Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. However, some deficiencies were identified over time, primarily related to incident reporting, resident safety, and medication management. The most recent report from September 17, 2025, cited a deficiency for failing to timely report a fire evacuation involving 42 residents, which was a procedural issue but did not involve immediate harm. Earlier reports noted a substantiated medication management deficiency involving missing medications posing an immediate risk, and safety hazards related to unrepaired flooring and incomplete resident reappraisals after falls. While the facility has had isolated issues, recent inspections show a mix of improvements and ongoing challenges without enforcement actions or fines listed in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 1
Sep 17, 2025
Visit Reason
The visit was an unannounced case management deficiencies inspection conducted due to a complaint investigation regarding the facility's failure to report a fire evacuation incident in Building B in a timely manner as required by Title 22, section 87211(a)(3).
Findings
The facility failed to report the fire evacuation of 42 residents in Building B to the licensing agency by the next working day as required, submitting the incident report three days later. This resulted in a Type B deficiency being issued.
Complaint Details
The visit was triggered by complaint number 18-AS-20250317191114 concerning the failure to timely report a fire evacuation incident that occurred on 03/14/2025.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not report fire evacuation in Building B's of the forty-two residents the next working day as required. | Type B |
Report Facts
Residents evacuated: 42
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Haley Logan | Wellness Director | Met with Licensing Program Analyst during inspection and received report and appeal rights |
| Valerie Flores | Licensing Program Analyst | Conducted the inspection and signed the report |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 0
Sep 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations related to emergency response procedures during an incident on 03/14/2025.
Findings
The investigation found that the allegations were unfounded. Staff did report the emergency appropriately, provided a verbal resident census to emergency personnel, did not fail to provide resident records as none were requested, executed the evacuation plan properly, and had adequate staffing to meet resident needs during the evacuation.
Complaint Details
The complaint alleged staff did not report the emergency to the Long-Term Care Ombudsman, were unable to provide emergency personnel with resident census and records, did not execute the evacuation plan, and lacked adequate staff to meet resident needs. The investigation determined these allegations were unfounded.
Report Facts
Staff on shift during evacuation: 4
Additional staff arrived: 2
Residents evacuated: 42
Facility capacity: 100
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Valerie Flores | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Haley Logan | Wellness Director | Facility representative interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 100
Deficiencies: 0
Sep 16, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident was neglected and not assisted with toileting needs.
Findings
The investigation found no preponderance of evidence to substantiate the allegation of neglect. Interviews with residents and staff, document reviews, and facility observations indicated residents were assisted with toileting needs as required and no neglect was observed.
Complaint Details
The complaint alleged that resident #1 was not assisted with toileting needs on 11/28/22. The allegation was unsubstantiated after investigation including interviews, document review, and facility tour.
Report Facts
Capacity: 100
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and signed the report |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 100
Deficiencies: 0
Sep 16, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 12/14/2022 regarding resident neglect and residents being left unattended in soiled clothing.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with residents and staff, as well as observations during the facility tour, indicated residents were provided care and assistance as needed, and no residents were found unattended in soiled or wet clothing.
Complaint Details
The complaint alleged resident neglect and residents being left unattended in soaking wet clothing with feces. The allegations were investigated through interviews with staff and residents, document reviews, and facility observations. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 100
Census: 85
Number of residents interviewed: 9
Number of staff interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Nicole Anguiano | Office Manager | Met with Licensing Program Analyst during the visit |
| Teresa Mapilis | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 100
Deficiencies: 1
Sep 16, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations of staff mismanaging medication and residents not being provided medications as prescribed.
Findings
The investigation substantiated that medications for seven residents were missing at the facility, posing an immediate risk to health and safety. However, interviews revealed no medication errors or missed doses for residents currently in care. One allegation regarding a missed medication on 5/24/22 was unsubstantiated.
