Inspection Reports for Atria Collwood
5308 Monroe Ave, San Diego, CA 92115, United States, CA, 92115
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. However, there were some substantiated deficiencies primarily related to resident care and supervision, staff training, and personal rights issues, including a serious incident in June 2023 involving insufficient staffing, medication errors, and intimidation of residents. The facility also received citations for inadequate supervision leading to a resident elopement in October 2025 and for coercing a resident to sign documents under duress in April 2025. The most recent inspection on October 28, 2025, found no deficiencies during a complaint investigation about missing resident money. Overall, the facility shows improvement in recent reports, with fewer deficiencies noted compared to earlier investigations.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
53% 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
Complaint Investigation
Census: 98
Capacity: 185
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
The visit was conducted as an unannounced Case Management - Incident inspection in response to a SOC341 Report submitted by the licensee regarding a report of missing money for Resident #1 on 2025-10-15.
Complaint Details
The complaint involved a report of missing money for Resident #1, who was admitted on 2025-10-14 and is currently hospitalized. The facility followed theft and loss protocols and investigated the incident. Resident #1 was documented as having no cognitive impairment and able to make their own decisions.
Findings
No immediate health or safety risks were observed and no deficiencies were cited during this visit. Additional case management and subsequent visits will be provided as needed.
Report Facts
Census: 98
Total Capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Administrator | Facility Administrator met during the inspection and signed receipt of the report |
| Amy Domingo | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 185
Deficiencies: 1
Date: Oct 16, 2025
Visit Reason
The inspection visit was conducted as an unannounced Case Management - Incident visit in response to a self-submitted LIC624 Incident Report regarding a resident elopement on 2025-10-13.
Complaint Details
The visit was complaint-related, triggered by a self-submitted LIC624 Incident Report about a resident elopement. The complaint was substantiated with findings of lapses in supervision and staff competency.
Findings
The investigation found that one resident (R1) eloped from the facility without staff supervision, posing a potential safety risk. The facility had an Absentee Notification Plan which was essentially followed, but lapses in supervision and staff competency/training were identified. One Type B deficiency was cited related to insufficient care and supervision.
Deficiencies (1)
Licensee did not ensure that 1 of 98 residents (R1) had the care and supervision needed to meet their individual needs, posing a potential safety risk.
Report Facts
Resident count: 98
Facility capacity: 185
Deficiency count: 1
Plan of Correction due date: Nov 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Naomie Peterson | Engage Life Director | Met during inspection and exit interview |
| Ashley Baino-Jaimes | Resident Services Director, LVN | Met during inspection |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection visit |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 98
Capacity: 185
Deficiencies: 0
Date: Jul 23, 2025
Visit Reason
An unannounced Case Management visit was conducted by the Licensing Program Analyst to discuss the purpose of the visit and obtain signatures on an amended complaint.
Findings
The visit included discussions with the Executive Director and an exit interview. The report and Licensee/Appeal Rights were provided to the facility representative. No specific deficiencies or findings are detailed in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Robyn Clark | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 185
Deficiencies: 0
Date: Jul 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-06-04 regarding an alleged unlawful eviction of Resident1 (R1) from the facility.
Complaint Details
The complaint alleged an unlawful eviction of Resident1 related to medication management non-compliance. The complaint was investigated and found unsubstantiated as the facility followed proper procedures and R1 remained non-compliant with medication management.
Findings
The investigation found that Resident1 had a history of non-compliance with medication management policies, including unsecured medications and failure to follow facility protocols. The complaint of unlawful eviction was determined to be unsubstantiated due to a preponderance of evidence showing R1 disregarded medication safeguarding policies.
Report Facts
Facility capacity: 185
Census: 101
Complaint received date: Jun 4, 2025
Eviction notice dates: Jun 4, 2025
Eviction notice dates: Jun 13, 2025
Narcotic painkillers count: 224
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation visit |
| Irma Miranda | Resident Service Coordinator | Met with the investigator during the visit |
| Julia Lopez | Administrator | Facility administrator named in the report |
| Robyn Clark | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 185
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the licensee did not allow a resident to keep their own medication without just cause.
Complaint Details
The complaint alleged that the licensee did not allow Resident #1 to keep their own medication. The investigation included interviews, record reviews, and facility tours. The resident had expressed suicidal ideation, prompting the licensee to take protective actions including one-on-one supervision and medication management. Medical professionals provided differing assessments, with the primary care physician ultimately authorizing the resident to self-manage medications. The licensee continued to manage medications pending further documentation. The allegation was found unsubstantiated.
