Inspection Report Summary
Most inspections over the past two years found no deficiencies, including the most recent report on October 23, 2025, which cited a single violation for failing to notify responsible parties and the ombudsman about license suspension proceedings. However, several complaint investigations in late 2023 and 2025 were substantiated, revealing serious issues such as failure to provide timely medical attention, inadequate staff training, neglect leading to severe pressure injuries, and insufficient incontinent care. The facility faced civil penalties, including a fine for allowing a caregiver without criminal record clearance to work alone and penalties related to these care failures. Earlier annual inspections identified multiple deficiencies involving staff training, fire safety, resident rights, and medication management, but some improvements were noted as later reports showed fewer or no deficiencies. While the facility has addressed some concerns, recent substantiated complaints indicate ongoing challenges in resident care and staff competency.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a October 2025 inspection.
Census over time
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
The unannounced visit was conducted to ensure the licensee notified the responsible parties and ombudsman that the Department of Social Services, Community Care Licensing Division had commenced proceedings to suspend or revoke the license, which was found not to have occurred.
Findings
The Licensing Program Analyst reviewed resident and staff files and discussed multiple topics with the facility manager. The licensee failed to notify responsible parties and ombudsman about the commencement of license suspension or revocation proceedings as required by California Health and Safety Code.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esmeralda Negrete | Manager | Discussed multiple topics with Licensing Program Analyst during the visit. |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced visit and authored the report. |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Follow-Up
Census: 6
Capacity: 6
Deficiencies: 2
Date: Sep 26, 2025
Visit Reason
Unannounced inspection to follow up on a substantiated complaint investigation regarding failure to seek timely medical attention, failure to report incidents, and inadequate staff training.
Complaint Details
The complaint investigation was substantiated. Allegations included staff not seeking timely medical attention for resident (R1), failure to report incidents involving R1, and inadequate staff training. Serious bodily injury was determined due to hospitalization of R1.
Findings
The licensee was cited for violations related to observation of the resident and reporting requirements. A civil penalty was issued due to serious bodily injury resulting from staff not notifying medical personnel of a resident's worsening condition, which led to hospitalization.
Deficiencies (2)
Violation of CCR, Title 22, § 87466 Observation of the Resident
Violation of CCR, Title 22, § 87211(a)(1) Reporting Requirements
Report Facts
Civil penalty amount: 9500
Immediate civil penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manpreet Dyal | Licensee | Met during inspection and acknowledged receipt of appeal rights. |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Troy Ordonez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Follow-Up
Census: 6
Capacity: 6
Deficiencies: 3
Date: Sep 26, 2025
Visit Reason
Unannounced inspection to follow up on a substantiated complaint investigation regarding allegations of severe pressure injury due to staff neglect and failure to seek timely medical attention.
Complaint Details
The complaint investigation concluded that a resident sustained severe pressure injury due to staff neglect, the facility failed to seek medical attention, and staff left the resident in a soiled diaper for an extended period. The complaint was substantiated.
Findings
The Department determined that a civil penalty is warranted for serious bodily injury due to the facility's failure to provide proper care and timely medical intervention, resulting in hospitalization and surgeries for the resident.
Deficiencies (3)
Violation of CCR Title 22, § 87466 Observation of the Resident
Violation of CCR Title 22, § 87411(a) Personnel Requirements
Violation of CCR Title 22, § 87468.1(a)(2) Personal Rights of Residents in All Facilities
Report Facts
Civil penalty amount: 9500
Immediate civil penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manpreet Dyal | Licensee | Met with during inspection and acknowledged receipt of appeal rights |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the inspection and signed the report |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager overseeing the case |
Inspection Report
Census: 6
Capacity: 6
Deficiencies: 0
Date: Sep 10, 2025
Visit Reason
Unannounced case management visit conducted to discuss several issues that do not affect the residents.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst met with the licensee and left several documents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manpreet Dyal | Licensee | Met with Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The inspection was a required annual unannounced visit to evaluate the facility's compliance using the full care tool.
Findings
The inspection found no deficiencies. The facility was toured, files reviewed, and multiple topics discussed. The kitchen had locked sharps and ample food supply.
