Inspection Reports for Angels Nursing Center
415 S Union Ave, Los Angeles, CA 90017, United States, CA, 90017
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally adequate care and compliance. However, there have been some notable issues over time, including substantiated complaints related to resident safety, confidentiality breaches, incomplete training, and medication administration errors. The facility received immediate civil penalties of $500 twice, once in March 2022 for inadequate supervision leading to an elopement and again in December 2022 for failing to prevent non-consensual sexual relations between residents. The most recent report from October 30, 2025, cited deficiencies related to fire clearance documentation and issued a civil penalty, reflecting ongoing attention needed in safety compliance. While some recent inspections show improvement in resident care and complaint outcomes, safety and documentation remain areas requiring continued focus.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
98% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 40
Capacity: 41
Deficiencies: 2
Date: Oct 30, 2025
Visit Reason
The visit was an unannounced case management inspection conducted to evaluate compliance with licensing requirements, specifically regarding fire clearance and safety measures.
Findings
The facility failed to maintain proper fire clearance documentation reflecting changes such as the installation of a knock box and the use of a double dead-bolt on the outside gate. Additionally, a staff member's car was observed double parked, creating a potential safety hazard. Deficiencies were cited under Title 22 and a civil penalty was issued.
Deficiencies (2)
Failed to report changes to the fire clearance, posing an immediate health, safety, or personal rights risk to residents.
Failed to report update to fire clearance indicating a knock box was added, posing a potential health, safety, or personal rights risk to residents.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with during inspection and provided information about residents and fire clearance |
| Brianna Miranda | Licensing Program Analyst | Conducted the inspection visit and signed the report |
| Brenda Chan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 41
Capacity: 41
Deficiencies: 0
Date: Oct 8, 2025
Visit Reason
The visit was an unannounced case management inspection conducted by Licensing Program Analyst B. Miranda to evaluate the facility and review resident documentation.
Findings
The Licensing Program Analyst observed a resident (R3) between the poles of an iron fence with staff attempting to redirect the resident. The fence opening mechanism was discussed and noted as potentially dangerous. Copies of resident R3's physical, reappraisal, and appraisal forms were obtained. The licensee was to provide approved fire clearance documentation by 10/13/2025, with a follow-up visit possible if citations are issued.
Report Facts
Capacity: 41
Census: 41
Date for fire clearance submission: Oct 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection |
| Brianna Miranda | Licensing Program Analyst | Conducted the unannounced case management visit |
| Anthony Barbato | Licensee | Responsible for providing approved fire clearance documentation |
Inspection Report
Annual Inspection
Census: 41
Capacity: 41
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
The inspection was an unannounced Required Annual Inspection conducted to evaluate compliance with licensing requirements for Redwood Senior Living Bakersfield facility.
Findings
The facility was found to be generally well maintained with no immediate health or safety risks observed. The medication storage and documentation were in full compliance. Some bathrooms were noted to need painting, with patching repairs completed but paint pending. The inspection was not fully completed due to time constraints and will be continued at a later date.
Report Facts
Water temperature: 98
Water temperature: 103.2
Food supply: 2
Food supply: 7
Emergency water supply: 4
Resident bedrooms observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection |
| Rachel Bruce | Licensing Program Analyst | Conducted the inspection |
| Barbara Martin | Med Tech | Granted entry to facility and assisted with tour and medication audit |
| Sabrina Arnelas | Assistant Administrator | Accompanied Licensing Program Analyst during facility tour |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not provide adequate food services to residents.
Complaint Details
The complaint alleging inadequate food services was investigated and found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The complaint was investigated through interviews with staff and residents. The allegation was determined to be unsubstantiated as residents are provided alternative menu options and appropriate efforts are made to accommodate their preferences.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel A Bruce | Licensing Program Analyst | Conducted the complaint investigation visit and delivered investigation findings. |
| Beatriz Ponce | Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Deficiencies: 0
Date: Oct 28, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-08-28 regarding medication management and staff communication with residents.