Findings
The investigation found that the licensee responded appropriately to a credible safety concern regarding the resident's suicidal ideation and took control of the resident's medications based on medical assessments. The allegation was unsubstantiated and no deficiency was cited.
Report Facts
Capacity: 185
Census: 95
Date complaint received: Jun 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met during the investigation and exit interview |
| Ashley Baino-Jaimes | Resident Services Director | Met during the investigation and exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the complaint investigation |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 185
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that staff were charging a resident for services not rendered.
Complaint Details
The complaint alleged that staff were charging Resident1 for assistance with showering that was never provided. The investigation found that Resident1 had refused assistance as of May 2023 and had requested removal of showering assistance from their care plan in July 2023, which was approved by the Primary Care Physician. No evidence supported the allegation.
Findings
The investigation included staff and resident interviews and record reviews, and determined the allegation to be unsubstantiated due to lack of evidence supporting the claim.
Report Facts
Complaint Control Number: 08-AS-20230628101740
Facility Capacity: 185
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation |
| Jennifer Lott | Licensing Program Manager | Named in report as Licensing Program Manager |
| Amy Barajas | Med-tech | Met with during the investigation and exit interview |
| Omar Zamudio | Director of Maintenance | Met with during the investigation |
| Julia Lopez | Executive Director | Met with during the investigation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 185
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not assisting a resident with bathing.
Complaint Details
The complaint alleged that staff were not assisting a resident with bathing. The investigation found that the resident refused assistance and had approval from their Primary Care Physician to shower independently. Interviews with staff and other residents found no issues with bathing assistance. The complaint was unsubstantiated.
Findings
The investigation included staff and resident interviews and record reviews, which revealed the resident had refused assistance with showering and had authorization to shower independently. The allegation was determined to be unsubstantiated due to lack of evidence.
Report Facts
Complaint Control Number: 08-AS-20230605091507
Facility Capacity: 185
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation |
| Amy Barajas | Med-Tech | Met with investigator during exit interview |
| Irma Arteaga | Administrator | Facility administrator named in report header |
| Omar Zamudio | Director of Maintenance | Met with investigator during visit |
| Julia Lopez | Executive Director | Met with investigator during visit |
Inspection Report
Census: 94
Capacity: 185
Deficiencies: 0
Date: May 22, 2025
Visit Reason
The inspection was an unannounced Case Management Visit conducted by Licensing Program Analyst Sabel Martinez to review facility compliance and secure report signatures.
Findings
The visit included an exit interview with the Executive Director, Julia Lopez, and delivery of an amended report. The document outlines the types of deficiencies and the process for correction, appeals, and penalties but does not list specific deficiencies.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met during the visit and participated in the exit interview. |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management Visit. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 185
Deficiencies: 0
Date: May 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not addressing mold at the facility.
Complaint Details
The complaint alleged that staff were not addressing mold at the facility, specifically mold in Resident1's room caused by a roof leak. The allegation was unsubstantiated after investigation.
Findings
The investigation included interviews, facility tour, and record review. The allegation was found to be unsubstantiated as the residue around the air conditioner was determined to be dirt, not mold, and no maintenance requests or resident reports supported mold or leak issues.
Report Facts
Maintenance requests submitted: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation visit and delivered investigative findings |
| Omar Zamudio | Maintenance Director | Met with the Licensing Program Analyst during the investigation and received the report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 185
Deficiencies: 0
Date: May 7, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff were not providing a comfortable environment for a resident and did not ensure the resident's room was free from odor.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not providing a comfortable environment and failure to ensure the resident's room was odor-free. Evidence showed staff efforts to manage the resident's behavior and maintain cleanliness, but the resident was noncompliant and eventually evicted.
Findings
The investigation found that Resident #1 exhibited disruptive and aggressive behavior, which staff attempted to manage by encouraging compliance with house rules and ultimately evicting the resident. Regarding the odor allegation, staff regularly cleaned the resident's room more than once per week, but the resident often refused assistance. Both allegations were unsubstantiated due to insufficient evidence.
Report Facts
Complaint Control Number: 08-AS-20241011124100
Eviction notice period (days): 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Omar Zamudio | Maintenance Director | Met with during the investigation and exit interview |
| Julia Lopez | Administrator | Facility administrator named in the report header |
Inspection Report
Census: 94
Capacity: 185
Deficiencies: 0
Date: May 7, 2025
Visit Reason
An unannounced Case Management visit was conducted by Licensing Program Analyst Sabel Martinez to evaluate the facility's compliance and deliver an amended report.
