Inspection Reports for
Westmont of Morgan Hill
1160 Cochrane Rd, Morgan Hill, CA 95037, United States, CA, 95037
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
73% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Census: 82
Capacity: 112
Deficiencies: 0
Date: Feb 24, 2026
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements at Westmont of Morgan Hill facility.
Findings
The inspection found the facility to be in compliance with no deficiencies cited. Resident files, medication records, staff files, and safety equipment were all complete and functional. The facility maintained proper environmental conditions and emergency preparedness.
Report Facts
Staff fingerprint clearance: 4
Staff annual training hours: 20
Fire extinguisher last service date: Jun 26, 2025
Emergency drill date: Jan 30, 2026
Resident files reviewed: 4
Resident medications reviewed: 4
Days of perishables: 2
Days of non-perishables: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Fountain | Executive Director | Met with Licensing Program Analyst during inspection |
| Steve Chang | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Chihhsien Chang | Licensing Program Analyst | Named on report |
| Romeo Manzano | Licensing Program Manager | Named on report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 112
Deficiencies: 0
Date: Feb 4, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that facility staff were not adhering to residents' care plans and were not addressing the issue of ants in residents' rooms and kitchen area.
Complaint Details
The complaint included allegations that staff were not adhering to residents' care plans and not addressing ant infestations. After interviews with staff and residents, and review of records, the allegations were found to be unfounded.
Findings
The investigation found that staff were providing timely care and supervision to residents, with no evidence of residents being left in wheelchairs all day. The facility addressed ant issues promptly through maintenance and a third-party vendor. The allegations were determined to be unfounded with no deficiencies cited.
Report Facts
Capacity: 112
Census: 85
Incidents reviewed: 6
Staff interviewed: 12
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Simranjit Rai | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Michael Fountain | Executive Director | Met with during investigation and exit interview |
| Jmy Ramos | Resident Service Director | Met with during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 112
Deficiencies: 0
Date: Nov 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on August 21, 2025, regarding improper care, supervision, and physical assault of a resident at Westmont of Morgan Hill facility.
Complaint Details
The complaint alleged that a resident was physically assaulted and not properly cared for, including not receiving medication, bathing, or escorting assistance. The investigation included interviews with multiple staff members, residents, and review of incident reports and service plans. The allegations were found to be unfounded.
Findings
Based on interviews with staff, residents, and review of records, the investigation found no evidence supporting the allegations. The department concluded the allegations were unfounded, meaning they were false or without reasonable basis.
Report Facts
Capacity: 112
Census: 90
Resident interviews: 17
Staff interviews: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Administrator | Named as facility administrator |
| Jmy Ramos | Resident Services Director | Interviewed during investigation regarding allegations |
| Manuel Monter | Licensing Program Analyst | Conducted the complaint investigation |
| Gladys Desmarais | Former Resident Services Director | Interviewed during investigation |
| Romeo Manzano | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 112
Deficiencies: 1
Date: Oct 22, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report regarding a resident (R1) who eloped from the facility on October 15, 2025.
Complaint Details
The visit was complaint-related, triggered by an incident report of a resident eloping. The resident was found outside the facility without injuries. The complaint was substantiated with findings of inadequate supervision and failure of door alarms to alert staff.
Findings
The investigation found that R1, who has a neurocognitive disorder and exit-seeking behavior, left the memory care unit unassisted and was found 0.4 miles away from the facility. Staff did not hear the door alarms, and deficiencies were cited for failure to provide adequate supervision. An immediate civil penalty of $500 was issued.
Deficiencies (1)
Failure to provide care, supervision, and services that meet individual needs, resulting in a resident eloping from the facility.
Report Facts
Civil penalty amount: 500
Distance resident eloped: 0.4
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Fountain | Administrator | Met with Licensing Program Analyst during inspection and reviewed report findings. |
| Manuel Monter | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report. |
| Jmy Ramos | Resident Services Director | Interviewed regarding the resident elopement incident. |
| Rohit Singh | Memory Care Coordinator | Interviewed regarding resident behavior and supervision. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 112
Deficiencies: 1
Date: Oct 22, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report regarding a resident who eloped from the facility.
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.
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.