Complaint Details
The complaint included allegations that staff did not ensure medications were properly managed and did not speak appropriately to residents. The investigation concluded both allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that Resident 1 was receiving medications as prescribed despite hiding medication, and staff communication with residents was appropriate. There was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during investigation |
| Beatriz Ponce | Administrator | Named in allegation regarding communication with residents |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Deficiencies: 0
Date: Oct 28, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not provide resident medication as prescribed and did not safeguard resident's belongings.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to provide medication as prescribed and failure to safeguard resident belongings. Evidence did not support the allegations sufficiently to confirm violations.
Findings
The investigation found that Resident 1 was receiving medications as prescribed and that although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violations occurred. Therefore, both allegations were unsubstantiated.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during the investigation and provided statements |
| Beatriz Ponce | Administrator | Named as facility administrator |
Inspection Report
Census: 40
Capacity: 41
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
An unannounced case management inspection was conducted to discuss care and supervision following an incident report involving an altercation between two residents.
Findings
The inspection found that the altercation was witnessed by staff who intervened appropriately, no injuries occurred, and the necessary notifications were made. Staff were reminded to remain vigilant and take appropriate action when needed, and residents reported staff handle issues effectively.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with during inspection and mentioned in relation to facility administration. |
| Rachel A Bruce | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager in the report. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-05-05 regarding inadequate food service, failure to prevent resident fighting, and staff behavior posing a risk to residents.
Complaint Details
The complaint investigation was triggered by allegations that staff did not provide adequate food service, did not prevent residents from fighting, and that staff behavior posed a risk to residents. The investigation concluded these allegations were unfounded.
Findings
The investigation found all allegations to be unfounded after reviewing facility files, interviewing staff and residents, and touring the facility. It was determined that food service was adequate, staff appropriately intervened in resident behavior, and financial matters were handled according to regulation.
Report Facts
Complaint Control Number: 24-AS-20240505222013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel A Bruce | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Beatriz Ponce | Administrator | Facility administrator met during the investigation and named in the report |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 41
Capacity: 41
Deficiencies: 1
Date: Jun 13, 2024
Visit Reason
An unannounced annual continuation visit was conducted to evaluate the facility's compliance with regulations and assess the condition of the facility and resident care.
Findings
The facility was generally well maintained with clean and organized areas including kitchen, dining, living room, bedrooms, backyard, and staff room. Some deficiencies were cited related to training documents not being up to date, and a request for submission of various compliance documents was made.
Deficiencies (1)
Training documents for residents and staff were found to be not up to date.
Report Facts
Capacity: 41
Census: 41
Document submission deadline: Jun 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection and involved in inspection process |
| Lissett Padgett | Licensing Program Analyst | Conducted the inspection visit |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager |
| Steven Cruz | Regional Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 39
Capacity: 41
Deficiencies: 2
Date: May 31, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations at Redwood Senior Living Bakersfield facility.
Findings
The inspection found deficiencies related to the improper use of full bed rails without hospice approval for 2 of 3 residents and incomplete annual training in 3 of 4 staff files. The facility was otherwise found to be in good condition with proper food storage, medication security, and functioning safety equipment.
Deficiencies (2)
Use of full bed rails without hospice care approval for 2 of 3 residents in hospital beds.
Failure to complete required annual training, including dementia care and postural supports, in 3 of 4 staff files reviewed.
Report Facts
Residents with full bed rails without hospice approval: 2
Staff files lacking required training: 3
Plan of Correction Due Date: 06/13/2024 for bed rails deficiency
Plan of Correction Due Date: 07/05/2024 for staff training deficiency
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection and involved in plan of correction |
| Lissett Padgett | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sergiy Pidgirny | Licensing Program Manager / Supervisor | Supervisor overseeing the inspection and report |
| Steven Cruz | Regional Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 1
Date: Apr 18, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2024-03-05 alleging that staff were disclosing personal information about a resident.
Complaint Details
The complaint was substantiated based on interviews, observations, and record reviews. Staff were found to be disclosing personal information about a resident via personal communication devices.