Findings
The visit involved securing report signatures, delivering an amended report, and conducting an exit interview with the Maintenance Director. No specific deficiencies or violations are detailed in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit and delivered the amended report. |
| Omar Zamudio | Maintenance Director | Met with the Licensing Program Analyst during the visit and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 185
Deficiencies: 0
Date: May 7, 2025
Visit Reason
The inspection visit was conducted to investigate a complaint alleging theft of a resident's personal belongings from their bedroom.
Complaint Details
The complaint alleged that Resident1 had $50 bonds stolen from their room on November 27, 2024. Law enforcement did not take a police report due to lack of evidence. The facility failed to produce a required theft log for reported thefts over $25. Interviews revealed no other concerns of theft. The allegation was unsubstantiated.
Findings
The investigation included interviews, record reviews, and staff and resident interviews. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence, despite some discrepancies in facility record keeping regarding theft logs.
Report Facts
Complaint Control Number: 08-AS-20241127101919
Complaint received date: Nov 27, 2024
Number of residents present: 94
Facility capacity: 185
Missing amount: 50
Estimated days of completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Omar Zamudio | Maintenance Director | Met with Licensing Program Analyst during the investigation and received report |
| Julia Lopez | Administrator | Facility administrator mentioned in relation to the complaint and law enforcement interaction |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 185
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of unlawful eviction of a resident at the facility.
Complaint Details
The complaint alleged unlawful eviction of Resident #1. The investigation revealed the resident was given a 30-day notice due to rule violations, refused to vacate, and was eventually removed by the Sheriff's office. The allegation was unsubstantiated.
Findings
The investigation found that the resident violated multiple house rules and the facility followed proper eviction procedures; therefore, the allegation of unlawful eviction was unsubstantiated.
Report Facts
Capacity: 185
Census: 97
Notice period: 30
Dates related to eviction: Jul 22, 2024
Dates related to eviction: Apr 9, 2025
Dates related to eviction: Apr 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Julia Lopez | Executive Director | Facility representative involved in the investigation and exit interview |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 185
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-03-20 regarding neglect, lack of supervision resulting in resident altercation, staff mistreatment of residents, and failure to assist a resident with incontinence care.
Complaint Details
The complaint was unsubstantiated. Allegations included neglect/lack of supervision causing resident altercation, staff not treating residents with dignity, and failure to assist a resident with incontinence care. Investigations included interviews with staff, residents, and the Executive Director, as well as facility observations.
Findings
The investigation found no substantiation for the allegations. Interviews and observations indicated no evidence of staff or resident assaults, mistreatment, or lack of incontinence supplies. The resident involved had left the facility and no injuries were confirmed.
Report Facts
Capacity: 185
Census: 97
Complaint Control Number: 08-AS-20250320090340
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met during investigation and interviewed regarding allegations |
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Lizzette Tellez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 185
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not respond to a resident's calls for assistance.
Complaint Details
The complaint alleged that staff did not respond to Resident #1's call for assistance with retrieving medication from under the bed and that the front desk did not answer the phone. The allegation was found to be unsubstantiated after investigation.
Findings
The investigation found that the allegation was unsubstantiated. Interviews revealed that the front desk phone line was sometimes transferred to a cordless phone which occasionally malfunctioned, but residents were advised to use call pendants for emergencies. Residents did not report concerns about staff response to calls, and the resident involved did not miss medication doses.
Report Facts
Capacity: 185
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Julia Lopez | Executive Director | Facility representative met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 185
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of lack of care and supervision resulting in Resident #1 falling and sustaining multiple fractures, which subsequently led to the resident's death.
Complaint Details
The complaint alleged questionable death due to lack of care and supervision resulting in a fall on July 20, 2024, and subsequent death on August 14, 2024. The allegation was unsubstantiated.
Findings
The investigation found insufficient evidence to prove neglect or lack of care and supervision by the facility. The resident's fractures were not the cause of death, and the allegation was unsubstantiated.
Report Facts
Resident census: 97
Facility capacity: 185
Fall date: Jul 20, 2024
Resident death date: Aug 14, 2024
Fall-risk check intervals: 15
Fall-risk check intervals: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Julia Lopez | Executive Director | Facility representative met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 185
Deficiencies: 1
Date: Apr 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the licensee coerced a resident to sign documents, took a resident's personal items, issued an unlawful eviction, and did not conduct a proper reassessment.
Complaint Details
The complaint investigation was substantiated for the allegation that the licensee coerced Resident 1 to sign documents under duress. Other allegations including theft of Resident 1's personal items, unlawful eviction, and failure to conduct a proper reassessment were unsubstantiated.
Findings
The investigation substantiated that the licensee coerced one resident into signing documents under duress, violating personal rights. Other allegations regarding theft of personal items, unlawful eviction, and improper reassessment were unsubstantiated based on interviews and record reviews.
