Inspection Report Summary
Most inspections found deficiencies related primarily to resident supervision, especially involving repeated incidents of a resident with dementia eloping from the facility, which led to civil penalties most recently on October 23, 2025, when a $1,000 fine was issued for inadequate supervision and personnel issues. Other notable issues included lapses in staff certifications, unlocked medications and cleaning supplies in memory care areas, and hot water temperatures exceeding regulatory limits, though some of these were addressed over time. Several complaint investigations were unsubstantiated, including allegations of retaliation, discrimination, and unlawful eviction. The most recent report from October 23, 2025, did have deficiencies and enforcement, indicating ongoing challenges with supervision despite some improvements in other areas. Overall, the facility has faced repeated supervision and safety-related citations but has maintained compliance in many operational and environmental aspects.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 79
Capacity: 95
Deficiencies: 1
Oct 23, 2025
Visit Reason
The visit was conducted as a Case Management - Incident Visit to follow up on a self-reported incident involving a resident who eloped from the facility on 10/10/2025.
Findings
The facility failed to provide adequate supervision to a resident with dementia, resulting in elopement. A repeat deficiency was cited for failure to meet personnel requirements, and a civil penalty of $1,000 was issued.
Complaint Details
The visit was complaint-related, following a self-reported incident of elopement by a resident diagnosed with dementia. The deficiency was substantiated and a civil penalty was issued for repeat violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not provide supervision to Resident 1 resulting in an elopement, which is an immediate risk to health, safety, and rights of residents. | Type A |
Report Facts
Civil penalty amount: 1000
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Beltz | Administrator | Met with Licensing Program Analyst during the visit and named in relation to the supervision deficiency. |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and delivered complaint findings. |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 83
Capacity: 95
Deficiencies: 1
May 27, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements for the assisted living and memory care facility.
Findings
The facility was found to be generally clean and compliant with safety and operational standards, including fire safety and medication administration. However, two direct care staff files lacked current first aid certification, posing a potential risk to residents.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 2 out of 5 direct care staff files reviewed did not have current 1st Aid certification. | Type B |
Report Facts
Residents in Assisted Living: 44
Residents in Memory Care: 39
Residents Receiving Hospice: 7
Direct Care Staff Files Reviewed: 5
Direct Care Staff Files Missing 1st Aid Certification: 2
Plan of Correction Due Date: Jun 6, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Beltz | Executive Director | Met during inspection and named in findings related to facility operations |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 95
Deficiencies: 1
May 13, 2025
Visit Reason
The visit was conducted as a Case Management - Incident Visit to follow up on a self-reported incident involving a resident elopement from the facility.
Findings
The facility failed to provide adequate supervision to a resident with dementia who eloped from the community, resulting in a cited deficiency and a civil penalty for absence of supervision.
Complaint Details
The visit was complaint-related, following a self-reported incident of a resident with dementia eloping from the facility. The deficiency was substantiated and a civil penalty of $500 was issued for zero tolerance, absence of supervision.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not provide supervision to Resident 1 resulting in an elopement, which is an immediate risk to health, safety, and rights of residents. | Type A |
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Beltz | Administrator | Met with Licensing Program Analyst during inspection and mentioned in relation to findings |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection visit |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 95
Deficiencies: 1
Feb 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff did not issue a refund to a resident's authorized representative.
Findings
The investigation found that the licensee did not issue the refund within the required 15 days after the removal of the resident's belongings, substantiating the complaint. The delay was due to lapses in processing and lack of staff knowledge of the refund regulation.
Complaint Details
The complaint alleging that staff did not issue a refund to the resident's authorized representative was substantiated based on record review and interviews. The refund was not paid within the required 15 days after the resident's belongings were removed following the resident's death.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to issue refund to resident's authorized representative within 15 days after removal of resident's belongings as required by Health & Safety Code 1569.562(c). | Type B |
Report Facts
Capacity: 95
Census: 78
Plan of Correction Due Date: Feb 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bethany Moellers | Licensing Program Manager | Oversaw complaint investigation |
| Elizabeth Alfaro | Business Office Manager | Interviewed during investigation; involved in refund processing |
| John Beltz | Administrator | Facility administrator; was out of building during investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 95
Deficiencies: 0
Feb 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including unlawful eviction of a resident and overcharging the resident.