Findings
The investigation substantiated the allegation that staff were using personal communication devices to communicate resident medical information, including pictures and text, which posed a potential personal rights risk to persons in care.
Deficiencies (1)
All information and records obtained from or regarding residents shall be confidential. This requirement was not met as staff used personal communication devices to communicate resident medical information using pictures and text.
Report Facts
Capacity: 41
Census: 41
Plan of Correction Due Date: Apr 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lissett Padgett | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Beatriz Ponce | Administrator | Facility administrator met during the investigation |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 41
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not ensure the facility was free from pests and were not taking universal precautions during an outbreak.
Complaint Details
The complaint alleged that staff did not ensure the facility was free from pests and were not taking universal precautions for an outbreak. The complaint was investigated and found to be unfounded.
Findings
The investigation found no live cockroaches or other pests during the facility tour, and pest control services were documented monthly. Staff and administrator were found to be in compliance with current COVID guidance during the outbreak. The complaint was determined to be unfounded.
Report Facts
Capacity: 41
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with during investigation and referenced in findings |
| Lissett Padgett | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 41
Deficiencies: 1
Date: Feb 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff were not providing a safe environment for residents in care.
Complaint Details
The complaint was substantiated. The allegation was that staff were not providing a safe environment for residents in care. The investigation confirmed the presence of an unsafe condition with the unknown white powder accessible to residents.
Findings
The investigator observed a thick layer of unknown white powder in four resident bedrooms and under the kitchen stove, accessible to residents. The licensee did not comply with safety and sanitation regulations, posing an immediate health and safety risk.
Deficiencies (1)
The facility was not clean, safe, sanitary, and in good repair as evidenced by a thick layer of unknown white powder in 4 resident rooms, posing an immediate health, safety, or personal rights risk.
Report Facts
Capacity: 41
Census: 39
Deficiencies cited: 1
Plan of Correction Due Date: Feb 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with during investigation and named in report |
| Lissett Padgett | Licensing Program Analyst | Conducted the complaint investigation |
| Sergiy Pidgirny | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 0
Date: Dec 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-28 regarding allegations including staff abandoning a resident and illegal eviction.
Complaint Details
The complaint involved allegations of staff abandoning a resident and illegal eviction. The allegations were investigated and found to be unsubstantiated.
Findings
The investigation found that the resident wanted to leave the facility voluntarily and was taken to a shelter who signed a statement indicating the resident's intent to leave. Based on interviews and observations, the allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 41
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
The visit was an unannounced Case Management inspection conducted in response to an incident report received on 2023-08-07 regarding an incident on 2023-07-31 where a resident was found with an open wound on the head.
Complaint Details
The visit was triggered by an incident report alleging a resident was found with an open head wound. The Licensing Program Analyst conducted a record review and interviews but found no deficiencies during the visit.
Findings
No deficiencies were cited during this Case Management visit. The Licensing Program Analyst reviewed the resident's records and conducted interviews, and will review additional documentation when received to determine if follow-up is necessary.
Report Facts
Incident report date: Aug 7, 2023
Incident date: Jul 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee Representative | Met with Licensing Program Analyst during the visit and participated in the exit interview |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the unannounced Case Management visit and record review |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-04-14 alleging that staff were not assisting residents with their care needs and were rude to residents.
Complaint Details
The complaint was unsubstantiated. The allegations that staff did not assist residents with care needs and were rude were not supported by sufficient evidence.
Findings
The investigation found no evidence to substantiate the allegations based on interviews with staff, residents, and the administrator, as well as observations. Although some incidents may have occurred, they were not reported to management, and there was insufficient evidence to prove the allegations.
Report Facts
Capacity: 41
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with the Licensing Program Analyst during the complaint investigation |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Annual Inspection
Census: 40
Capacity: 41
Deficiencies: 1
Date: Apr 20, 2023
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations at Redwood Senior Living Bakersfield.