Deficiencies (1)
Residents shall be free from intimidation, abuse, or other punitive actions such as coercion to sign documents; this requirement was not met as the licensee intimidated one resident into signing documents.
Report Facts
Capacity: 185
Census: 95
Deficiencies cited: 1
Plan of Correction Due Date: Apr 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 185
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that facility staff did not provide resident records within two business days as required by regulation.
Complaint Details
The complaint alleged that staff did not provide resident records within two business days. The investigation included interviews and record reviews and concluded the allegation was unsubstantiated.
Findings
The investigation found that the facility provided monthly itemized invoices as required, but did not generate cumulative itemized bills dating back to admission as requested by the resident. The allegation was determined to be unsubstantiated as the facility was not required to maintain cumulative billing records.
Report Facts
Capacity: 185
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation |
| Fernando Soto | Director of Culinary Services | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 97
Capacity: 185
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The visit was an unannounced Case Management visit conducted in response to a self-reported incident regarding Resident 1 (R1).
Findings
A wellness check was conducted at the facility with no health or safety issues identified. No deficiencies were cited or observed during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the visit and involved in the exit interview. |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Census: 97
Capacity: 185
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
The visit was an unannounced Case Management visit conducted in response to a Death Report received on December 30, 2024, regarding a resident.
Findings
No deficiencies were cited during the visit. Follow-up visits or phone calls may be necessary before determining if a violation occurred.
Report Facts
Capacity: 185
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the visit |
| Ashley Baino-Jaimes | Resident Service Director | Met with Licensing Program Analyst during the visit and notified of follow-up |
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Jennifer Lott | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not provide a comfortable environment, including incidents involving a resident yelling and slamming a door and gardening work disturbing residents.
Complaint Details
The complaint alleged that staff did not provide a comfortable environment due to a resident yelling and slamming a door and early morning gardening work disturbing residents. The investigation found no supporting evidence and the complaint was unsubstantiated.
Findings
The investigation included interviews with residents, staff, and the Executive Director, and review of records. No evidence was found to substantiate the allegations, and the complaint was determined to be unsubstantiated.
Report Facts
Capacity: 185
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met during the investigation and named in the report |
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named in the report |
Inspection Report
Annual Inspection
Census: 96
Capacity: 185
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
The visit was an unannounced case management annual continuation inspection to continue the annual inspection commenced on December 5, 2024.
Findings
No deficiencies were cited at the time of this continuation visit. The inspection included a facility tour and an exit interview with the Executive Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the inspection and participated in the facility tour and exit interview. |
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced case management annual continuation visit. |
Inspection Report
Annual Inspection
Census: 96
Capacity: 185
Deficiencies: 0
Date: Dec 5, 2024
Visit Reason
The inspection was an unannounced required one-year inspection to ensure substantial compliance with Title 22 regulations.
Findings
The Licensing Program Analyst conducted a review of resident, facility, and staff records, confirming compliance. The annual inspection was not fully completed due to time constraints and will be finished at a later date.
Report Facts
Capacity: 185
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during inspection and received report |
| Debbie Correia | Licensing Program Analyst | Conducted the inspection visit |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 0
Date: Dec 5, 2024
Visit Reason
The visit was conducted in response to an Incident Report received on November 22, 2024, regarding a resident incident at the facility.
Complaint Details
The visit was triggered by an incident report concerning Resident 1. No deficiencies were found during the investigation.
Findings
No deficiencies were cited during the unannounced case management visit. The Licensing Program Analyst conducted staff interviews and reviewed resident records.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 185
Deficiencies: 0
Date: Sep 26, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not provide a comfortable environment for a resident, specifically regarding another resident entering the complainant's room causing distress.
Complaint Details
The complaint alleged that staff did not provide a comfortable environment for a resident because another resident entered the resident's room causing distress. The investigation included interviews with residents, staff, review of physician's report, and outside agency investigation. The allegation was found unsubstantiated as the resident who entered was confused and did not actually enter the room.
Findings
The investigation found that the allegation was unsubstantiated. The resident who allegedly entered the complainant's room did so due to confusion as a new resident unfamiliar with the facility layout, and did not actually enter the room but interacted at the door entrance. The evidence did not support the claim that the environment was uncomfortable due to staff actions.
Report Facts
Complaint Control Number: 08-AS-20240627112813
Capacity: 185
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during complaint investigation and provided statements |
| Ramon Serrano | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 97
Capacity: 185
Deficiencies: 0
Date: Sep 25, 2024
Visit Reason
An unannounced case management visit was conducted to obtain signatures and deliver two amended reports originally delivered on September 19, 2024.