Findings
The investigation found no evidence to support the allegations of unlawful eviction or overcharging. Interviews and document reviews confirmed the allegations were unfounded, and no deficiencies were cited.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.
Report Facts
Capacity: 95
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Frank | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Elizabeth Alfaro | Business Office Director | Met with investigators during the visit |
| John Beltz | Administrator | Facility administrator not present during visit |
| Victoria Bertozzi | Licensing Program Manager | Named in report header and signature |
Inspection Report
Follow-Up
Census: 80
Capacity: 95
Deficiencies: 1
Aug 20, 2024
Visit Reason
The visit was an unannounced case management inspection to follow up on a self-reported incident where a resident eloped from the facility without staff knowledge.
Findings
The inspection found that resident R1, diagnosed with dementia, eloped from the facility on 6/11/2024, sustaining minor injuries. A citation and civil penalty were issued for failure to provide adequate supervision and safety measures.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials not met as resident (R1) eloped from the facility without supervision. | Type A |
Report Facts
Civil Penalty Amount: 250
Previous Citation Date: Feb 1, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Beltz | Administrator | Administrator not available during inspection |
| Elizabeth Alfaro | Business Office Director | Met with Licensing Program Analyst during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and signed the report |
| Bethany Moellers | Licensing Program Manager | Supervisor named in report |
Inspection Report
Annual Inspection
Census: 79
Capacity: 95
Deficiencies: 4
Jun 10, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing regulations and facility operations.
Findings
The facility was generally clean and well-maintained with appropriate safety measures, but several deficiencies were found including staff not completing required annual trainings, unlocked medications and cleaning supplies in memory care areas, and hot water temperatures exceeding regulatory limits in some resident bathrooms.
Deficiencies (4)
| Description |
|---|
| 3 out of 3 direct care providers did not obtain required annual trainings including dementia care and hospice care. |
| Residents' unlocked lidocaine strips, shampoos, conditioners, and cleaning supplies found in memory care areas, posing safety risks. |
| 1 out of 3 direct care staff did not have current first aid certification. |
| 5 out of 11 resident bathroom faucets had hot water temperatures between 121.8 and 128.3 degrees F, exceeding the acceptable range. |
Report Facts
Residents on Hospice: 10
Assisted Living Residents: 41
Dementia Residents: 38
Direct Care Providers without Required Training: 3
Direct Care Providers without First Aid Certification: 1
Resident Bathroom Faucets with High Hot Water Temperature: 5
Civil Penalty Amount: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Beltz | Administrator | Met during inspection and interviewed regarding training and compliance |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
| Elizabeth Alfaro | Business Office Manager | Welcomed the Licensing Program Analyst and participated in facility tour |
| Russell Echeverria | Building Service Director | Provided information about facility upgrades and lock installations |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 95
Deficiencies: 0
Jun 3, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was retaliating against a resident.
Findings
The investigation found that the allegation of retaliation against the resident was false and without reasonable basis. The complaint was determined to be unfounded and was dismissed with no citations issued.
Complaint Details
The complaint alleged that the facility was retaliating against a resident. The complainant later stated they did not want the complaint investigated and denied having a complaint. The investigation concluded the allegation was unfounded.
Report Facts
Capacity: 95
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation |
| Sammy Howeidy | Director of Memory Care | Met with the investigator during the inspection |
Inspection Report
Follow-Up
Census: 77
Capacity: 95
Deficiencies: 1
Feb 1, 2024
Visit Reason
The visit was an unannounced case management inspection to follow up on two self-reported incident reports submitted to Community Care Licensing, including an elopement incident and an attempted suicide.