Findings
The inspection found that the facility was generally compliant with regulations regarding safety, medication storage, and resident accommodations; however, a deficiency was cited related to medication administration where medication was not given to a resident for 16 consecutive days, posing a potential health and safety risk.
Deficiencies (1)
Medication was not administered to a resident for 16 consecutive days as ordered by the physician, posing a potential health, safety, or personal rights risk.
Report Facts
Deficiency duration: 16
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the annual inspection and authored the report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 1
Date: Dec 30, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to a complaint received on 08/22/2022 alleging the licensee did not prevent a resident from having non-consensual sexual relations with other residents in care.
Complaint Details
The complaint was substantiated based on interviews and record reviews. An immediate civil penalty of $500 was assessed, with additional penalties pending review.
Findings
The investigation found that the facility failed to prevent resident R1 from engaging in non-consensual sexual relations with other residents. The allegation was substantiated and an immediate civil penalty of $500 was assessed.
Deficiencies (1)
87411(a) Personnel Requirements - Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs, contributing to failure to prevent non-consensual sexual relations.
Report Facts
Civil penalty amount: 500
Capacity: 41
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during inspection and findings delivery. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 0
Date: Dec 30, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that residents were using drugs in the facility.
Complaint Details
The complaint alleged that residents were using drugs in the facility. The investigation found no substantiated evidence to support the allegations, resulting in an unsubstantiated finding.
Findings
The investigation included interviews and observations. Staff, residents, and the administrator denied drug use, but some residents' rooms had odors of drugs. Family members also complained of drug odors. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 41
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Deficiencies: 0
Date: Nov 10, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that animals pose a risk to the residents while in care.
Complaint Details
The complaint was unsubstantiated based on the preponderance of evidence standard not being met.
Findings
The investigation found insufficient evidence to prove or disprove that stray animals were in areas where residents sleep. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mai Yang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Beatriz Ponce | Administrator | Met with Licensing Program Analyst during investigation |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Deficiencies: 0
Date: Sep 22, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints alleging that the facility pressured a resident's representative to place the resident on hospice and that facility staff did not seek medical attention in a timely manner.
Complaint Details
Two complaints were investigated: 1) Facility pressured resident's representative to place resident on hospice, found unfounded. 2) Facility staff did not seek medical attention in a timely manner, found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found the allegation that the facility pressured the resident's representative to place the resident on hospice to be unfounded, with hospice documents signed by family/POA and medical personnel. The allegation that staff did not seek medical attention timely was unsubstantiated due to insufficient evidence to prove negligence.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Les Xiong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Beatrice Ponce | Administrator | Met with Licensing Program Analyst during investigation |
| Anthony Barbato | Licensee | Informed of the purpose of the visit |
Inspection Report
Follow-Up
Census: 38
Capacity: 41
Deficiencies: 0
Date: Aug 23, 2022
Visit Reason
The visit was a Case Management follow-up on an incident that occurred on 2022-07-15.
Findings
The facility followed proper procedures related to the incident. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the Case Management visit and interview. |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 41
Deficiencies: 0
Date: Aug 11, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2022-06-10 regarding inappropriate touching of residents and medication administration issues.
Complaint Details
The complaint involved allegations that staff were inappropriately touching residents and not administering medication as prescribed. The first allegation was unsubstantiated, and the second was unfounded.
Findings
The investigation found the allegation of inappropriate touching unsubstantiated, with the licensee admitting physical contact but denying any sexual or inappropriate nature. The medication administration allegation was found unfounded, with no evidence of errors or refusal to administer medication.
Report Facts
Capacity: 41
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during complaint investigation and named in findings |
| Malia Thao | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Deficiencies: 0
Date: Jul 21, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff hit a resident with a broom stick.
Complaint Details
The allegation that facility staff hit a resident with a broom stick was investigated but found unsubstantiated due to insufficient evidence.
Findings
The investigation was unable to determine if the alleged incident occurred due to lack of preponderance of evidence; therefore, the allegation was unsubstantiated.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Martin | Medtech/Staff | Met with Licensing Program Analyst during complaint investigation |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 41
Deficiencies: 0
Date: Jul 21, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of unlawful eviction received on 2022-04-22.