Complaint Details
The complaint investigation was substantiated regarding staff mismanaging medication due to missing medications for multiple residents. The allegation that residents were not provided medications as prescribed was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure medications for residents R1, R2, R4, R6, R7, R8, and R9 were available at the facility, posing an immediate risk to health, safety, or personal rights. | Type A |
Report Facts
Residents missing medications: 7
Residents interviewed: 9
Staff interviewed: 6
Facility capacity: 100
Facility census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation. |
| Nicole Anguiano | Office Manager | Met with Licensing Program Analyst during the investigation. |
| Benita Knoop | Administrator | Facility administrator during the investigation. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 100
Deficiencies: 0
Sep 15, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2022-11-09 regarding staff speaking inappropriately to residents and not answering call bells timely.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with residents and staff indicated respectful communication and timely response to call bells. Observations and tests of call light systems confirmed staff responded within 2 minutes.
Complaint Details
The complaint involved allegations that staff spoke inappropriately to residents and failed to answer call bells timely. The allegations were unsubstantiated after interviews, observations, and testing of call light systems.
Report Facts
Staff interviewed: 6
Residents interviewed: 9
Call light cords tested: 3
Staff response time: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
| Teresa Mapilis | Administrator | Facility administrator present during exit interview |
| Nicole Anguiano | Office Manager | Met with Licensing Program Analyst during investigation |
| Bianey Sandoval | Wellness Coordinator | Accompanied Licensing Program Analyst during facility tour |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 2
Sep 11, 2025
Visit Reason
The inspection was conducted as part of the Department’s investigation of Complaint #18-AS-20231201143530 regarding safety concerns following a resident's fall.
Findings
The facility was found to have a lifted floor in a resident's bedroom that posed a trip hazard and was not repaired despite being known for over two months. Additionally, the facility failed to complete a reappraisal of the resident following hospitalizations for falls, posing potential health and safety risks.
Complaint Details
Investigation of Complaint #18-AS-20231201143530 revealed safety hazards related to facility maintenance and failure to update resident reappraisals after falls.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility was aware of disrepair of resident's floor for at least two months before 08/02/2023 but did not repair it, posing an immediate health and safety risk. | Type A |
| Facility did not complete a reappraisal of the resident following hospitalizations for falls on 06/25/2021 and 03/19/2023. | Type B |
Report Facts
Census: 86
Total Capacity: 100
Deficiency Due Date: Oct 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Aguiano | Office Manager | Met during inspection and received report and appeal rights |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Abdoulaye Zerbo | Licensing Program Analyst | Created and signed the report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 0
Sep 11, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff neglect or lack of supervision resulted in a resident's death.
Findings
The investigation found that the resident sustained bilateral skull fractures and brain bleeds from a ground-level fall, with no evidence supporting the allegation of neglect causing the death. The facility was aware of damaged flooring but there was insufficient evidence that it contributed to the fall. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged staff neglect/lack of supervision resulted in a resident's death. The allegation was investigated and found to be unsubstantiated based on medical evidence and interviews.
Report Facts
Facility capacity: 100
Resident census: 86
Date complaint received: Dec 1, 2023
Resident death date: Aug 11, 2023
Incident date: Aug 2, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abdoulaye Zerbo | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Nicole Aguiano | Office Manager | Met with Licensing Program Analyst during the investigation visit |
| Teresa Mapilis | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 1
Sep 11, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-02-07 regarding allegations that staff did not report incidents to licensing, threatened a resident, and retaliated against a resident.
Findings
The investigation substantiated that staff failed to report 21 out of 23 incidents involving a resident to licensing, posing a potential health and safety risk. The allegations that staff threatened and retaliated against the resident were found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for failure to report incidents to licensing but unsubstantiated for allegations that staff threatened and retaliated against the resident. The resident was unavailable for interview as they no longer resided at the facility.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report incidents to licensing as required by CCR 87211(a)(1)(D), with only 2 out of 23 incidents reported. | Type B |
Report Facts
Incidents not reported: 21
Capacity: 100
Census: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abdoulaye Zerbo | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Nicole Aguiano | Office Manager | Met with the Licensing Program Analyst during the investigation. |
| Teresa Mapilis | Administrator | Facility administrator mentioned in the report and meeting regarding resident behavior. |
Inspection Report
Census: 86
Capacity: 100
Deficiencies: 0
Sep 9, 2025
Visit Reason
The visit was an unannounced case management incident visit triggered by a death report received on 09/05/2025 regarding a resident who passed away on 09/03/2025.