Deficiencies (1)
Failure to provide care, supervision, and services that meet individual needs, resulting in a resident eloping from the facility.
Report Facts
Civil penalty amount: 500
Distance resident eloped: 0.4
Plan 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. |
| Jmy Ramos | Resident Services Director | Interviewed regarding resident elopement incident. |
| Rohit Singh | Memory Care Coordinator | Interviewed regarding resident behavior and supervision. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 112
Deficiencies: 0
Date: Oct 20, 2025
Visit Reason
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.
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.
Findings
The resident was found outside the community and safely returned with no visible injuries. The Licensing Program Analyst interviewed staff and requested relevant documentation. The incident requires further investigation.
Report Facts
Capacity: 112
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brianne Merritt | Business Office Director | Met with Licensing Program Analyst during the visit and reviewed the report |
| Manuel Monter | Licensing Program Analyst | Conducted the unannounced case management visit |
| Romeo Manzano | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 112
Deficiencies: 0
Date: Oct 20, 2025
Visit Reason
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.
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.
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.
Report Facts
Census: 85
Total Capacity: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brianne Merritt | Business Office Director | Met with Licensing Program Analyst during the visit and reviewed the report |
| Manuel Monter | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 112
Deficiencies: 0
Date: May 20, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 01/29/2025 regarding resident care and facility practices.
Complaint Details
The complaint included allegations that facility staff told a resident to use their diaper rather than assist them to the bathroom, did not offer water resulting in dehydration, failed to safeguard resident's personal belongings, and handled a resident roughly. These allegations were found to be unsubstantiated due to lack of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Contradictory information and lack of proof led to the conclusion that the allegations were unsubstantiated.
Report Facts
Capacity: 112
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ria Hernandez | Resident Services Director | Met with the evaluator during the investigation |
Inspection Report
Annual Inspection
Census: 82
Capacity: 112
Deficiencies: 0
Date: Feb 19, 2025
Visit Reason
The inspection was an unannounced annual required 1-year inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations.
Findings
The facility was found to be in compliance with no deficiencies cited. Resident files, medication records, staff files, and safety equipment were all reviewed and found complete and in good condition. Emergency preparedness and environmental conditions met regulatory standards.
Report Facts
Staff files reviewed: 4
Resident files reviewed: 4
Emergency drill frequency: 1
Fire extinguisher last service date: Jun 28, 2024
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. |
| Christine Kabariti | Licensing Program Analyst | Conducted the annual inspection. |
Inspection Report
Annual Inspection
Census: 82
Capacity: 112
Deficiencies: 0
Date: Feb 19, 2025
Visit Reason
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: 4
Resident medications reviewed: 4
Staff files reviewed: 4
Fire extinguisher last service date: Jun 28, 2024
Emergency drill frequency: 1
Hot water temperature range: 111
Kitchen refrigerator temperature: 26
Kitchen freezer temperature: 0
Walk-in refrigerator temperature: 36
Walk-in freezer temperature: 0
Food supply duration: 2
Food 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 |
| Christine Kabariti | Licensing Program Analyst | Conducted the inspection |
| Jackie Jin | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 72
Capacity: 112
Deficiencies: 0
Date: Feb 20, 2024
Visit Reason
The Licensing Program Analyst conducted an unannounced required 1-year annual inspection of the facility.
Findings
The inspection found no deficiencies cited under California Code of Regulations, Title 22, but advisory notes were provided. Some egress doors in memory care were in disrepair and did not alarm, and the facility took immediate corrective actions while scheduling repairs. Medication records had minor omissions that were promptly corrected.