Complaint Details
The complaint alleging unlawful eviction was investigated and found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.
Findings
The investigation found that the allegation of unlawful eviction was unfounded. The resident moved voluntarily with family agreement due to inability to pay rent after loss of supplemental income.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation visit |
| Barbara Martin | Medtech/Staff | Met with Licensing Program Analyst during investigation |
| Kenny Espinal | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 38
Capacity: 41
Deficiencies: 0
Date: May 11, 2022
Visit Reason
The Licensing Program Analyst conducted an unannounced Annual Inspection focused on Infection Control at the facility.
Findings
The facility was found to be in compliance with no deficiencies observed. Infection control measures such as visitor log-in, temperature checks, disinfection stations, and staff facial coverings were in place. Resident rooms and common areas met safety and equipment standards.
Report Facts
Food supply: 7
Food supply: 2
Facility capacity: 41
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the annual inspection |
| Anthony Barbato | Licensee Representative | Facility representative who granted entry and participated in the inspection |
| Kenny Espinal | Administrator | Facility administrator who participated in the exit interview and signed the report |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 41
Deficiencies: 1
Date: Mar 24, 2022
Visit Reason
Unannounced case management visit regarding an incident report of elopement received by the facility.
Complaint Details
Visit was complaint-related due to an incident report of elopement. The deficiency was substantiated with a civil penalty assessed.
Findings
The licensee failed to ensure proper care and supervision of Client 1, posing a potential health, safety, or personal rights risk. An immediate $500 civil penalty was assessed.
Deficiencies (1)
Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by failure to ensure Client 1 was provided proper care and supervision.
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the case management visit and cited the deficiency. |
| Brenda White | Licensing Program Manager | Supervisor of the licensing evaluation. |
| Anthony Barbato | Licensee Representative | Met with Licensing Program Analyst during the visit. |
| Kenny Espinal | Administrator | Participated in exit interview. |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 41
Deficiencies: 0
Date: Mar 24, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-02-17 alleging that the facility accepted residents beyond the level of care it could provide.
Complaint Details
The complaint alleged that the facility accepted residents beyond the level of care it could provide. The allegation was investigated and found to be unfounded.
Findings
Based on observations, conversations with residents, and records reviewed, it was determined that the allegation was unfounded. Residents were ambulatory or could self-transfer and could communicate their needs to staff.
Report Facts
Capacity: 41
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Barbara Martin | Med Tech | Completed temperature check upon entry |
| Anthony Barbato | Licensee Representative | Met with Licensing Program Analyst during the investigation |
| Kenny Espinal | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 41
Deficiencies: 0
Date: Mar 17, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to a complaint received on 2021-09-17 regarding alleged issues at the facility.
Complaint Details
The complaint included allegations that facility staff did not notify the resident's POA of a change of condition, the facility was not providing opportunities for physical activity, and the facility had insects. The investigation found these allegations to be unsubstantiated.
Findings
The investigation found that the resident did not have a change in condition requiring notification to the POA, the resident declined physical activity when offered, and although flies were observed in the facility, the licensee took steps to mitigate the issue. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 41
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malia Thao | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Andy Xiong | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during the investigation |
Inspection Report
Census: 37
Capacity: 41
Deficiencies: 0
Date: Feb 22, 2022
Visit Reason
The inspection was conducted as an Informal Meeting with the Licensee regarding the number of complaints the facility has received since licensing on 05/18/2021.
Findings
The facility has received 11 complaints since licensing. Discussions covered assessment of potential residents, age acceptance and compatibility, hospice care waivers, staffing, and protocols on unwitnessed falls. No deficiencies were issued during this visit.
Report Facts
Complaints received: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee Representative | Met with Licensing Program Manager and Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 41
Deficiencies: 0
Date: Feb 22, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to multiple allegations including residents having head lice, insufficient food supply, unclean resident rooms, insufficient staffing at night, and non-adherence to COVID-19 protocols.