Findings
During the visit, no health or safety concerns were observed. The official death certificate had not been issued at the time of the visit, and the Executive Director was advised to submit it once available.
Report Facts
Facility capacity: 100
Census: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Mapilis | Executive Director | Met with Licensing Program Analyst during the visit and provided information regarding the incident |
| Javina George | Licensing Program Analyst | Conducted the unannounced case management incident visit |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 0
May 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not ensure residents were provided nutritious meals and did not safeguard a resident's personal belongings.
Findings
The investigation found that the facility generally provides balanced and nutritious meals according to their menu and accommodates special dietary needs, though some concerns about meal variety were noted. Regarding the missing bracelets allegation, evidence was inconclusive as some bracelets were found and returned, and the resident was no longer available for interview; therefore, the allegations were unsubstantiated.
Complaint Details
The complaint involved allegations that staff did not ensure nutritious meals for Resident 1 and failed to safeguard Resident 1's personal belongings, specifically three missing bracelets. The investigation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 100
Census: 86
Bracelets missing: 3
Bracelets found: 1
Bracelets returned: 2
Staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Teresa Mapilis | Administrator | Interviewed regarding meal service and personal belongings allegations |
| Nicole Anguiano | Office Manager | Met with Licensing Program Analyst during the visit and involved in exit interview |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 100
Deficiencies: 0
May 21, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff yelled at a visitor in front of residents.
Findings
The investigation found no preponderance of evidence to substantiate the allegation that Administrator Teresa Mapilis yelled at a visitor in the presence of residents; the allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that Administrator Teresa Mapilis yelled at a visitor near the Office Manager's office in the presence of approximately 20 to 25 residents. Interviews with staff, residents, and the Administrator did not confirm the allegation. The allegation was unsubstantiated.
Report Facts
Residents present during incident: 20
Residents present during incident: 25
Residents interviewed and found unreliable: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Teresa Mapilis | Administrator | Named in the allegation of yelling at a visitor |
| Nicole Anguiano | Office Manager | Interviewed regarding the incident and allegation |
| Carolyn Tuba | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 87
Capacity: 100
Deficiencies: 0
May 13, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies cited. The physical plant, care and supervision, records, medications, disaster preparedness, and infection control measures were all satisfactory.
Report Facts
Facility capacity: 100
Census: 87
Administrator certificate expiration: 2026
Date of last fire drill: Mar 12, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Mapilis | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Venus Mixson | Licensing Program Analyst | Conducted the inspection |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager in report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
May 13, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2022-11-15 alleging that staff did not safeguard a resident while in care and did not follow appropriate reporting requirements.
Findings
The investigation found the allegations to be unfounded as the resident was not residing at the facility at the time of the alleged incident. Interviews and record reviews confirmed no issues with safeguarding or reporting requirements.
Complaint Details
The complaint alleged staff did not safeguard a resident and failed to follow reporting requirements. The findings determined the allegations were unfounded due to the resident not being at the facility during the incident and no reporting issues were observed.
Report Facts
Complaint Control Number: 18-AS-20221115152403
Facility Capacity: 100
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Venus Mixson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Teresa Mapilis | Administrator | Facility administrator who provided information and denied allegations |
| Jazmond D Harris | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
May 12, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-03-11 regarding staff mismanagement of a resident's medication and staff restraining a resident in care.
Findings
Based on interviews, record reviews, and observations, the allegations that staff mismanaged the resident’s medication and restrained the resident in care may have happened or are valid, but there was not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations were determined unsubstantiated.