Report Facts
Resident files reviewed: 4
Staff records reviewed: 6
Fire drills conducted: 3
First Aid certification course scheduled: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during inspection and reviewed report |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection |
| Ria Hernandez | Resident Care Director | Reviewed report with Licensing Program Analyst |
| Myrene Carasi | Memory Care Director | Reviewed report with Licensing Program Analyst |
Inspection Report
Annual Inspection
Census: 72
Capacity: 112
Deficiencies: 0
Date: Feb 20, 2024
Visit Reason
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, 2023
First Aid certification course scheduled: Feb 26, 2024
Fire drills conducted: 3
Resident files reviewed in memory care: 4
Residents using oxygen with physician order: 3
Residents using half rails with physician order: 2
Resident files reviewed in assisted living: 4
Residents interviewed: 5
Staff records reviewed: 6
Staff with First Aid Certification: 1
Resident apartments toured in memory care: 6
Resident 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 |
| Ria Hernandez | Resident Care Director | Reviewed report with Licensing Program Analyst |
| Myrene Carasi | Memory Care Director | Reviewed report with Licensing Program Analyst |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sarah Yip | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Sep 20, 2023
Visit Reason
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.
Complaint Details
The complaint alleged that staff did not allow resident (R1) to have visitors. The investigation found the allegation unsubstantiated based on interviews and documentation, including a visitation list signed by the resident and their Power of Attorney.
Findings
Based on interviews, record review, and observation, the allegation was found to be unsubstantiated. The resident had a signed visitation list specifying allowed and disallowed visitors, and the resident refused to see visitors. No deficiencies were cited.
Report Facts
Capacity: 112
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during complaint investigation and named in findings |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 0
Date: Sep 20, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 07/20/2023 alleging that facility staff did not file a resident's insurance paperwork for payment since January 2023.
Complaint Details
The complaint alleged that staff did not file resident (R1)'s insurance paperwork for reimbursement since January 2023. The allegation was found unsubstantiated after investigation.
Findings
The investigation found that the allegation was unsubstantiated based on interviews, record review, and observation. The facility was notified of the issue in June 2023 and acted immediately. There was no written agreement that the facility was responsible for filing insurance paperwork, and no deficiencies were cited.
Report Facts
Capacity: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Yip | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Sep 20, 2023
Visit Reason
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.
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.
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.
Report Facts
Capacity: 112
Census: 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 |
| Sarah Yip | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Aug 11, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 08/25/2020 regarding staff response to resident call buttons, dietary requests not being met, and failure to maintain resident rooms in good repair.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not responding timely to call buttons, dietary requests not met, and failure to maintain resident rooms. Interviews with staff and review of records found no preponderance of evidence to prove the allegations.
Findings
After interviews, record reviews, and investigation, there was insufficient evidence to substantiate the allegations. The facility follows a pre-set menu and accommodates special dietary needs, staff response times to call pendants were within expected limits, and maintenance work orders were addressed timely.
Report Facts
Complaint Control Number: 26-AS-20200825152249
Incident dates: 8/23/2020 and 8/25/2020 for call pendant incident
New call system installation date: 5/25/2022
Work order request and completion dates: Requests on 08/09/2020, 08/26/2020, 08/27/2020 completed within 1-10 days
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manuel Monter | Licensing Evaluator | Conducted complaint investigation |
| Jolie Higgins | Administrator | Interviewed regarding allegations and facility policies |
| Steve Chang | Licensing Program Analyst | Conducted complaint investigation |
| Simi Rai | Licensing Program Analyst | Conducted complaint investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Aug 11, 2023
Visit Reason
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.
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 promptly. After interviews, record reviews, and observations, the allegations were determined to be unsubstantiated or unfounded.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff response to emergency cords was timely during the visit, and records showed the refund was issued according to policy. Medical attention was sought appropriately based on hospice records. All allegations were ultimately unsubstantiated or unfounded.
Report Facts
Capacity: 112
Census: 76
Response time: 12
Response time: 10
Refund date: Oct 30, 2020
Refund cashed date: Dec 1, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Interviewed during investigation and exit interview |
| Simranjit Rai | Licensing Evaluator | Conducted complaint investigation |
| Steven Silacci | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Aug 11, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident sustained injuries while in care.
Complaint Details
The complaint alleged that a resident sustained injuries while in care. The investigation included interviews with staff and review of incident and physician reports. The allegation was found unsubstantiated due to lack of evidence showing staff caused the injury.
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.