Complaint Details
The complaint investigation was initiated based on allegations received on 02/17/2022. The findings determined the head lice and food supply allegations as unfounded and other allegations as unsubstantiated due to insufficient evidence.
Findings
The investigation found that the allegations of head lice and insufficient food supply were unfounded, with proper protocols followed and adequate food observed. Allegations regarding unclean rooms, insufficient staffing, and COVID-19 protocol adherence were unsubstantiated due to lack of evidence, with staff interviews confirming daily cleaning and adherence to protocols despite resident resistance.
Report Facts
Capacity: 41
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation |
| Barbara Martin | Med Tech | Completed temperature check upon entry |
| Kenny Espinal | Administrator | Facility administrator mentioned in report |
| Anthony Barbato | Licensee Representative | Met with investigators during inspection |
| Brenda White | Licensing Program Manager | Named in report as Licensing Program Manager |
| S. Moua | Licensing Program Manager (LPM) | Assisted in conducting the complaint inspection |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 41
Deficiencies: 0
Date: Feb 22, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff were not providing adequate care, hygiene care, and dental care to a resident.
Complaint Details
The complaint was unsubstantiated based on interviews, records review, and observations during the unannounced visit.
Findings
The investigation found that the resident was on Hospice and receiving hygiene care two to three times a week. Facility staff denied the allegations, and no specific incidents were discovered. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 41
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation |
| Barbara Martin | Med Tech | Completed temperature check upon entry |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 41
Deficiencies: 1
Date: Feb 10, 2022
Visit Reason
An unannounced complaint inspection was conducted to open a complaint investigation regarding the facility's compliance with regulations.
Complaint Details
The visit was complaint-related, and the deficiency was substantiated based on the incomplete Needs and Services Plan for resident R1.
Findings
During the investigation, it was found that the Needs and Services Plan for resident R1 was incomplete, resulting in a cited deficiency based on records review in accordance with CCR Title 22.
Deficiencies (1)
The Needs and Services Plan for resident R1 was incomplete, failing to meet the requirement to assess the person's need for personal assistance and care by determining their ability to perform specified activities of daily living.
Report Facts
Deficiency Type: 1
Capacity: 41
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee Representative | Met during exit interview and acknowledged receipt of report |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint inspection and authored the report |
| Brenda White | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 41
Deficiencies: 0
Date: Feb 10, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that there was no heat at the facility and that a resident was pressured to sign paperwork.
Complaint Details
The complaint investigation was unannounced and conducted by Evaluator Kamaldeep Kaur. The allegations were that there was no heat at the facility and that the resident was pressured to sign paperwork. Both allegations were found to be unfounded.
Findings
The investigation found that heat was operational at the facility and that the resident signed the admission paperwork voluntarily. Both allegations were determined to be unfounded.
Report Facts
Capacity: 41
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the complaint investigation |
| Barbara Martin | Med Tech | Completed temperature check upon entry |
| Anthony Barbato | Licensee contacted during investigation |
Inspection Report
Follow-Up
Census: 34
Capacity: 41
Deficiencies: 2
Date: Dec 3, 2021
Visit Reason
The visit was a Case Management follow-up to incidents that occurred on 11/21/2021, focusing on deficiencies related to the facility's condition and reporting requirements.
Findings
The inspection found a strong odor of urine in the facility and failure to submit an incident report within the required 7 days, both posing potential health and safety risks to persons in care.
Deficiencies (2)
Facility was not free of urine odor which poses a potential health and safety risk to persons in care.
Licensee did not submit incident report within 7 days as required, posing a potential health and safety risk to persons in care.
Report Facts
Capacity: 41
Census: 34
Plan of Correction Due Date: Dec 17, 2021
Plan of Correction Due Date: Dec 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | Licensee Representative | Met with during inspection and exit interview |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the inspection and signed the report |
| Brenda White | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 41
Deficiencies: 0
Date: Dec 1, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including facility cleanliness, unlawful eviction, resident sexual assault, staff hygiene maintenance, timely assistance to residents, resident bladder infection, and rent increase notice.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included facility dirtiness, unlawful eviction, resident sexual assault by another resident, staff not maintaining hygiene, untimely assistance, bladder infection, and failure to provide 60-day rent increase notice. Some issues were previously addressed; sexual assault allegation was indeterminate; other allegations lacked sufficient evidence.
