.
Findings
Based on interviews, record review, and observation, the allegations were found to be unfounded. The facility does have a director and an activities director, and staff assist residents with telephone and video calls as needed. No deficiencies were cited.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
The inspection was an unannounced case management incident visit triggered by an incident report received on 07/24/2023 regarding a resident (R1) who eloped from the facility on 07/22/2023.
Findings
The investigation found that one delayed egress door did not reset properly after multiple power outages, allowing resident R1 to elope. The facility updated R1's care plan, conducted staff training, and plans to designate staff to ensure egress doors function properly after outages. A deficiency was cited related to this safety issue.
Complaint Details
The visit was complaint-related due to an incident report of resident elopement. The complaint was substantiated based on the findings of the malfunctioning delayed egress door.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Resident (R1) was able to elope through a delayed egress door that was not checked to be functioning properly after several power outages, posing an immediate health, safety, and personal rights risk.
Type A
Report Facts
Census: 76Total Capacity: 112Deficiency Count: 1Plan of Correction Due Date: Jul 29, 2023
Employees Mentioned
Name
Title
Context
Jolie Higgins
Executive Director
Met during inspection and involved in findings discussion
Ria Hernandez
Resident Service Director
Met during inspection and involved in findings discussion
The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with regulatory requirements.
Findings
The inspection found multiple deficiencies including uncovered perishable food items in the refrigerator, improperly maintained centrally stored medication records in the memory care medication room, and accessible cleaning supplies and laundry detergent in residents' apartments. The facility also had one delayed egress door that did not alarm but was fixed during the visit. An activities calendar was observed in the Assisted Living area but was missing in the memory care dining room.
Severity Breakdown
Type A: 3
Deficiencies (3)
Description
Severity
Facility refrigerator contained uncovered food items such as lettuce, deli turkey meat, and a pitcher of liquid substance.
Type A
Compass Rose medication room did not properly maintain centrally stored medication records for residents R1 - R3.
Type A
Residents' apartments in Compass Rose contained accessible cleaning supplies and laundry detergent.
Type A
Report Facts
POC Due Date: May 23, 2023Facility Capacity: 112Census: 69
Employees Mentioned
Name
Title
Context
Jolie Higgins
Executive Director
Met with Licensing Program Analyst during inspection and discussed findings
Christine Dolores
Licensing Program Analyst
Conducted the inspection and authored the report
Sarah Yip
Licensing Program Manager
Supervisor of the Licensing Program Analyst and named in the report
Ria Hernandez
Resident Service Director
Participated in report review with Executive Director
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 01/27/2021 alleging that a resident suffered from dehydration.
Findings
Based on interviews with hospice care staff and record review, the allegation of dehydration was unsubstantiated. The resident was under hospice care, visited regularly, and there was no evidence that facility staff neglected or refused to provide food or fluids. No deficiencies were cited.
Complaint Details
The complaint alleged that a resident suffered from dehydration. The investigation included interviews with three hospice care staff and review of medical and hospice records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 112Census: 74
Employees Mentioned
Name
Title
Context
Christine Dolores
Licensing Program Analyst
Conducted the complaint investigation and delivered findings
Jolie Higgins
Executive Director
Met with Licensing Program Analyst during investigation
The visit was an unannounced complaint investigation triggered by an allegation that staff discontinued resident services without adequate notice.
Findings
The investigation found that the allegation was unsubstantiated. Residents confirmed they continued receiving all services, and the discontinuation of water bottle supply was communicated through resident council meetings and memos. The supply of water bottles was a courtesy during communicable disease outbreaks and not part of resident services. Multiple hydration stations were available.
Complaint Details
The complaint alleged that staff discontinued resident services without adequate notice. The investigation determined the allegation was unsubstantiated based on interviews and records review.