Complaint Details
The complaint alleged that staff mismanaged Resident #1's medication by administering 300 mg when the physician ordered 200 mg, and that staff restrained the resident by using a Geri chair and positioning the resident in bed to prevent exiting. Investigations included interviews with staff, administrator, hospice nurses, and review of medication orders and administration records. Resident #1 was on hospice and passed away on 2025-03-09. No conclusive evidence was found to substantiate the allegations.
Report Facts
Facility capacity: 100
Resident census: 87
Medication dosage: 200
Medication dosage: 300
Medication dosage: 100
Date of complaint received: Mar 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Venus Mixson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Teresa Mapilis | Administrator | Facility administrator interviewed during investigation |
| Jazmond D Harris | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 86
Capacity: 100
Deficiencies: 0
May 8, 2025
Visit Reason
An unannounced visit was conducted to re-deliver amended findings and inform the facility of the purpose of the visit.
Findings
The Licensing Program Analyst delivered amended LIC9099 and LIC9099-C forms along with the report. No new deficiencies or findings are detailed in this report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Anguiano | Business Office Director | Met with Licensing Program Analyst during the visit. |
| Seo Jeon | Licensing Program Analyst | Conducted the unannounced visit and delivered amended findings. |
| Teresa Mapilis | Administrator | Named as facility administrator. |
Inspection Report
Census: 87
Capacity: 100
Deficiencies: 0
Jan 15, 2025
Visit Reason
Licensing Program Analyst Seo Jeon conducted an unannounced case management visit following a report received on 10-31-2024 regarding an incident between two residents.
Findings
The analyst observed no immediate health and safety concerns and confirmed adequate staff coverage during the incident. Resident relocation was implemented for safety. No deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Anguiano | Business Office Manager | Met during the visit and provided information about the incident and staffing. |
| Seo Jeon | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Teresa Mapilis | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Oct 25, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that, because of lack of supervision, a resident got into a physical altercation with another resident.
Findings
The investigation found that the facility had sufficient staff coverage at the time of the incident, and interviews and documentation review determined the allegation of lack of supervision leading to the altercation was unsubstantiated.
Complaint Details
The complaint alleged that due to lack of supervision, a resident got into a physical altercation with another resident. The allegation was found to be unsubstantiated after investigation.
Report Facts
Staff to resident ratio: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Seo Jeon | Licensing Program Analyst | Conducted the complaint investigation |
| Nicole Anguiano | Business Office Director | Met with Licensing Program Analyst during investigation |
| Rikesha Stamps | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Oct 25, 2024
Visit Reason
The inspection was an unannounced visit to investigate complaints alleging staff physically abused residents and yelled at residents in care.
Findings
Based on interviews, records review, and discussions with facility staff, the allegations were found to be unfounded, with evidence indicating that the incidents involved resident-to-resident aggression rather than staff abuse.
Complaint Details
The complaint alleged staff physically abused residents and yelled at residents. The investigation found these allegations to be unfounded, meaning the allegations were false or without reasonable basis.
Report Facts
Facility capacity: 100
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Anguiano | Business Office Manager | Met with during investigation and exit interview |
| Seo Jeon | Licensing Program Analyst | Conducted the complaint investigation |
| Rikesha Stamps | Licensing Program Manager | Oversaw the complaint investigation |
| Eloisa Mireles | Wellness Director | Discussed allegations with Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 100
Deficiencies: 0
Aug 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations of staff verbally and physically abusing a resident, and failure to safeguard a resident's belongings.
Findings
The investigation found the allegations of staff verbally and physically abusing residents to be unfounded, with evidence indicating that the alleged aggressor was another resident. The allegation that staff did not safeguard a resident's belongings was unsubstantiated due to insufficient evidence, despite reports of missing items and possible theft by a former resident.
Complaint Details
The complaint investigation addressed allegations of staff verbally abusing a resident, staff physically abusing a resident, and staff failing to safeguard a resident's belongings. The verbal and physical abuse allegations were found to be unfounded. The allegation regarding safeguarding belongings was unsubstantiated due to lack of sufficient evidence.
