Inspection Report Summary
Most inspections found no deficiencies, with the facility maintaining compliance in annual visits through October 1, 2025, which had no deficiencies noted. Some complaint investigations were unsubstantiated, including concerns about food quality, medication assistance, and communication by the administrator. However, there were isolated issues such as unsanitary conditions found in June 2025 and a failure to conduct required disaster drills between November 2024 and June 2025, which posed a health and safety risk but were addressed promptly. A more serious issue occurred in July 2022 when staff were found working without proper criminal record clearances, representing an immediate safety risk. Since then, the facility has shown improvement, with recent reports indicating compliance and no new deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 49
Capacity: 72
Deficiencies: 0
Oct 1, 2025
Visit Reason
An unannounced annual inspection visit was conducted to evaluate the facility's compliance with licensing requirements and state regulations.
Findings
The facility was found to be in compliance with no deficiencies noted during the inspection. The facility maintains conformity with State Fire Marshall regulations and has appropriate emergency preparedness measures in place.
Report Facts
Hospice residents: 5
Hospice waiver capacity: 10
Resident rooms: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rick Olds | Administrator | Met with Licensing Program Analyst during inspection |
| Kristin Kontilis | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 72
Deficiencies: 0
Aug 15, 2025
Visit Reason
An unannounced complaint investigation was conducted based on allegations that staff do not ensure resident binders are up to date and that staff are pre-pouring medications.
Findings
The investigation found that resident binders were up to date with all required documents and that staff followed proper procedures when pre-pouring medications, including wearing gloves and labeling medication cups. Both allegations were unsubstantiated and no deficiencies were noted.
Complaint Details
The complaint investigation was unsubstantiated based on records reviewed, interviews conducted, and observations made regarding the allegations about resident binders and medication pre-pouring.
Report Facts
Capacity: 72
Census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation |
| Rick Olds | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 72
Deficiencies: 1
Jul 8, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the licensee does not ensure staff are conducting disaster drills and receiving required training.
Findings
The allegation that staff were not conducting disaster drills was substantiated as the facility had not conducted a disaster drill between November 2024 and June 2025, posing an immediate health and safety risk. A disaster drill was conducted on 6/26/2025 to address this. The allegation that staff were not receiving required training was unsubstantiated, with records showing monthly all-staff trainings covering safety and emergency topics.
Complaint Details
The complaint investigation was substantiated regarding failure to conduct disaster drills but unsubstantiated regarding failure to provide required staff training.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not conduct a disaster drill at least quarterly as required by §1569.695(c), with no drill conducted between November 2024 and June 2025. | Type B |
Report Facts
Capacity: 72
Census: 51
Deficiency count: 1
Plan of Correction Due Date: Jul 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jessica Hong | Interim Administrator | Facility representative met during the investigation |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 72
Deficiencies: 1
Jun 10, 2025
Visit Reason
An unannounced complaint investigation was conducted based on allegations received on 2025-06-03 regarding unsanitary conditions, presence of rodents, and failure to maintain accurate residents' records at the facility.
Findings
The allegation that the facility is unsanitary was substantiated due to observations of a fly trap with dead flies above a food preparation area, mold and dirt in a staff room, and stained carpets in residents' rooms. The allegation of rodents was unsubstantiated as no evidence or sightings were found. The allegation that staff failed to maintain accurate residents' records was also unsubstantiated based on interviews and record reviews.
Complaint Details
The complaint investigation was substantiated for unsanitary conditions but unsubstantiated for allegations of rodents and failure to maintain accurate residents' records.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility was not clean and sanitary as evidenced by a fly trap with trapped flies above a food service area, mold and dirt on the wall in a staff room, and stained and soiled carpets in residents' rooms. | Type B |
Report Facts
Capacity: 72
Census: 51
Plan of Correction Due Date: Jun 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Hong | Interim Executive Director | Met with Licensing Program Analyst during investigation and provided statements regarding facility conditions |
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation |
| June Davila | Wellness Director | Participated in the visit and interviews related to investigation |
| Holly Walling | Sales & Marketing Manager | Participated in the visit and interviews related to investigation |
Inspection Report
Annual Inspection
Census: 47
Capacity: 72
Deficiencies: 0
Oct 1, 2024
Visit Reason
The inspection was an unscheduled, required annual evaluation visit to ensure compliance with Title 22 regulations and to assess the facility's health and safety conditions.
Findings
The facility was found to be in compliance with health and safety regulations, including proper food service and storage, clean and well-maintained physical plant areas, appropriate resident accommodations, and operational safety equipment. No hazards or deficiencies were noted during the inspection.
Report Facts
Facility capacity: 72
Hospice waiver capacity: 10
Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Phillips | Licensing Program Analyst | Conducted the inspection and authored the report |
| Michael Easbey | Executive Director | Met with the Licensing Program Analyst during the inspection |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Lourdes Espinoza | Administrator | Facility Administrator with pending certificate as of 05/28/2024 |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 72
Deficiencies: 0
May 16, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following a complaint alleging that staff do not provide adequate food service to the residents.
Findings
Based on observations, interviews with residents and staff, documentation review, food sampling, and photographs, the allegation that staff do not provide adequate food service was found to be unsubstantiated at this time.
Complaint Details
The complaint alleged that staff do not provide adequate food service to residents, with some residents complaining about the quality of food. The investigation included interviews with 12 residents and 5 staff members, review of menus and dietary contracts, and observation of food service. The complaint was determined to be unsubstantiated.