Findings
The investigation found the facility was dirty and had issued an unlawful eviction, but both issues were previously addressed with plans of correction. The sexual assault allegation could not be substantiated as it occurred prior to current licensee. Staff hygiene and timely care allegations were not substantiated based on interviews. The resident's bladder infection was treated properly and the facility provided proper rent increase notice. Overall, allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 41
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Kamaldeep Kaur | Licensing Program Analyst | Assisted in complaint investigation |
| Anthony Barbato | Licensee Representative | Met with investigators and participated in exit interview |
| Kenny Espinal | Administrator | Facility administrator named in report header |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 41
Deficiencies: 0
Date: Nov 29, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 09/07/2021 regarding allegations of resident injuries, pest infestation, and cleanliness issues at the facility.
Complaint Details
The complaint included allegations that residents sustained injuries while in care, the facility had pest infestation, and the facility was not clean. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation found no evidence of resident injuries due to inadequate care, no pest infestation other than flies which were controlled, and the facility was clean. All allegations were unsubstantiated and no deficiencies were cited.
Report Facts
Complaint Control Number: 24-AS-20210907140249
Capacity: 41
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Ayers | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during the investigation |
| Kenny Espinal | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 41
Deficiencies: 1
Date: Nov 4, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/28/2021 regarding multiple allegations including facility cleanliness and resident care issues.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility was filthy. Other allegations including resident falls with minor injuries, staff leaving resident in soiled diaper, medication administration, wheelchair disrepair, bed discomfort, patio furniture disrepair, and exposed wires were unsubstantiated.
Findings
The investigation substantiated the allegation that the facility was filthy, specifically noting grease spots and damaged drywall in the kitchen area. Other allegations related to resident falls, medication administration, wheelchair condition, bed comfort, patio furniture, and exposed wires were found to be unsubstantiated based on observations, interviews, and record reviews.
Deficiencies (1)
Facility was not clean and sanitary, with grease spots on kitchen backsplash and damaged drywall behind the sink.
Report Facts
Capacity: 41
Census: 38
Deficiencies cited: 1
Plan of Correction Due Date: Nov 11, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during investigation and plan of correction discussion |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 41
Deficiencies: 1
Date: Nov 4, 2021
Visit Reason
The inspection visit was conducted in response to information on Resident 1's physician report indicating a prohibited health condition.
Complaint Details
The visit was complaint-related based on information from Resident 1's physician report. The deficiency cited was under appeal.
Findings
The Licensee admitted and retained Resident 1 who required total assistance with all activities of daily living, a prohibited health condition, without obtaining an exception as required by regulation.
Deficiencies (1)
Licensee admitted and retained Resident 1 with a prohibited health condition requiring total assistance with all activities of daily living without obtaining an exception.
Report Facts
Deficiency due date: Nov 8, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the facility visit and discussed plan of correction with Licensee |
| Serigy Pidgirny | Licensing Program Manager | Supervisor named in the report |
| Anthony Barbato | Licensee | Facility Licensee met during the visit and discussed plan of correction |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 41
Deficiencies: 2
Date: Oct 21, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/01/2021 regarding multiple allegations including sexual assault of a resident, incomplete admission agreements, failure to notify responsible persons, residents left in soiled clothing, and lack of telephone service.
Complaint Details
The complaint investigation was substantiated for the allegation of sexual assault and incomplete admission agreement. The allegation that the resident's responsible person was not notified was unsubstantiated. The allegation that residents were left in soiled clothing was unsubstantiated. The complaint about lack of telephone service was unfounded.