Report Facts
Complaint Control Number: 26
Facility Capacity: 112
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Administrator | Named as facility administrator |
| Jolie Higgins | Executive Director | Interviewed during investigation |
| Chihhsien Chang | Licensing Evaluator | Conducted the complaint investigation |
| Steve Chang | Licensing Program Analyst | Conducted investigation visit |
| Simi Rai | Licensing Program Analyst | Conducted investigation visit |
| Manuel Monter | Licensing Program Analyst | Conducted investigation visit |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Aug 11, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation received on 2022-04-25 that staff were not assisting a resident with incontinence needs.
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 alleged violation.
Findings
Based on interviews with the Executive Director and Resident Service Director, and review of the resident's care plan and records, the allegation was found to be unsubstantiated due to insufficient evidence. No citations were issued.
Report Facts
Capacity: 112
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Interviewed during complaint investigation |
| Ria Hernandez | Resident Service Director | Interviewed during complaint investigation |
| Steve Chang | Licensing Program Analyst | Conducted investigation visit |
| Simi Rai | Licensing Program Analyst | Conducted investigation visit |
| Manuel Monter | Licensing Program Analyst | Conducted investigation visit |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Aug 11, 2023
Visit Reason
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.
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.
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.
Report Facts
Complaint Control Number: 26-AS-20200825152249
Capacity: 112
Census: 76
Call response time: 12
Call system installation date: New call system installed on 5/25/2022
Work 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 |
| Steve Chang | Licensing Program Analyst | Conducted the complaint investigation |
| Simi Rai | Licensing Program Analyst | Conducted the complaint investigation |
| Romeo Manzano | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Aug 11, 2023
Visit Reason
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.
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.
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.
Report Facts
Capacity: 112
Census: 76
Refund check date: Oct 30, 2020
Refund check cashed date: Dec 1, 2020
Call response time: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Simranjit Rai | Licensing Program Analyst | Conducted complaint investigation |
| Steve Chang | Licensing Program Analyst | Conducted complaint investigation |
| Manuel Monter | Licensing Program Analyst | Conducted complaint investigation |
| Jolie Higgins | Executive Director | Interviewed during investigation |
| Steven Silacci | Administrator | Facility administrator listed in report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Aug 11, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident sustained injuries while in care.
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.
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.
Report Facts
Complaint Control Number: 26-AS-20210506115407
Capacity: 112
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Administrator | Facility administrator named in report header |
| Jolie Higgins | Executive Director | Interviewed during investigation |
| Chihhsien Chang | Licensing Program Analyst | Conducted investigation and signed report |
| Romeo Manzano | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Aug 11, 2023
Visit Reason
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.
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.
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.
Report Facts
Complaint Control Number: 26-AS-20220425155409
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Interviewed during the complaint investigation |
| Ria Hernandez | Resident Service Director | Interviewed during the complaint investigation |
| Chihhsien Chang | Licensing Program Analyst | Conducted the investigation |
| Steve Chang | Licensing Program Analyst | Conducted the investigation |
| Simi Rai | Licensing Program Analyst | Conducted the investigation |
| Manuel Monter | Licensing Program Analyst | Conducted the investigation |
| Romeo Manzano | Licensing Program Manager | Oversaw the investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 1
Date: Jul 28, 2023
Visit Reason
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.
Complaint Details
The visit was complaint-related due to an incident report of resident elopement. The deficiency was substantiated as the door failure allowed the elopement. The facility corrected the deficiency before the visit and submitted a plan of correction.
Findings
The investigation found that one delayed egress door did not reset properly after power outages, allowing resident R1 to elope, posing an immediate health, safety, and personal rights risk. The facility corrected the deficiency before the visit and implemented staff training and updated care plans.
Deficiencies (1)
Resident 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.
Report Facts
Deficiencies cited: 1
Capacity: 112
Census: 76
Delayed egress doors tested: 5
Delayed egress doors working: 4
Delayed egress doors not working: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during visit and named in findings |
| Ria Hernandez | Resident Service Director | Met with Licensing Program Analyst during visit and named in findings |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
An unannounced complaint investigation was conducted based on allegations received on 07/20/2023 that the facility lacked a director and activities director, and staff were not assisting residents with making phone calls.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22.
Findings
Based on interviews, record review, and observation, the allegations were found to be unfounded. The facility does have a director and activities director, and staff assist residents with telephone and video calls as needed. No deficiencies were cited.