Report Facts
Missing money amount: 3
Value of missing juicer: 50
Number of underwear pairs retrieved: 5
Facility capacity: 100
Census: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Tricia Danielson | Licensing Program Manager | Oversaw the complaint investigation. |
| Eloisa Mireles | Wellness Director | Facility representative met during the investigation and recipient of the report. |
| Teresa Mapilis | Administrator | Facility administrator named in the report. |
Inspection Report
Annual Inspection
Census: 92
Capacity: 100
Deficiencies: 0
Jul 12, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted by the Community Care Licensing Division to evaluate compliance with licensing requirements and ensure resident safety and care standards.
Findings
The facility was found to be operating within licensing conditions with no deficiencies cited. Physical plant, food service, staff training, medication management, and safety measures were all compliant with regulatory requirements.
Report Facts
Residents receiving hospice services: 18
Medication carts inspected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Mapilis | Administrator | Met during inspection and reviewed report |
| Nicole Anguiano | Business Office Manager | Met during inspection |
| Stephanie Martinez | Licensing Program Analyst | Conducted inspection |
| Reyna Lacey | Regional Manager | Participated in inspection visit |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Jun 21, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-01-17 regarding medication administration without POA consent, unmet hygiene needs, and failure to ensure use of a walking device for a resident.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff followed the resident's care plan and physician orders, hygiene needs were addressed with reminders and assistance despite resident refusal, and the walking device was available and used when possible. The allegations were deemed unsubstantiated.
Complaint Details
The complaint involved allegations that staff administered medication without POA consent, did not meet the resident's hygiene needs, and failed to ensure use of the resident's walking device. The findings were unsubstantiated due to insufficient evidence.
Report Facts
Facility capacity: 100
Resident census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Mapilis | Administrator | Met with Licensing Program Analyst during investigation and named in report |
| Venus Mixson | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 90
Capacity: 100
Deficiencies: 0
May 22, 2024
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst Yolanda Delgado to evaluate the facility's compliance with regulations.
Findings
The inspection was partially completed due to time constraints, with no deficiencies cited during this visit per Title 22, Division 6 of The California Code of Regulations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Delgado | Licensing Program Analyst | Conducted the annual inspection visit. |
| Teresa Mapilis | Administrator | Facility administrator met with the Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 0
May 22, 2024
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging illegal eviction of Resident #1 from the facility.
Findings
The investigation included interviews and record reviews, concluding that the facility properly delivered a 30-day eviction notice with resources for alternate housing. The complaint was found to be unfounded.
Complaint Details
The complaint alleged illegal eviction of Resident #1, who was accused of providing incorrect information and threatening other residents. The investigation found no basis for the allegation and deemed it unfounded.
Report Facts
Capacity: 100
Census: 90
Attempts to contact Resident #1: 3
Eviction notice period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yolanda Delgado | Licensing Program Analyst | Conducted the complaint investigation |
| Teresa Mapilis | Administrator | Facility administrator interviewed during the investigation |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 1
Apr 22, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not notify the responsible party of a resident's change in health condition, specifically regarding residents experiencing rashes.
Findings
The investigation substantiated the complaint that the facility failed to notify the responsible party of Resident One's rash due to the resident receiving hospice services. The facility did not meet the requirement to inform representatives of residents about care-related activities, posing a potential threat to residents' health and rights. A citation will be issued.
Complaint Details
The complaint was substantiated based on evidence that the facility did not notify the responsible party of Resident One's rash because the resident was under hospice care, and the hospice agency was expected to notify the responsible party. This failure poses a potential threat to residents' health, safety, and personal rights.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident One's representative was informed of health condition changes related to a rash, violating personal rights of residents. | Type B |
Report Facts
Census: 90
Total Capacity: 100
Deficiency Type Count: 1
Plan of Correction Due Date: Apr 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Mapilis | Administrator | Named in relation to the finding that the responsible party was not notified |
| Nicole Anguiano | Business Office Manager | Participated in exit interview regarding the complaint investigation |
| Stephanie Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Rikesha Stamps | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 0
Apr 22, 2024
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff did not ensure the facility was kept free of bed bugs and residents had untreated rashes possibly caused by bed bug bites.