Findings
The investigation substantiated that a resident was sexually assaulted while in care and that staff did not complete an individual written admission agreement with the resident or responsible person. The allegation that the resident's responsible person was not notified of an incident was unsubstantiated, as was the allegation that residents were left in soiled clothing. The complaint regarding lack of telephone service was found to be unfounded as the facility had restored phone service.
Deficiencies (2)
Licensee did not ensure Resident 1 was free from being sexually assaulted by another resident, posing an immediate health and safety risk.
Licensee did not ensure an admission agreement was signed by Resident 1 or authorized representative, posing a potential personal rights risk.
Report Facts
Capacity: 41
Census: 39
Deficiencies cited: 2
Plan of Correction Due Dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during investigation and discussed plan of correction |
| Kenny Espinal | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 41
Deficiencies: 0
Date: Oct 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was charging a resident for services not provided and that staff were not administering medications according to physician's orders.
Complaint Details
The complaint alleged that the facility was charging a resident for services not provided and that staff were not administering medications according to physician's orders. The complaint was found to be unfounded and dismissed.
Findings
The investigation found the allegations to be unfounded. Interviews and records review confirmed the facility continued to provide services and medication to the resident as required.
Report Facts
Capacity: 41
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lady Cabrera | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
| Kenny Espinal | Administrator | Facility administrator named in report |
| Anthony Barbato | Licensee | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 1
Date: Sep 10, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging unlawful eviction received on 2021-08-31.
Complaint Details
Complaint alleging unlawful eviction was substantiated based on evidence including an incomplete 30 Day Notice of Eviction issued to resident R1 on 2021-08-31.
Findings
The investigation found that the 30 Day Notice of Eviction issued to resident R1 on 2021-08-31 was incomplete and therefore unlawful. The allegation of unlawful eviction was substantiated based on interviews and record review.
Deficiencies (1)
Licensee issued a 30 Day Notice of Eviction that did not include the reason for eviction, specifically nonpayment of the rate for basic services within ten days of the due date, posing a potential health and safety risk to persons in care.
Report Facts
Estimated Days of Completion: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Barbato | Licensee interviewed during the investigation and recipient of the report |
Inspection Report
Census: 37
Capacity: 41
Deficiencies: 0
Date: Aug 6, 2021
Visit Reason
An unannounced Case Management visit was conducted regarding a reported AWOL by the facility.
Findings
The Licensing Program Analyst toured the facility, interviewed the Administrator and Licensee, and reviewed Resident 1's records. Due to insufficient information, further investigation is required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the unannounced Case Management visit and interviews. |
| Barket Hussain | Administrator | Met with Licensing Program Analyst during the visit. |
| Anthony Barbato | Licensee | Interviewed by Licensing Program Analyst during the visit. |
Inspection Report
Original Licensing
Census: 40
Capacity: 41
Deficiencies: 0
Date: May 10, 2021
Visit Reason
The inspection was a prelicensing televisit conducted for the change of ownership of a currently licensed facility.
Findings
The facility was observed to be clean, in good repair, properly furnished, and compliant with safety and health requirements. No deficiencies were found during the prelicensing inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Barbato | CEO | Met with during the prelicensing televisit. |
| Kenny Espinal | Administrator | Present during the prelicensing televisit. |
Inspection Report
Census: 40
Capacity: 41
Deficiencies: 0
Date: Apr 27, 2021
Visit Reason
The visit was an office type evaluation related to a Change of Ownership (CHOW) application and pre-licensing inspection, including a COVID-19 Mitigation Plan Report.
Findings
The applicant and administrator successfully completed Component II (COMP II) by telephone with the Community Care Licensing analyst, confirming understanding of Title 22 and various operational areas including facility operation, staff qualifications, training, grievances, food service, medication management, and application document review.
Report Facts
Capacity: 41
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenny Espinal | Administrator | Named as the new administrator participating in COMP II |
| Antony Barbato | Owner | Named as owner participating in COMP II |
| Shannon Betker | Analyst | Community Care Licensing analyst participating in COMP II |
| Jude De La Concepcion | Licensing Program Manager | Named in report header and signature section |
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