Report Facts
Capacity: 112
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Ria Hernandez | Resident Service Director | Met with Licensing Program Analyst during investigation and named in findings |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
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.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
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.
Report Facts
Capacity: 112
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Met during investigation and named in report |
| Ria Hernandez | Resident Service Director | Met during investigation and named in report |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Yip | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 112
Deficiencies: 1
Date: Jul 28, 2023
Visit Reason
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.
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.
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.
Deficiencies (1)
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.
Report Facts
Census: 76
Total Capacity: 112
Deficiency Count: 1
Plan 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 |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sarah Yip | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 69
Capacity: 112
Deficiencies: 3
Date: May 22, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced annual inspection of the facility to evaluate compliance with regulatory requirements.
Findings
The inspection found several deficiencies including uncovered food items in the refrigerator, accessible cleaning supplies in residents' apartments, and incomplete centrally stored medication records in the memory care medication room. The facility also had one delayed egress door that was not alarming or opening properly but was fixed during the visit.
Deficiencies (3)
Facility's refrigerator contained uncovered food items such as lettuce, deli turkey meat, and a pitcher of liquid substance.
Compass Rose medication room did not properly maintain centrally stored medication records for residents R1-R3.
Residents' apartments in Compass Rose contained accessible cleaning supplies and laundry detergent.
Report Facts
Capacity: 112
Census: 69
POC Due Date: May 23, 2023
Fire extinguisher last serviced: May 13, 2022
Fire extinguisher next service: May 31, 2023
Facility temperature: 71
Facility temperature: 72
Refrigerator temperature: 33
Freezer temperature: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during inspection and reviewed report |
| Ria Hernandez | Resident Service Director | Reviewed report with Licensing Program Analyst |
| Christine Dolores | Licensing Program Analyst | Conducted the annual inspection and authored the report |
| Sarah Yip | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 69
Capacity: 112
Deficiencies: 3
Date: May 22, 2023
Visit Reason
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.
Deficiencies (3)
Facility refrigerator contained uncovered food items such as lettuce, deli turkey meat, and a pitcher of liquid substance.
Compass Rose medication room did not properly maintain centrally stored medication records for residents R1 - R3.
Residents' apartments in Compass Rose contained accessible cleaning supplies and laundry detergent.
Report Facts
POC Due Date: May 23, 2023
Facility Capacity: 112
Census: 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 |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 112
Deficiencies: 0
Date: Dec 15, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 01/27/2021 alleging that a resident suffered from dehydration.
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.
Findings
Based on interviews with hospice care staff and record review, the allegation of dehydration was unsubstantiated. The resident was under hospice care, dependent on assistance for all activities of daily living, and there was no evidence that facility staff neglected to provide food or fluids. No deficiencies were cited.
Report Facts
Capacity: 112
Census: 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 |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 112
Deficiencies: 0
Date: Dec 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 01/27/2021 alleging that a resident suffered from dehydration.
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.
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.
Report Facts
Capacity: 112
Census: 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 |
| Steven Silacci | Administrator | Facility administrator named in report header |
| Sarah Yip | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff discontinued resident services without adequate notice.
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.
Findings
The investigation found that the allegation was unsubstantiated. Residents confirmed they were receiving all services and were informed about the discontinuation of water bottle supply, which was not part of resident services. The facility provided multiple hydration stations and held resident council meetings to inform residents.
Report Facts
Capacity: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Ria Hernandez | Resident Service Director | Accompanied Licensing Program Analyst during tour and interviews |
Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff discontinued resident services without adequate notice.
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.
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.
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 |
| Sarah Yip | Licensing Program Manager | Named in report |
Inspection Report
Routine
Census: 69
Capacity: 112
Deficiencies: 0
Date: Dec 3, 2021
Visit Reason
The visit was a scheduled technical assistance visit conducted 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.
Report Facts
COVID-19 positive residents: 8
COVID-19 positive staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeeteeh Gigliotti | Resident Service Director | Met with Licensing Program Analyst during the visit and involved in review |
| Jocelyne Bailon | Compass Rose Resident Service Director | Met with Licensing Program Analyst during the visit |
| Christine Dolores | Licensing Program Analyst | Conducted the scheduled technical assistance visit |
| Jackie Jin | Licensing Program Manager | Participated in Facetime tour and supervised the visit |
| Helen Shi | PCC | Provided recommendations during the tele-visit |
Inspection Report
Routine
Census: 69
Capacity: 112
Deficiencies: 0
Date: Dec 3, 2021
Visit Reason
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.