Report Facts
Residents files reviewed: 5
Staff files reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the inspection and met with caregiver |
| Rajveer Kaur | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 6
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not safeguard a resident's personal belongings.
Complaint Details
The complaint alleged that staff did not safeguard a resident's personal belongings. After interviews and file review, the allegation was found unsubstantiated due to insufficient evidence.
Findings
The investigation found that the former resident waived the inventory of their belongings upon move-in and had moved several times since leaving the facility. Due to lack of evidence, the allegation that staff did not safeguard the resident's belongings was unsubstantiated.
Report Facts
Capacity: 6
Census: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Met with during the investigation and involved in the investigation findings |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 5
Capacity: 6
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
This office meeting was conducted at the request of Licensees Rajveer Kaur and Manpreet Dyal to review floor plans for their new location and discuss change of location procedures.
Findings
The discussion focused on change of location procedures and floor plans. Licensees were advised to contact the Central Application Bureau for more information and to keep Licensing Program Analyst Hiratsuka updated on progress.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator/Director | Facility representative present during the office meeting. |
| Manpreet Dyal | Facility representative present during the office meeting. | |
| Troy Ordonez | Licensing Program Manager | Present from Community Care Licensing during the meeting. |
| Kerry Hiratsuka | Licensing Program Analyst | Present from Community Care Licensing during the meeting. |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 0
Date: Jul 31, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-03-11 regarding facility disrepair, unsafe and unsanitary environment, and staff working without criminal record clearance.
Complaint Details
The complaint included allegations that the facility was in disrepair, did not ensure a safe or sanitary environment, and that staff were working without criminal record clearance. The investigation concluded the first three allegations were unsubstantiated and the last allegation was unfounded.
Findings
The investigation found the allegations of facility disrepair, unsafe and unsanitary environment to be unsubstantiated due to lack of evidence. The allegation of staff working without criminal record clearance was found to be unfounded as the cited caregiver was no longer employed at the facility.
Report Facts
Capacity: 6
Census: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Named as facility administrator |
| Kerry Hiratsuka | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Oversaw the complaint investigation |
| Manpreet Dyal | Met with during the investigation |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 0
Date: Mar 20, 2024
Visit Reason
The visit was an unannounced required annual inspection conducted by Licensing Program Analysts to assess compliance using the full care tool.
Findings
The facility was toured including resident rooms, kitchen, and common areas. Staff and resident files were reviewed and found to be complete. Several suggestions were made regarding lighting in a shower, smoke detector placement, and bathroom window privacy. No deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Named as facility administrator |
| Manpreet Dyal | Caregiver | Met with Licensing Program Analysts during inspection |
| Cassie Yang | Licensing Program Analyst | Conducted the inspection |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the inspection |
| Anthony Perez | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 6
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-12-06 regarding staff ignoring resident calls for assistance, not assisting a resident with restroom use, and leaving a resident on the floor.
Complaint Details
The complaint involved three allegations: 1) Facility staff ignored resident's calls for assistance; 2) Facility staff did not assist resident with using the restroom; 3) Facility staff left resident on the floor. The investigation found no preponderance of evidence to prove these allegations, resulting in an unsubstantiated status.
Findings
The investigation included interviews with the administrator, licensee, caregiver, and residents, as well as a review of resident files. The allegations could not be substantiated due to lack of sufficient evidence, and the findings were determined to be unsubstantiated.
Report Facts
Facility capacity: 6
Census: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Met during investigation and involved in interviews |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Enforcement
Census: 4
Capacity: 6
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
The visit was a Case Management - Legal/Non-compliance meeting to discuss a high volume of citations and a substantiated complaint against the facility.
Complaint Details
The complaint was substantiated as discussed during the non-compliance conference.
Findings
The facility was cited 29 times in the last year, including 15 Type A citations and 14 Type B citations. Issues included staffing and training problems, communication breakdown, lack of administrator oversight, insufficient wound care supplies, failure to seek medical attention, night supervision deficiencies, lack of incontinence care plans, personal rights violations, and accountability concerns.
Report Facts
Citations: 29
Type A citations: 15
Type B citations: 14
Capacity: 6
Census: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Named in relation to lack of oversight and accountability issues |
| Manpreet Dyal | Licensee | Present at non-compliance conference |
Inspection Report
Census: 3
Capacity: 6
Deficiencies: 3
Date: Dec 5, 2023
Visit Reason
The visit was a case management health check conducted to review staff and resident files, medication administration, and compliance with licensing regulations.