Report Facts
Capacity: 112
Employees Mentioned
Name
Title
Context
Christine Dolores
Licensing Program Analyst
Conducted the complaint investigation
Jolie Higgins
Executive Director
Met with Licensing Program Analyst during investigation
Ria Hernandez
Resident Service Director
Met with Licensing Program Analyst during investigation
The visit was a scheduled technical assistance visit focused on Case Management related to COVID-19 to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility.
Findings
No deficiencies were cited during the visit. Recommendations were made to improve infection control practices related to COVID-19, including use of PPE and isolation room protocols. The facility had 8 COVID-19 positive residents and 2 COVID-19 positive staff at the time of the visit.
The visit was an unannounced complaint investigation triggered by a complaint received on 2019-11-14 alleging that facility staff caused injury to a resident resulting in bruising.
Findings
The investigation found that the allegations of staff causing injury and pushing the resident were unsubstantiated based on record reviews and staff interviews. The resident sustained bruising and a swollen breast, but no evidence showed staff caused the injury.
Complaint Details
The complaint alleged staff caused injury to a resident and pushed the resident, resulting in bruising and swelling. The investigation included interviews with staff and review of resident records. The allegations were found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 112Census: 71
Employees Mentioned
Name
Title
Context
Christine Dolores
Licensing Program Analyst
Conducted the complaint investigation visit and authored the report
Jolie Higgins
Executive Director
Met with Licensing Program Analyst during the investigation and exit interview
Steven Silacci
Administrator
Facility administrator named in the report
Karen Taku
Licensing Program Analyst
Conducted initial complaint investigation visit and subsequent visits
Natkarn Shugan
Licensing Program Analyst
Conducted initial complaint investigation visit and interviewed staff
Jackie Jin
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
Diane Martinez
Resident Services Director
Interviewed during initial complaint investigation visit
Charmanie Verador
Resident Services Director
Interviewed during initial complaint investigation visit
An unannounced complaint investigation was conducted in response to an allegation that a resident was sexually assaulted while in care.
Findings
The investigation included interviews with staff and review of records, finding no evidence of abuse. The allegation was determined to be unfounded based on interviews, records, and observations.
Complaint Details
The complaint alleged that a resident was sexually assaulted while in care. The investigation found the allegation to be unfounded, meaning it was false, could not have happened, or was without reasonable basis.
Report Facts
Staff interviewed: 8
Employees Mentioned
Name
Title
Context
Christine Dolores
Licensing Program Analyst
Conducted the complaint investigation
Jolie Higgins
Executive Director
Met with investigator during the visit
Steven Silacci
Administrator
Named as facility administrator
Jackie Jin
Licensing Program Manager
Named as licensing program manager overseeing the investigation
Unannounced complaint investigation visit conducted due to allegations including failure to provide services agreed to in the admissions agreement, lack of activities, inadequate food and water, and failure to assist residents with toileting needs.
Findings
Based on observations, interviews, and records review, the allegations were found to be unsubstantiated. The facility provided daily activities, adequate food and water, and assistance with toileting needs as required. No evidence supported the claims of unmet resident needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to provide agreed services, activities, adequate food and water, and toileting assistance. Multiple interviews with residents, visitors, and staff, as well as observations and record reviews, did not support the allegations.
Report Facts
Capacity: 112Census: 72Complaint control number: 26-AS-20190722105729Number of residents interviewed: 21Number of staff interviewed: 6Investigation visit dates: 7/25/2019, 9/17/2019, 10/18/2019, and 9/24/2021
Employees Mentioned
Name
Title
Context
Yatfai Eric Ng
Licensing Program Analyst
Conducted the unannounced complaint investigation visits
Jolie Higgins
Executive Director
Met with Licensing Program Analyst during investigation
Sarah Yip
Licensing Program Manager
Named as Licensing Program Manager overseeing the investigation
An unannounced complaint investigation was conducted in response to an allegation that the facility feels cold to residents.
Findings
Interviews with residents, a visitor, and staff, as well as temperature observations, found no substantiated evidence that the facility temperature was uncomfortable. The temperature was within regulatory standards, and the allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that the facility feels cold to residents. After interviewing 12 residents (9 successful interviews), 1 visitor, and 1 staff member, most reported no concern about temperature. Observations showed temperatures within the required range. The allegation was unsubstantiated.