Findings
The Licensing Program Manager delivered two amended reports and obtained signatures from the facility representative. An exit interview was conducted and copies of the report and Licensee Rights were provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Rodriguez | Driver | Met during the visit and participated in the exit interview. |
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced case management visit and delivered amended reports. |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 185
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-07-15 regarding inadequate provision of toileting supplies at the facility.
Complaint Details
The complaint alleged that facility staff did not provide adequate toileting supplies. The investigation found no preponderance of evidence to substantiate the allegation, concluding it was unsubstantiated.
Findings
The investigation included staff and resident interviews and a facility tour. The allegation that residents were not provided adequate toileting supplies was found to be unsubstantiated based on interviews indicating residents received two rolls of toilet paper per week, which was deemed adequate.
Report Facts
Census: 99
Total Capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation visit |
| Julia Lopez | Executive Director | Facility representative interviewed during the investigation |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 185
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The visit was conducted as an unannounced complaint investigation following allegations that staff did not ensure residents' bathrooms were in good repair and that laundry was not returned in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
Based on staff and resident interviews, facility records review, and a facility tour, the allegations were found to be unsubstantiated. Residents expressed satisfaction with housekeeping and laundry services, and no issues were observed with bathrooms or toilets during the visit.
Report Facts
Capacity: 185
Census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 185
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff were not ensuring residents were taken to their appointments.
Complaint Details
The complaint alleged that staff were not ensuring residents were transported to their appointments. The investigation included interviews with staff and residents and review of facility records. The finding was unsubstantiated.
Findings
Based on staff and resident interviews and facility records review, the allegation was found to be unsubstantiated as there was no preponderance of evidence to prove the violation occurred. The facility maintains a transportation schedule accommodating residents' needs, and residents reported no issues with transportation.
Report Facts
Capacity: 185
Census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the investigation and involved in exit interview |
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 0
Date: Aug 30, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that staff did not provide a comfortable temperature for residents in care.
Complaint Details
The complaint alleged that staff did not provide a comfortable temperature for residents. The allegation was unsubstantiated after investigation.
Findings
The investigation included staff and resident interviews and a facility tour. It was found that each resident room has its own air conditioning unit which residents can control. Although one resident had trouble adjusting their AC unit, maintenance fixed the issue. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 185
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation and facility visit |
| Julia Lopez | Administrator | Facility administrator mentioned in the report |
| Sharmaine Osea | Resident Service Assistant | Met with the Licensing Program Analyst during the investigation |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Capacity: 185
Deficiencies: 0
Date: Aug 30, 2024
Visit Reason
The visit was an unannounced case management visit to obtain signatures on an amended report originally delivered on August 29, 2024.
Findings
During the visit, the Licensing Program Analyst obtained the Resident Service Assistant's signature on the amended report and conducted an exit interview, providing a copy of the report and licensee appeal rights.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced visit and obtained signatures on the amended report. |
| Sharmaine Osea | Resident Service Assistant | Provided signature on the amended report during the visit. |
| Julia Lopez | Administrator/Director | Named as facility administrator/director. |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 0
Date: Aug 29, 2024
Visit Reason
The visit was conducted as an unannounced complaint investigation following a complaint received on 08/27/2024 alleging that facility staff did not provide transportation to a resident in care.
Complaint Details
The complaint alleged that staff did not provide transportation to a resident on August 27, 2024. Interviews and record reviews showed the transportation calendar was fully booked that day, and the resident was transported the following day. The complaint was unsubstantiated.
Findings
The investigation included interviews with residents and staff and a review of facility records. It was found that although the allegation may have occurred, there was insufficient evidence to prove a violation, and the complaint was determined to be unsubstantiated. The resident was provided transportation the following day, and other residents reported no issues with transportation services.
Report Facts
Complaint Control Number: 08-AS-20240827164134
Capacity: 185
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with during investigation and provided information about transportation scheduling |
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ashley Baino-Jaimes | Resident Service Director | Participated in exit interview and acknowledged receipt of report |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 0
Date: Aug 29, 2024
Visit Reason
The visit was conducted in response to a Special Incident Report received regarding a resident eloping from the facility on August 24, 2024.
Complaint Details
The complaint involved Resident 1 eloping from the facility on August 24, 2024. The resident was found by a neighbor who called 911, and the resident was returned to the facility by a family member later that evening.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst conducted interviews and record reviews, and follow-up visits or calls may be necessary before determining if a violation occurred.