Findings
The inspection found outdated needs and service plans for residents, missing medications that were ordered, and noncompliance with diabetes care requirements where a caregiver not qualified as a skilled professional was performing glucose testing and insulin injections. Additionally, medication lists did not match medications present, and reappraisals for residents were overdue.
Deficiencies (3)
Noncompliance with diabetes care requirements: resident unable to perform glucose testing and insulin injections, but caregiver not appropriately skilled is performing these tasks, posing immediate risk.
Medication lists did not match medications present in the facility, posing immediate health, safety, or personal rights risk.
Reappraisals for residents were overdue by more than 12 months, posing potential health, safety, or personal rights risk.
Report Facts
Census: 3
Total Capacity: 6
Deficiency Count: 3
Plan of Correction Due Date: Dec 6, 2023
Plan of Correction Due Date: Dec 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Met with during inspection and referenced in medication administration findings |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted inspection, file reviews, and signed report |
| Bethany Mirlohi | Licensing Program Analyst | Conducted file review and walk through during inspection |
| Troy Ordonez | Licensing Program Manager | Named as supervisor and licensing program manager |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 8
Date: Nov 15, 2023
Visit Reason
The inspection was conducted while investigating Complaints 59-AS-20230731122901 and 59-AS-20230717132508 to assess compliance with regulations and address reported issues.
Complaint Details
The visit was complaint-related, investigating Complaints 59-AS-20230731122901 and 59-AS-20230717132508. The report documents multiple substantiated deficiencies related to resident care and facility management.
Findings
Multiple deficiencies were found including lack of overnight incontinent care, absence of required staff training and qualifications, missing written agreements and communication with home health agency, failure to document and manage a resident's pressure injury, and inadequate resident assessments and records.
Deficiencies (8)
Facility staff working overnight do not provide incontinent care, lack required training, and do not meet qualifications for night supervision.
No written agreement or ongoing communication between the facility and home health agency for resident R1.
Failure to document resident R1's pressure injury and lack of preappraisal and reappraisal documentation.
No functional capability assessment conducted prior to accepting resident R1.
Medical assessment for resident R1 was not in the file as it was sent to hospital and not replaced.
No centrally stored medication list for resident R1 as it was sent to hospital and not replaced.
Administrator lacks knowledge and staff lack required training, do not check residents needing incontinent care, and are not qualified.
Failure to ensure staff on each shift can communicate with home health agency, licensing staff, and emergency personnel.
Report Facts
Capacity: 6
Census: 5
Plan of Correction Due Dates: Nov 16, 2023
Plan of Correction Due Dates: Dec 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Named in relation to facility management and cited deficiencies |
| Troy Ordonez | Licensing Program Manager | Supervisor overseeing the inspection |
| Kerry Hiratsuka | Licensing Program Analyst | Licensing evaluator conducting the inspection |
Inspection Report
Plan of Correction
Census: 5
Capacity: 6
Deficiencies: 1
Date: Nov 15, 2023
Visit Reason
The visit was conducted to discuss deficiencies cited on 11/02/2023 and to review the plan of correction submitted by the licensee.
Findings
A citation was issued because staff did not have required medication training as per California Health and Safety Code §1569.69(a)(2). The plan of correction was submitted late on 11/10/2023, resulting in civil penalties. The cited deficiency was cleared as of 11/10/2023 after the licensee submitted proof of purchasing training.
Deficiencies (1)
Staff did not have medication training as required by California Health and Safety Code §1569.69(a)(2).
Report Facts
Capacity: 6
Census: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Met with during the visit |
| Kerry Hiratsuka | Licensing Program Analyst | Issued citation for medication training deficiency |
| Troy Ordonez | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 3
Date: Nov 15, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following allegations that a resident sustained a severe pressure injury due to staff neglect, failure to seek medical attention, leaving a resident in a soiled diaper for an extended period, and staff being unable to communicate with medical personnel.
Complaint Details
The complaint was substantiated based on evidence that a resident developed a severe pressure injury due to neglect, was left in soiled diapers for extended periods, and staff failed to seek timely medical attention. Communication barriers with staff were also documented.