The visit was an unannounced Case Management Visit to obtain additional information related to 4 incident reports received for the period 7/18/2021 to 7/25/2021 involving a resident (R1), during which 911 was called for each incident.
Findings
The LPAs reviewed resident records, interviewed staff, and toured the facility. R1 had transitioned from Assisted Living to Memory Care and exhibited exiting behaviors. Staff were monitoring the transition and had notified family and primary care provider of changes. A care conference was held and staff were directed to call 911 in emergencies. No citations were issued per California Code of Regulations Title 22.
Report Facts
Incident reports: 4
Employees Mentioned
Name
Title
Context
Billy Mitchell
Executive Director
Met with LPAs during the visit and discussed findings
An unannounced complaint investigation visit was conducted in response to a complaint received on 07/08/2021 alleging multiple concerns including unmet resident needs, failure to prevent resident altercations, visitor restrictions, lack of assistance with medical appointments, poor food quality, and failure to safeguard residents' personal property.
Findings
After interviews with residents, staff, and witnesses, review of records, and observations, the investigation found that although the allegations may have occurred or be valid, there was insufficient evidence to substantiate the complaints. The facility was generally found to be meeting resident needs, preventing altercations, allowing visitors, assisting with medical appointments, serving good quality food, and safeguarding personal property. No deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included unmet resident needs, failure to prevent resident altercations, visitor restrictions, lack of assistance with medical and dental appointments, poor food quality, and failure to safeguard residents' personal property. Interviews and observations did not provide a preponderance of evidence to prove violations occurred.
The visit was an unannounced Case Management visit to conduct a welfare check on a resident (R1) who resides in Memory Care.
Findings
The resident (R1) was observed to be doing well with no injuries despite recent falls. The resident's care plan and physician's report were reviewed, and no deficiencies were cited during the visit.
Employees Mentioned
Name
Title
Context
Billy Mitchell
Executive Director
Met during the visit and involved in discussion about resident welfare.
Karen Taku
Licensing Program Analyst
Conducted the unannounced Case Management visit.
Jeeteeh Gigliottii
Resident Services Director of Assisted Living
Met during the visit and provided information about the resident.
Jocelyne Bailon
Resident Services Director of Memory Care
Met during the visit and provided information about the resident.
An unannounced complaint investigation was conducted regarding allegations that staff locked residents in rooms, left residents in soiled bedding for extended periods, did not meet residents' needs, and that the facility smelled like urine.
Findings
The investigation found no evidence to substantiate the allegations. Residents were not locked in rooms, needs were met including timely changing of soiled bedding, and the facility did not smell like urine according to staff statements.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 112Census: 75
Employees Mentioned
Name
Title
Context
Billy Mitchell
Executive Director
Met with Licensing Program Analyst during investigation and exit interview
The visit was a virtual tele-visit conducted to provide technical assistance to prevent and mitigate the spread of COVID-19 within the facility.
Findings
Recommendations were made to the facility to reach out to the local county health department for assistance regarding incomplete vaccinations and to contact occupational medicine clinics or industrial hygienists for Fit Testing.
Employees Mentioned
Name
Title
Context
Patrick Frazier
interim Executive Director
Met with during the tele-visit and reviewed the report
Karen Taku
Licensing Program Analyst
Conducted the virtual tele-visit and provided technical assistance
Marylene Majeska
Health Facility Evaluator Nurse
Conducted the virtual tele-visit and provided technical assistance
The visit was a virtual tele-visit conducted to provide technical assistance to prevent and mitigate the spread of COVID-19 within the facility.
Findings
The Licensing Program Analyst and Clinical Consultant made recommendations to promote social distancing in the break room and community elevator, including signage and limited occupancy.
Employees Mentioned
Name
Title
Context
Brianne Merritt
Business Office Director
Met with during the tele-visit and involved in review of the report.
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