Report Facts
COVID-19 positive residents: 8
COVID-19 positive staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeeteeh Gigliotti | Resident Service Director | Met with Licensing Program Analyst during the visit |
| Jocelyne Bailon | Compass Rose Resident Service Director | Met with Licensing Program Analyst during the visit |
| Christine Dolores | Licensing Program Analyst | Conducted the scheduled technical assistance visit |
| Jackie Jin | Licensing Program Manager | Participated in Facetime tour and visit |
| Helen Shi | PCC | Provided recommendations during the tele-visit |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 112
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint alleging that facility staff caused injury to a resident, including bruising and pushing.
Complaint Details
The complaint alleged staff caused injury to a resident and pushed the resident. The investigation included interviews with staff and review of resident records. The allegations were found unsubstantiated due to lack of preponderance of evidence.
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 was hospitalized due to a swollen left breast but no evidence supported abuse by staff.
Report Facts
Capacity: 112
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Karen Taku | Licensing Program Analyst | Conducted initial complaint investigation visits and subsequent visits |
| Natkarn Shugan | Licensing Program Analyst | Conducted initial complaint investigation visit and interviewed Resident Service Director |
| Diane Martinez | Resident Services Director | Interviewed during initial complaint investigation visit |
| Charmanie Verador | Resident Services Director | Interviewed during initial complaint investigation visit |
| Romeo Manzano | Licensing Program Manager | Conducted subsequent visit and interviews |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 112
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident was sexually assaulted while in care.
Complaint Details
The complaint alleged that a resident was sexually assaulted while in care. After investigation, including interviews and records review, the allegation was found to be unfounded.
Findings
The investigation included interviews with staff and review of records, concluding that the allegation was unfounded. The resident denied any sexual abuse and was found to have a urinary tract infection unrelated to abuse.
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 the investigator during the visit |
| Steven Silacci | Administrator | Facility administrator named in the report |
| Jackie Jin | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 112
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
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.
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.
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.
Report Facts
Capacity: 112
Census: 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 |
| Romeo Manzano | Licensing Program Manager | Conducted subsequent visit and interviews |
| Grace Davis | Licensing Program Analyst | Conducted unannounced subsequent complaint investigation tele-visit |
| Shugan | Licensing Program Analyst | Interviewed Resident Service Director on 11/21/2019 |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 112
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident was sexually assaulted while in care.
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.
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.
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 |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 112
Deficiencies: 0
Date: Sep 24, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/22/2019 regarding allegations that the facility was not providing services agreed to in the Admissions Agreement, failed to provide activities, adequate food, water, and toileting assistance to residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to provide agreed services, activities, adequate food and water, and toileting assistance. Multiple unannounced visits and interviews were conducted between 07/25/2019 and 10/18/2019. Evidence did not support the allegations.
Findings
Based on observations, interviews with residents, visitors, and staff, and records review, the Department found the allegations to be unsubstantiated. Activities were provided daily, residents had adequate food and water, and toileting needs were met. No evidence supported the complaint allegations.
Report Facts
Capacity: 112
Census: 72
Resident interviews: 21
Staff interviews: 6
Visitor interviews: 2
Inspection visits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yatfai Eric Ng | Licensing Program Analyst | Conducted the complaint investigation visits and interviews |
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during investigation |
| Steven Silacci | Administrator | Facility administrator named in report header |
| Sarah Yip | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 112
Deficiencies: 0
Date: Sep 24, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility feels cold to residents.
Complaint Details
The complaint alleged that the facility felt cold to residents. After investigation including interviews with 9 residents, 1 visitor, and 1 staff member, and temperature measurements, the allegation was determined to be unsubstantiated.
Findings
Based on interviews with residents, a visitor, and staff, as well as temperature observations, the allegation was found to be unsubstantiated. Most residents and staff reported no concern about the facility temperature, and observed temperatures were within regulatory standards.