Findings
The investigation substantiated the allegations, finding that the facility failed to provide required care for a resident's pressure injury, resulting in worsening of the wound. Overnight staff did not perform incontinent care or check residents, and communication issues with staff were noted. Immediate civil penalties were assessed for violations of Title 22 regulations.
Deficiencies (3)
Failure to regularly observe residents for changes in physical, mental, emotional and social functioning and to provide appropriate assistance when unmet needs are revealed.
Facility personnel were not sufficient in numbers or competent to provide necessary services; staff did not seek medical attention timely, did not provide incontinent care overnight, and could not communicate with home health agency staff.
Residents were not accorded safe, healthful and comfortable accommodations; overnight staff did not change residents out of soiled clothes and diapers.
Report Facts
Capacity: 6
Census: 5
Immediate civil penalty: 500
Plan of Correction Due Date: Nov 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Facility administrator met during the investigation |
| Kerry Hiratsuka | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Manager overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 6
Deficiencies: 2
Date: Nov 15, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to an allegation that facility staff were not assisting with incontinence care.
Complaint Details
The complaint alleged that facility staff were not assisting with incontinence care. The allegation was substantiated based on interviews with staff, complainant, resident, and review of resident files. The resident often refused care, and staff did not consistently assist with incontinence needs. There was no documentation of incontinent care plans.
Findings
The investigation found that the allegation was substantiated. Staff and resident interviews, as well as file reviews, revealed that a resident refused care and staff often did not assist with incontinence care. There was no written record regarding the resident's incontinent needs, and home health care staff found the resident in soiled clothing on multiple occasions.
Deficiencies (2)
Failure to complete and maintain a current, written record of care for each resident including documentation from the physician regarding incontinent care needs.
No incontinent care plan for any of the residents, posing an immediate health, safety, or personal rights risk.
Report Facts
Facility capacity: 6
Plan of Correction due date: Nov 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Troy Ordonez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 3
Date: Nov 2, 2023
Visit Reason
The inspection visit was conducted as a case management investigation triggered by a complaint to evaluate deficiencies related to staff training and licensing compliance.
Complaint Details
The visit was complaint-related, with deficiencies observed by Licensing Program Analyst Hiratsuka during the investigation. The report does not explicitly state substantiation status.
Findings
The investigation found that staff lacked required medication training and annual training since 2021, and the licensee had not paid the annual licensing fees, which were overdue. These deficiencies posed potential health, safety, or personal rights risks to residents.
Deficiencies (3)
Employees assisting residents with self-administration of medication lacked proof of required initial and annual medication training.
Staff did not complete the required additional 20 hours of annual training, including dementia care and specific health condition training.
Licensee failed to pay annual licensing fees, including overdue fees and late fees.
Report Facts
Annual fees owed: 716.5
Facility census: 6
Facility capacity: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Evaluator | Observed deficiencies and signed the report. |
| Troy Ordonez | Licensing Program Manager | Supervisor named in the report. |
Inspection Report
Census: 4
Capacity: 6
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The visit was conducted as a Case Management - Other type of visit to return the file of a resident that was removed earlier to make copies.
Findings
No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Babita Sharma | Met with during the visit | |
| Rajveer Kaur | Administrator | Facility administrator |
| Troy Ordonez | Licensing Program Manager | Named in report header |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the visit and named in report |
Inspection Report
Census: 5
Capacity: 6
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The visit was a Case Management - Other type of unannounced inspection conducted to review facility operations and resident files.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst obtained a resident's file to make a copy and planned to return it the same day.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Babita Sharma | Met with during the visit | |
| Rajveer Kaur | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 1
Date: Jul 19, 2023
Visit Reason
The visit was a complaint investigation triggered by an observation of a caregiver working without criminal record clearance.
Complaint Details
The visit was complaint-related and substantiated by the observation of a caregiver working without required criminal record clearance.
Findings
The licensing program analyst observed that a caregiver without criminal record clearance was working alone, which is not allowed and poses an immediate health and safety risk. Immediate civil penalties of $500 were issued.
Deficiencies (1)
Allowed a caregiver without criminal record clearance to work alone, posing an immediate health and safety risk.