Report Facts
Time resident eloped: 1115
Time resident returned: 2100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the visit and was notified of findings |
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 0
Date: Aug 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not treat a resident with dignity, specifically that a staff member had yelled at a resident.
Complaint Details
The complaint alleged that staff did not treat a resident with dignity by yelling at the resident. The allegation was unsubstantiated after investigation.
Findings
The investigation found no evidence to corroborate the allegation that staff yelled at a resident. Interviews with staff, residents, and the Executive Director did not reveal any concerns or confirm the incident, resulting in the allegation being unsubstantiated.
Report Facts
Capacity: 185
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met during the investigation and named in relation to the complaint findings |
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 0
Date: Aug 7, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff does not provide a comfortable temperature for residents in care.
Complaint Details
The complaint was unsubstantiated based on the investigation findings.
Findings
The investigation included facility inspection, observation, record reviews, and interviews. It was determined that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the violation occurred, and the complaint was unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Julia Lopez | Administrator | Met with the Licensing Program Analyst during the investigation and participated in the exit interview. |
| Simon Jacob | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 0
Date: Jul 3, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations that the licensee did not provide fresh fruit and that staff were unable to communicate residents' needs due to a language barrier.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to provide fresh fruit and staff communication barriers. Evidence did not support these claims.
Findings
The investigation found that fresh fruit was offered and served during each meal, with accommodations made for resident preferences and chewing/swallowing needs. Staff and residents reported no communication issues related to language barriers. The allegations were determined to be unsubstantiated based on interviews, observations, and records review.
Report Facts
Capacity: 185
Census: 96
Complaint Control Number: 08-AS-20240625095223 (alphanumeric)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met during the investigation and involved in exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation |
| Ryan Fulton | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Jennifer Lott | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 92
Capacity: 185
Deficiencies: 0
Date: May 30, 2024
Visit Reason
An unannounced case management visit was conducted to deliver an amended report and obtain signatures.
Findings
The Licensing Program Manager delivered an amended version of a report, obtained signatures, and provided copies of the report and Licensee Rights to the facility representative during an exit interview.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kitty Totorica | Business Director | Met with Licensing Program Manager during the visit and participated in the exit interview. |
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced case management visit and delivered the amended report. |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 185
Deficiencies: 1
Date: May 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that facility staff do not maintain the fire alarm system in good repair.
Complaint Details
The complaint was substantiated. The allegation that the facility staff do not maintain the fire alarm system in good repair was found valid based on the preponderance of evidence.
Findings
The allegation was substantiated based on interviews and facility records review. The facility had six deficiencies identified during a fire inspection on April 9, 2024; two were repaired but four deficiencies related to facility doors not latching or dragging remained uncorrected, posing an immediate threat to 92 residents.
Deficiencies (1)
Facility did not address 4 facility doors that did not pass a fire system inspection due to doors not latching or dragging, posing an immediate threat to residents.
Report Facts
Deficiencies cited: 6
Deficiencies unrepaired: 4
Residents at risk: 92
Plan of Correction Due Date: May 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation and exit interview |
| Omar Zamudio | Maintenance Director | Facility staff member interviewed and involved in plan of correction |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 185
Deficiencies: 0
Date: May 17, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation received on 2024-01-23 that staff did not provide a resident with water.
Complaint Details
The complaint alleged that staff did not provide resident with water. After investigation, including interviews with Resident 1, Resident 2, staff, and outside sources, and observation of multiple water stations and bottled water availability, the allegation was determined to be unsubstantiated.
Findings
The investigation included facility inspection, interviews with residents, staff, and outside sources, and observation of water availability. The evidence did not support the allegation, and the complaint was found to be unsubstantiated.
Report Facts
Capacity: 185
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation and facility inspection |
| Omar Zamudio | Maintenance Director | Interviewed during the investigation and present at exit interview |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 185
Deficiencies: 0
Date: May 17, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that the facility plumbing was in disrepair and that residents had no running water to wash their hands after using the restroom.
Complaint Details
The complaint alleged poor plumbing with no running water in resident bathrooms on January 23, 2024. Interviews with residents and staff confirmed repairs were made the same day and alternative facilities were provided. The allegation was found to be unsubstantiated.
Findings
Based on interviews with residents, staff, and an outside source, observations, and records review, the investigation found that plumbing repairs were completed promptly on January 23, 2024, alternative bathrooms were provided during repairs, and residents were informed. Therefore, the allegation was unsubstantiated.
Report Facts
Complaint Control Number: 08-AS-20240123162901
Facility Capacity: 185
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Omar Zamudio | Maintenance Director | Met with Licensing Program Analyst during inspection and exit interview |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 185
Deficiencies: 0
Date: May 9, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not meet a resident's needs.