Findings
The investigation found that one resident was diagnosed with an infectious condition and receiving appropriate treatment and infection control measures were in place. Other residents with rashes were receiving treatment and no evidence of a bed bug infestation was found. The complaint was deemed unfounded.
Complaint Details
The complaint alleged residents had rashes from bed bug bites that were untreated. The investigation included interviews, record reviews, and staff training verification. The complaint was found to be unfounded.
Report Facts
Residents with rash reported: 4
Residents in care: 90
Facility capacity: 100
Date complaint received: Apr 17, 2024
Staff training date: Apr 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Teresa Mapilis | Administrator | Facility administrator interviewed during investigation |
| Nicole Anguiano | Business Office Manager | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 100
Deficiencies: 1
Feb 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-01-05 regarding a resident being physically assaulted by another resident due to lack of supervision and concerns about the safety and comfort of residents.
Findings
The investigation substantiated that a resident was physically assaulted by another resident resulting in injury due to insufficient supervision and staffing. Another allegation regarding staff not providing a safe and comfortable environment was unsubstantiated. The facility acknowledged staffing shortages and agreed to revise schedules and provide additional training.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident was physically assaulted by another resident due to lack of supervision. The allegation that staff did not provide a safe and comfortable environment was unsubstantiated. The investigation included observations, interviews, and records review. The assault was witnessed by a newly hired staff member, and police were called but no charges filed.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide the services necessary to meet resident needs, leading to lack of supervision during the assault. | Type B |
Report Facts
Capacity: 100
Census: 88
Plan of Correction Due Date: Mar 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Shaw Ross | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jazmond D Harris | Licensing Program Manager | Oversaw the complaint investigation |
| Nicole Anguiano | Business Office Manager | Met with Licensing Program Analyst during the investigation and exit interview |
| Teresa Mapilis | Administrator / Executive Director | Provided interview regarding facility safety and resident environment |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 100
Deficiencies: 0
Jan 9, 2024
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct additional interviews with witnesses regarding complaint 18-AS-20240105081727.
Findings
The Licensing Program Analyst conducted an interview with the Executive Director and documented the information. No additional interviews were conducted due to a staff witness calling out.
Complaint Details
Complaint 18-AS-20240105081727 was the reason for the visit; additional interviews were attempted but only the Executive Director was interviewed. No substantiation status was provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Mapilis | Executive Director | Interviewed during complaint investigation |
| Jacqueline Shaw Ross | Licensing Program Analyst | Conducted the complaint investigation visit and interview |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 100
Deficiencies: 0
Jun 30, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that residents were left in soiled diapers for an extended period of time.
Findings
The investigation, including interviews and documentation review, found no evidence to support the allegation. The complaint was deemed unsubstantiated due to lack of corroborating evidence.
Complaint Details
The allegation that residents were left in soiled diapers for an extended period was investigated and found to be unsubstantiated.
Report Facts
Capacity: 100
Census: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation |
| Deborah Mullen | Licensing Program Manager | Oversaw the complaint investigation |
| Theresa Mapilis | Facility Administrator present during the investigation | |
| Emma Andrade | Wellness Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 76
Capacity: 100
Deficiencies: 0
May 24, 2022
Visit Reason
An unannounced annual inspection was conducted focusing on infection control measures at the facility.
Findings
The facility was found to have implemented adequate infection control measures including symptom screenings, hand hygiene supplies, social distancing, masking policies, and sufficient PPE supply. No deficiencies were noted during the visit.
Report Facts
Staff present: 11
Fingerprint status: 4
PPE supply: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Mapillis | Executive Director | Met with Licensing Program Analyst during inspection |
| Janira Arreola | Licensing Program Analyst | Conducted the inspection visit |
| Joel Esquivel | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 100
Deficiencies: 1
Dec 14, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that a resident was not being allowed to have visitors.