Report Facts
Immediate civil penalty amount: 500
Capacity: 6
Census: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Observed the deficiency during the complaint visit |
| Troy Ordonez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 4
Capacity: 6
Deficiencies: 2
Date: Apr 24, 2023
Visit Reason
Unannounced Plan of Correction (POC) visit to verify correction of previously cited deficiencies.
Findings
The inspection found that the side gate was locked with a padlock without fire clearance and a smoke detector was chirping due to low battery. Civil penalties were assessed and a plan of correction was required by 04/25/2023. All other deficiencies from the annual inspection on 03/06/2023 were cleared.
Deficiencies (2)
Licensee placed a lock on the side gate without a fire clearance, posing an immediate health, safety, or personal rights risk to persons in care.
Smoke detector with a low battery that continuously beeps, posing an immediate health and safety risk to persons in care.
Report Facts
Capacity: 6
Census: 4
Plan of Correction Due Date: Apr 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bethany Mirlohi | Licensing Program Analyst | Conducted the inspection and cited deficiencies. |
| Troy Ordonez | Licensing Program Manager | Supervisor named in the report. |
| Babita Sharma | Caregiver | Met with Licensing Program Analyst during inspection. |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 5
Date: Mar 6, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the health, safety, and compliance of the facility with regulatory requirements.
Findings
Several deficiencies were cited related to staff training, fire clearance, use of storage room as staff room, locked exterior doors, and care of persons with dementia. Plans of correction were submitted with due dates for compliance.
Deficiencies (5)
The facility did not ensure at least one staff member with CPR and first aid training was on duty at all times.
The facility did not meet training requirements including dementia care and postural supports training for staff.
The facility used the storage room as a staff room without proper fire clearance.
The facility placed a lock on the side gate without fire clearance approval, posing a safety risk.
Residents with dementia did not have required annual medical assessments and reappraisals.
Report Facts
Capacity: 6
Census: 4
Deficiencies cited: 5
Plan of Correction Due Dates: Mar 8, 2023
Plan of Correction Due Dates: Mar 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Met with Licensing Program Analyst during inspection and named in plans of correction |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the inspection and signed the report |
| Troy Ordonez | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Plan of Correction
Census: 5
Capacity: 6
Deficiencies: 0
Date: Feb 16, 2022
Visit Reason
Unannounced Plan of Correction (POC) visit to verify compliance with previously cited deficiencies.
Findings
Deficiencies cited under Title 22 Regulations have been cleared. The licensee complied with the terms of the Plan of Correction by the due date and was provided a POC cleared letter.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manpreet Dyal | Co-Licensee | Met with Licensing Program Analyst during Plan of Correction visit. |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 5
Date: Feb 15, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on infection control and overall compliance with regulations.
Findings
The inspection found multiple deficiencies including locked exits restricting residents' ability to leave, medications accessible to residents with dementia, lack of fire clearance for a storage room used as a staff bedroom, incomplete annual medical assessments for residents with dementia, and non-operational auditory exit devices posing health and safety risks.
Deficiencies (5)
Residents were locked in the building, violating their personal rights to leave at any time.
Medications were accessible to residents with dementia, posing health and safety risks.
Fire clearance was not obtained for the storage room used as a staff bedroom.
Three of four residents with dementia did not have annual medical assessments and reappraisals.
Auditory devices on exits were not operational, posing immediate health and safety risks.
Report Facts
Residents with dementia: 5
Residents reviewed: 5
Residents with annual medical assessment missing: 3
Plan of Correction due dates: Feb 16, 2022
Plan of Correction due dates: Feb 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Thao | Licensing Program Analyst | Conducted the inspection and documented findings |
| Troy Ordonez | Licensing Program Manager | Supervisor and licensing program manager overseeing the inspection |
| Babita Sharma | Care Staff | Facility staff member who assisted during the inspection and provided information |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Date: Dec 13, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to evaluate the facility's compliance with infection control protocols.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rajveer Kaur | Administrator | Met with Licensing Program Analyst during inspection and involved in the inspection process. |
| Dawn Keane | Licensing Program Analyst | Conducted the Required-1 Year Inspection and infection control domain evaluation. |
Viewing
Loading inspection reports...