Report Facts
Residents interviewed: 12
Staff interviewed: 5
Capacity: 72
Census: 51
Food preparation & meal service scores: 89
Residents partook in breakfast: 33
Breakfast consumption rate: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Jeffries | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lourdes Espinoza | Administrator | Facility administrator met during investigation and named in report |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 72
Deficiencies: 0
Feb 9, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff do not ensure residents are served food of good quality, including claims of overcooked proteins and limited meal variety over the past three months.
Findings
The Licensing Program Analyst observed the dining areas and kitchen, interviewed residents and staff, and reviewed documentation. The food was found to be of good quality with no expired or stale items, proper storage, and sufficient variety. Most residents reported satisfaction with the food quality, and staff denied claims of budget cuts affecting food quality. The allegation was deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged poor food quality, including overcooked proteins and limited meal variety. The investigation found no evidence to substantiate these claims, and the complaint was unsubstantiated.
Report Facts
Facility capacity: 72
Census: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lourdes Espinoza | Administrator | Met during the investigation and involved in the complaint discussion |
| Brian Phillips | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Shayla Sanchez | Human Resources Specialist | Met during the investigation and involved in the complaint discussion |
Inspection Report
Annual Inspection
Census: 44
Capacity: 72
Deficiencies: 0
Oct 10, 2023
Visit Reason
The visit was a required 1-Year Annual facility site inspection to ensure compliance with Title 22 Regulations for the Residential Care for the Elderly facility.
Findings
The facility was found to be in compliance with all applicable regulations, including health and safety standards, infection control, medication management, and record keeping. No deficiencies were cited during the inspection.
Report Facts
Hospice Waiver residents: 5
Food supply duration: 7
Fire extinguisher service year: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lourdes Espinoza | Administrator | Facility Administrator present during inspection |
| Michael Easbey | Executive Director | Facility Executive Director present during inspection |
| Brian Phillips | Licensing Program Analyst | Conducted the inspection |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 72
Deficiencies: 0
Jun 1, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not providing medication assistance and were not meeting residents' needs.
Findings
The investigation found insufficient evidence to prove the allegations that facility staff allowed a private caregiving company to provide medication assistance exclusively and that staff did not meet residents' needs. The caregiving company was fully licensed and contracted to assist residents, and the allegations were deemed unsubstantiated.
Complaint Details
The complaint alleged that staff were not providing medication assistance and not meeting residents' needs, specifically that a private caregiving company provided medication assistance without background clearance. The allegations were found unsubstantiated.
Report Facts
Capacity: 72
Census: 40
Complaint Control Number: 29-AS-20220628153056
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Phillips | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
| Joan Schuermann | Administrator | Facility Administrator |
| Jeff LaBelle | Administrator | Met with Licensing Program Analyst during visit |
| Lourdes Espinosa | Associate Executive Director | Met with Licensing Program Analyst during visit |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 72
Deficiencies: 0
Jun 1, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the administrator was not communicating residents' conditions with representatives and was inappropriately speaking to residents in care.
Findings
The investigation found insufficient evidence to substantiate the allegations. The administrator did communicate with responsible parties about the flu-like outbreak symptoms but did not specify the illness. The administrator's statements to residents regarding quarantine and late payments were factual and not inappropriate.
Complaint Details
The complaint alleged that the administrator failed to communicate the resident's condition to representatives and spoke inappropriately to residents by forcing isolation and threatening eviction for late payments. Both allegations were found unsubstantiated based on interviews and evidence.
Report Facts
Residents exhibiting symptoms: 3
Capacity: 72
Census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Phillips | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kelly Burley | Licensing Program Manager | Named in report as Licensing Program Manager |
| Jeff Labelle | Administrator | Named in allegations and investigation findings |
| Lourdes Espinosa | Associate Executive Director | Met with during investigation visit |
Inspection Report
Annual Inspection
Census: 38
Capacity: 72
Deficiencies: 0
Sep 14, 2022
Visit Reason
The visit was a required unannounced 1-year infection control annual inspection to evaluate the facility's compliance with infection control protocols.
Findings
No deficiencies were observed during the visit. The facility has implemented and is following all infection control protocols, including screening, PPE use, isolation procedures, and staff training.
Report Facts
PPE supply duration: 30
Capacity: 72
Census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffrey LaBelle | Administrator | Met with Licensing Program Analyst during the inspection and responsible for infection control plans. |
| Jeannette Olson | Licensing Program Analyst | Conducted the on-site 1 year infection control annual visit. |
| Kelly Burley | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 72
Deficiencies: 1
Jul 7, 2022
Visit Reason
An unannounced complaint investigation was conducted based on an allegation that staff were not associated with the facility.
Findings
The investigation substantiated that fifteen staff from a home care agency and eight facility staff were working at the facility without being properly associated or having appropriate criminal record clearance transfers, posing an immediate health and safety risk to residents.
Complaint Details
The complaint alleging that staff were not associated with the facility was substantiated based on record review and interviews.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure all individuals working in the facility had appropriate criminal record clearance transfers as required by CCR 87355(e)(1). Fifteen staff from a home care agency and eight facility staff were not associated with the facility prior to working. | Type A |
Report Facts
Civil Penalty: 11200
Staff not associated: 15
Staff not associated: 8
Capacity: 72
Census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristin Kontilis | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation. |
| Joan Schuermann | Administrator | Facility administrator named in the report. |
| Lourdes Espinoza | Interim Administrator | Met with Licensing Program Analyst during investigation. |
| Jeff LaBelle | Consultant | Consultant for West Bay Senior Living involved in the investigation. |
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