Complaint Details
The allegation that staff did not meet a resident's needs was unsubstantiated based on interviews, record reviews, and observations.
Findings
The investigation found that Resident #1 was able to ambulate independently and had declined escorting services due to additional charges. The facility agreed to remove the charge and service, and there was insufficient evidence to substantiate the allegation.
Report Facts
Capacity: 185
Census: 87
Complaint Control Number: 08-AS-20240329084536
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met during the investigation and involved in exit interview |
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Omar Zamudio | Maintenance Director | Participated in exit interview |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 185
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-02-26 regarding improper cleaning of resident restrooms, pest infestation, untimely assistance to residents, and failure to empty resident trash cans.
Complaint Details
The complaint included allegations that staff were not properly cleaning resident restrooms, not addressing pest infestation, not assisting residents in a timely manner, and not emptying resident trash cans. The investigation found these allegations unsubstantiated based on interviews, observations, and evidence gathered.
Findings
The investigation found insufficient evidence to support any of the allegations. Interviews with staff and residents, as well as observations, did not substantiate claims of improper cleaning, pest infestation, untimely assistance, or failure to empty trash cans. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 185
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Denise Powell | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Patricia Totorica | Business Director | Facility representative met during the investigation |
| Julia Lopez | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 185
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-02-23 regarding staff not providing a resident with clean linens and staff yelling at a resident.
Complaint Details
The complaint involved allegations that staff did not provide a resident with clean linens and that staff yelled at a resident. The investigation included interviews with staff, the resident, outside sources, and direct observations. The allegations were found to be unsubstantiated based on a preponderance of evidence.
Findings
The investigation found that the resident's bedding was changed according to their preference and requests, and no evidence supported the allegation that staff yelled at the resident. Interviews, observations, and records review led to the conclusion that the allegations were unsubstantiated.
Report Facts
Capacity: 185
Census: 84
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Julia Lopez | Executive Director | Facility administrator met during the investigation |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 185
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
The visit was conducted in response to a self-reported incident involving second degree burns to a resident.
Complaint Details
The visit was complaint-related due to a self-reported incident of second degree burns involving Resident 1. No deficiencies were found.
Findings
A wellness check was conducted with no health or safety issues identified and no deficiencies cited or observed during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the visit and involved in the exit interview. |
| Nacole Patterson | Licensing Program Analyst | Conducted the unannounced Case Management Visit. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 185
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including unlawful eviction, untimely laundry service, and medication mismanagement.
Complaint Details
The complaint included allegations of unlawful eviction, failure to provide timely laundry service, and staff mismanagement of resident medication. All allegations were found unsubstantiated based on interviews, record reviews, and observations.
Findings
The investigation found insufficient evidence to support the allegations. The eviction was lawful due to nonpayment, laundry services were provided timely according to staff and resident interviews, and medication management was not mishandled by staff as the resident self-managed medications.
Report Facts
Amount owed leading to eviction: 10000
Capacity: 185
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during investigation and participated in exit interview |
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 185
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-01-02 regarding staff handling residents roughly and not treating residents with dignity.
Complaint Details
The complaint alleged that staff handled residents in a rough manner and did not treat residents with dignity. The investigation included interviews, record reviews, and direct observations, all of which did not support the allegations. An outside agency investigation also found no evidence to validate the claims. The findings were unsubstantiated.
Findings
The investigation found no evidence to substantiate the allegations. Interviews with staff, residents, and outside sources, as well as direct observations during three unannounced visits, did not corroborate claims of rough handling or disrespectful treatment. The allegations were deemed unsubstantiated.
Report Facts
Complaint allegations: 2
Unannounced facility visits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with during the investigation and exit interview |
| Nacole Patterson | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 185
Deficiencies: 0
Date: Feb 6, 2024
Visit Reason
The visit was an unannounced complaint investigation following a complaint received on 2023-05-22 alleging staff inappropriately spoke to and made false accusations against a resident in care.
Complaint Details
The complaint alleged staff verbally assaulted a resident by saying the resident was suicidal and implemented one-to-one supervision without consent, and falsely accused the resident of making threats to kill relatives. The investigation found the resident denied making threats and refused treatment, and the facility did not charge for additional supervision. The allegations were unsubstantiated based on the preponderance of evidence.
Findings
The investigation found insufficient evidence to support the allegations. Interviews, record reviews, and outside sources indicated that the allegations were unsubstantiated, and the facility's actions, including one-to-one supervision, were based on safety concerns and consistent with facility policy.