Findings
The investigation substantiated the allegation that a resident was not permitted to have visitors, violating Title 22 Section 6 Chapter 8 Article 9 Resident Records 87468.1(a)11 Personal Rights of Residents in All Facilities. This posed a potential health and safety risk to residents.
Complaint Details
The complaint was substantiated based on interviews with the resident, responsible party, and administrator, confirming the resident was not allowed visitors as required by regulation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to allow residents to have visitors privately during reasonable hours without prior notice, infringing on residents' personal rights. | Type B |
Report Facts
Capacity: 100
Census: 76
Plan of Correction Due Date: Dec 28, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Reyna Lacey | Licensing Program Manager | Oversaw the complaint investigation |
| Teresa Mapilis | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 100
Deficiencies: 0
Dec 7, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2021-12-01 regarding staff overmedicating a resident, making a resident dance for food, and a resident leaving the facility unsupervised.
Findings
The investigation found that the allegations were unsubstantiated. Record reviews and interviews confirmed that the resident was given medication as ordered and was able to leave the facility unassisted. There was no preponderance of evidence to prove the alleged violations occurred.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations did or did not occur.
Report Facts
Capacity: 100
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation |
| Deborah Mullen | Licensing Program Manager | Named in report as Licensing Program Manager |
| Nicole Anguiano | Business Office Manager | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 100
Deficiencies: 0
Oct 21, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 02/21/2020 regarding resident care concerns at Yorkshire Village facility.
Findings
The investigation found insufficient evidence to substantiate the allegations that a resident was left on the floor for an extended period or that the resident fell and sustained an injury. Both allegations were determined to be unsubstantiated based on interviews, document reviews, and observations.
Complaint Details
The complaint involved allegations that a resident was left on the floor for an extended period and that the resident fell and sustained an injury. Both allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 18-AS-20200221104723
Capacity: 100
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Cuevas | Licensing Program Analyst | Conducted the complaint investigation |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
| Teresa Mapilis | Executive Director | Facility representative met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 100
Deficiencies: 0
Jul 15, 2021
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff were not allowing a resident to leave the facility.
Findings
The investigation included interviews with residents and staff and a records review. The allegation was found to be unsubstantiated due to lack of evidence to prove the alleged violation.
Complaint Details
The complaint alleged that staff were not allowing a resident to leave the facility. Interviews with residents and staff indicated residents were able to leave as they wished, and the allegation was unsubstantiated.
Report Facts
Facility capacity: 100
Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Licensing Program Analyst | Conducted the complaint investigation |
| Efren Malagon | Licensing Program Manager | Oversaw the complaint investigation |
| Theresa Mapilis | Facility representative met during investigation |
Inspection Report
Annual Inspection
Census: 69
Capacity: 100
Deficiencies: 0
May 18, 2021
Visit Reason
The visit was an unannounced required annual inspection with an emphasis on infection control due to the COVID-19 pandemic.
Findings
The inspection found no health and safety concerns or deficiencies. The facility demonstrated appropriate infection control measures, sufficient PPE supplies, and staff training in PPE use.
Report Facts
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Licensing Program Analyst | Conducted the inspection and made observations |
| Elecia Weathersby | Licensing Program Analyst | Conducted the inspection and made observations |
| Theresa Mapilis | Administrator | Met with inspectors and provided information about COVID-19 status |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 100
Deficiencies: 0
Sep 29, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of illegal eviction received on 07/23/2020.
Findings
The investigation found that the facility provided an eviction notice to Resident #1 with a 30-day effective date and that the resident's belongings were retrieved before the eviction date. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged illegal eviction. The investigation was unsubstantiated, meaning there was not enough evidence to prove the alleged violation did or did not occur.
Report Facts
Capacity: 100
Census: 62
Complaint received date: Jul 23, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Williams | Licensing Evaluator | Conducted the complaint investigation and delivered findings |
| Efren Malagon | Supervisor | Supervisor overseeing the complaint investigation |
| Teresa Mapilis | Facility representative met during the investigation and exit interview |
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