Report Facts
Residents interviewed: 9
Visitor interviewed: 1
Staff interviewed: 1
Temperature range: 79
Temperature range: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yatfai Ng | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during investigation |
| Steven Silacci | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 112
Deficiencies: 0
Date: Sep 24, 2021
Visit Reason
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.
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.
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.
Report Facts
Capacity: 112
Census: 72
Complaint control number: 26-AS-20190722105729
Number of residents interviewed: 21
Number of staff interviewed: 6
Investigation 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 |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 112
Deficiencies: 0
Date: Sep 24, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility feels cold to residents.
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.
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.
Report Facts
Residents interviewed: 12
Successful resident interviews: 9
Visitor interviewed: 1
Staff interviewed: 1
Facility capacity: 112
Facility census: 72
Temperature observed: 79
Temperature observed: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yatfai Eric Ng | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jolie Higgins | Executive Director | Met with Licensing Program Analyst during investigation |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 58
Capacity: 112
Deficiencies: 0
Date: Aug 25, 2021
Visit Reason
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 Licensing Program Analysts reviewed resident records, interviewed staff, and toured the facility. Resident R1 transitioned from Assisted Living to Memory Care and exhibited exiting behaviors. Staff were monitoring the transition, family and PCP were notified, and a care conference was held. 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 Licensing Program Analysts and discussed findings |
| Christine Dolores | Licensing Evaluator | Conducted the unannounced Case Management Visit |
Inspection Report
Census: 58
Capacity: 112
Deficiencies: 0
Date: Aug 25, 2021
Visit Reason
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 |
| Jocelyn Bailon | Compass Rose Resident Service Director | Met with LPAs during the visit |
| Jeeteeh Gigliotti | Resident Service Director | Met with LPAs during the visit |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 112
Deficiencies: 0
Date: Aug 10, 2021
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 07/08/2021 alleging multiple issues including 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.
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 sufficient evidence to substantiate these claims.
Findings
After interviews with residents, staff, and witnesses, review of records, and observations, 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 occurred. Therefore, the allegations were unsubstantiated and no deficiencies were cited.
Report Facts
Residents interviewed: 7
Staff interviewed: 10
Witnesses interviewed: 4
Allegations: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | Executive Director | Facility representative met during the investigation and report review |
| David Marrufo | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Jackie Jin | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 112
Deficiencies: 0
Date: Aug 10, 2021
Visit Reason
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.
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.
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.
Report Facts
Residents interviewed: 7
Staff interviewed: 10
Witnesses interviewed: 4
Facility capacity: 112
Facility census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | Executive Director | Met with Licensing Program Analyst during the investigation and reviewed the report |
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 69
Capacity: 112
Deficiencies: 0
Date: Jul 7, 2021
Visit Reason
The visit was an unannounced Case Management visit conducted to perform a welfare check on a resident (R1) residing in Memory Care.
Findings
The resident was observed to be in good spirits, eating well, and involved in activities. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | Executive Director | Met with Licensing Program Analyst during the visit and involved in resident welfare discussion. |
| Karen Taku | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Jeeteeh Gigliotti | Resident Services Director of Assisted Living | Provided information about the resident's condition and care. |
| Jocelyne Bailon | Resident Services Director of Memory Care | Provided information about the resident's condition and care. |
Inspection Report
Census: 69
Capacity: 112
Deficiencies: 0
Date: Jul 7, 2021
Visit Reason
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. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 112
Deficiencies: 0
Date: Apr 22, 2021
Visit Reason
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.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
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.
Report Facts
Capacity: 112
Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 112
Deficiencies: 0
Date: Apr 22, 2021
Visit Reason
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.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
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.
Report Facts
Capacity: 112
Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Billy Mitchell | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
| David Marrufo | Conducted investigation interviews with staff | |
| Karen Taku | Conducted investigation interviews with staff |
Inspection Report
Census: 78
Capacity: 112
Deficiencies: 0
Date: Mar 15, 2021
Visit Reason
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 |
Inspection Report
Census: 85
Capacity: 112
Deficiencies: 0
Date: Jan 4, 2021
Visit Reason
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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