Findings
The inspection found that resident R1 eloped from the facility due to an unlocked garden latch, resulting in a citation. The facility also reported an attempted suicide by resident R2, who was sent to the emergency room and is being placed in a different facility post-discharge. A deficiency related to safety measures for persons with dementia was cited but cleared at the visit.
Complaint Details
The visit followed up on two self-reported incidents: one involving resident R1 eloping from the facility without staff knowledge, and another involving an attempted suicide by resident R2. The citation was issued for the elopement incident.
Deficiencies (1)
| Description |
|---|
| Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by resident R1 eloping from facility. |
Report Facts
Facility Capacity: 95
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary McClure | Administrator | Met with Licensing Program Analyst during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and issued citation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager and Supervisor |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 95
Deficiencies: 0
Feb 1, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 10/04/2023 regarding staff not ensuring resident privacy, discriminating against a resident, and threatening a resident.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The complaints about staff not ensuring resident privacy, discrimination, and threats were all determined to be unsubstantiated based on interviews, record reviews, and observations.
Complaint Details
The complaint investigation addressed allegations that staff were not ensuring resident privacy, discriminating against a resident, and threatening a resident. The investigation included interviews with staff and residents, record review, and observation. The allegations were found to be unsubstantiated.
Report Facts
Facility capacity: 95
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Mary McClure | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 95
Deficiencies: 1
Oct 5, 2023
Visit Reason
The visit was an unannounced complaint investigation and case management visit to address unsigned documents at the facility.
Findings
The investigation found that one resident did not have a signed Admissions Agreement, which is a violation of California Code of Regulations 87507(c). The facility received a technical violation but no citations were issued during the visit.
Complaint Details
Complaint investigation regarding unsigned documents; substantiation status not explicitly stated but a technical violation was issued.
Deficiencies (1)
| Description |
|---|
| Resident did not have a signed Admissions Agreement, violating regulation 87507(c). |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liz Alfaro | Business Office Director | Met with Licensing Program Analyst during complaint investigation regarding unsigned documents. |
| Sammy Howeidy | Memory Care Director | Met with Licensing Program Analyst during complaint investigation regarding unsigned documents. |
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and case management visit. |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 72
Capacity: 95
Deficiencies: 1
Sep 21, 2023
Visit Reason
The visit was an unannounced case management inspection to clear a previously cited deficiency related to First Aid certifications from a Post Licensing visit on 2023-08-22. The visit also addressed ongoing repairs and a medication error incident reported by the facility.
Findings
The facility provided proof of First Aid certifications completed on 2023-09-19, clearing that citation. Repairs were still in progress for water damage in the Garden Neighborhood dining area. The facility was cited for a medication error where a resident was given scheduled pain medication beyond the prescribed 3 days for an additional 8 days, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care plan was not met as the facility neglected to change a resident's pain medication order from scheduled to PRN after 3 days, continuing scheduled medication for 8 additional days. | Type A |
Report Facts
POC Due Date: 2023
POC Second Due Date: 2023
Medication Error Duration: 8
Facility Capacity: 95
Census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Savoie | Administrator | Requested extension for Plan of Correction due date |
| Liz Alfaro | Business Office Director | Met with Licensing Program Analyst during visit and provided documentation |
| Russell Echevira | Building Services Director | Provided information about ongoing repairs and anticipated completion |
| Shannan Hansen | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Bethany Moellers | Licensing Program Manager | Supervisor of the Licensing Program Analyst and named in report |
Inspection Report
Original Licensing
Census: 74
Capacity: 95
Deficiencies: 5
Aug 22, 2023
Visit Reason
The inspection was an unannounced Post-Licensing visit conducted to evaluate compliance with licensing requirements following initial licensing.
Findings
The facility was generally clean and well maintained, but several deficiencies were noted including hot water temperature exceeding regulatory limits in memory care bathrooms, unlocked medication and wound care supplies accessible to residents, and incomplete staff certifications. Civil penalties were assessed for repeat violations and failure to timely report incidents.
Severity Breakdown
Type A: 3
Type B: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Hot water temperature in 6 of 10 resident bathroom faucets (all memory care) measured between 120.7 and 121.8 degrees F, exceeding the acceptable range. | Type A |
| Unlocked bathroom cabinet in memory care containing wound cleaner accessible to residents. | Type A |
| Unattended unlocked insulin medication cart containing syringes and insulin accessible to residents. | Type A |
| Incident report for resident's hospital visit due to fractured ribs was not reported timely; major water damage in memory care dining room was not reported. | Type B |
| Three out of five staff lacked required first aid certification. | Type B |
Report Facts
Civil Penalty Amount: 250
Residents on Hospice: 9
Residents in Assisted Living: 35
Residents in Memory Care: 39
Staff Records Reviewed: 5
Resident Records Reviewed: 5
Resident Medications Reviewed: 4
Hot Water Faucets Measured: 10
Hot Water Faucets Out of Range: 6
Staff Without CPR & First Aid Certification: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Savoie | Administrator | Named in relation to certification recertification pending and responsible for compliance. |
| Elizabeth Alfaro | Business Office Manager | Met with Licensing Program Analyst during inspection and involved in observations. |
| Russell Echevira | Building Services Director | Informed Licensing Program Analyst about water damage in memory care dining area. |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Census: 74
Capacity: 95
Deficiencies: 1
Jun 15, 2023
Visit Reason
The inspection visit was a Case Management - Health Checks inspection conducted to deliver complaint findings and follow up on residents transferred from another licensed facility after an evacuation.
Findings
The inspection found that the gate on the northeast side of memory care had a new operational egress device functioning properly. However, hot water temperatures in 3 of 6 resident bathroom faucets exceeded the regulatory maximum of 120 degrees Fahrenheit, measuring 120.6, 121.2, and 122.3 degrees Fahrenheit, constituting a deficiency.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Hot water temperature in 3 of 6 resident bathroom faucets exceeded the regulatory limit of 120 degrees Fahrenheit, measuring 120.6, 121.2, and 122.3 degrees Fahrenheit. | Type A |
Report Facts
Residents from Vista Terrace: 7
Assisted living residents: 35
Caregivers: 4
Medication Technicians: 1
Hot water temperature readings: 120.6
Hot water temperature readings: 121.2
Hot water temperature readings: 122.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Savoie | Administrator | Met with Licensing Program Analyst during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted inspection and delivered complaint findings |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Original Licensing
Census: 82
Capacity: 95
Deficiencies: 2
May 31, 2023
Visit Reason
An unannounced pre-licensing inspection was conducted due to a change of ownership and to evaluate the facility for licensing approval.
Findings
The facility was toured and inspected, including resident apartments and common areas, with findings noting comfortable temperatures, unobstructed exits, and functioning fire safety systems. Some citations were noted related to hot water temperature exceeding regulatory limits and delayed egress door alarm not being connected to a pager.
Deficiencies (2)
| Description |
|---|
| Hot water temperature in 9 bathroom faucets exceeded regulation requirements of 105 to 120 degrees F. |
| Delayed egress door alarm was not connected to a pager, so no notification would occur when alarm sounded. |
Report Facts
Residents present: 82
Licensed capacity: 95
Dementia residents: 39
Bedridden residents: 11
Residents under Hospice care: 7
Evacuated residents: 16
Non-ambulatory residents capacity: 80
Bedridden residents capacity: 15
Hot water temperature readings: 9
Disaster drills frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Savoie | Administrator | Met with Licensing Program Analyst during inspection and involved in findings |
| Michael Sahati | Building Services Director | Joined facility tour during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 59
Capacity: 95
Deficiencies: 0
Apr 5, 2023
Visit Reason
The visit was conducted as a Change of Ownership application process for a Residential Care Facility for the Elderly, including a COMP II telephone interview to verify identification and understanding of California Code Title 22 Regulations.
Findings
The applicant and administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restricted health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. No deficiencies or violations were noted in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Savoie | Administrator | Applicant/administrator who participated in COMP II and confirmed understanding of regulations. |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager overseeing the evaluation. |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst conducting the evaluation. |
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