Report Facts
Complaint Control Number: 08-AS-20230522153113
Capacity: 185
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation visit |
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 185
Deficiencies: 1
Date: Jan 26, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation following a complaint received on 07/17/2023 alleging that the facility did not provide a resident's personal care needs.
Complaint Details
The complaint was substantiated. The allegation was that staff did not provide Resident 1 with scheduled showers on July 15 and July 18, 2023. Staff interviews and record reviews confirmed the failure to provide personal care. Staff were not trained to document refusals of showers.
Findings
The investigation found that Resident 1 did not receive scheduled showers on July 15 and July 18, 2023, and staff were not trained to document refusals of showers. The allegation that the facility did not afford the resident's personal care needs was substantiated.
Deficiencies (1)
Failure to provide personal assistance and care with activities of daily living such as dressing, eating, bathing, and assistance with taking prescribed medications, posing a potential health, safety, and personal rights risk to 1 of 185 residents.
Report Facts
Deficiencies cited: 1
Resident count: 91
Total capacity: 185
Plan of Correction due date: Mar 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Pena | Licensing Program Analyst | Conducted the complaint investigation visit |
| Julia Lopez | Executive Director | Facility representative met during investigation and recipient of report and licensee rights |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 185
Deficiencies: 2
Date: Jan 9, 2024
Visit Reason
The visit was conducted in response to a self-submitted incident report involving a theft of jewelry from a resident's bedroom between 12/23/2023 and 12/26/2023.
Complaint Details
The visit was triggered by an LIC624 Incident Report regarding the theft of jewelry from Resident #1's nightstand. The complaint was substantiated by records review and staff interviews.
Findings
The licensee failed to maintain a complete written personal property inventory for the affected resident and did not maintain documentation of lost and stolen resident property valued at $25 or more for the past 12 months, posing potential personal rights risks.
Deficiencies (2)
Licensee did not maintain a personal property inventory completed by the licensee and the resident or their representative.
Licensee did not maintain documentation of lost and stolen resident property with a value of $25 or more within the past 12 months.
Report Facts
Residents present: 87
Total licensed capacity: 185
Deficiencies cited: 2
Plan of Correction due date: Feb 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with during the visit and involved in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and signed the report |
| Juliana Barfield | Licensing Program Analyst | Conducted the inspection |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 88
Capacity: 185
Deficiencies: 0
Date: Dec 14, 2023
Visit Reason
The inspection was an unannounced required one-year inspection to ensure substantial compliance with Title 22 regulations.
Findings
The facility was found to be in substantial compliance with regulations, with clean and sufficient linens, properly equipped resident rooms, sanitary bathrooms, operational safety equipment, proper food storage, compliant medication administration, complete staff and resident records, and sufficient staffing to meet residents' needs.
Report Facts
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Amy Rodgers | Licensing Program Analyst | Conducted the inspection visit |
| Denise Powell | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 185
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of unlawful eviction received on 2023-11-15.
Complaint Details
The complaint alleged that Resident 1 was unlawfully evicted. The investigation determined the allegation was false and without reasonable basis, as the eviction notice complied with Title 22 mandates.
Findings
The investigation found the allegation of unlawful eviction to be unfounded after reviewing facility records and conducting interviews. The facility was in compliance with Title 22 regulations at the time of the visit.
Report Facts
Complaint Control Number: 08-AS-20231115104846
Capacity: 185
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation visit |
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 2
Date: Oct 31, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report regarding Resident #1 eloping from the facility without staff supervision on 10/15/2023.
Complaint Details
The complaint involved Resident #1 eloping from the facility on 10/15/2023. The resident was unharmed and able to leave unassisted per physician report. The complaint was investigated and substantiated by the findings.
Findings
The resident was found safe and unharmed during the visit. Staff devices and alarms were functioning properly. No deficiencies were cited, but two Technical Violations were issued related to Reporting Requirements and Delayed Egress Doors.
Deficiencies (2)
Reporting Requirements
Delayed Egress Doors
Report Facts
Technical Violations issued: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Julia Lopez | Executive Director | Facility representative met during the visit and exit interview |
| Lizzette Tellez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 185
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of management retaliation against staff regarding reporting requirements.
Complaint Details
The complaint alleged management retaliation against a staff member regarding reporting requirements. After investigation, the allegation was found unsubstantiated due to lack of corroborating evidence.
Findings
The investigation found no corroborating evidence to support the allegation of retaliation. Interviews with staff and management revealed misunderstandings, and the complaint was determined to be unsubstantiated.
Report Facts
Capacity: 185
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation visit |
| April Princesa | Assistant Executive Director | Met with Licensing Program Analyst during the investigation |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 185
Deficiencies: 0
Date: Jun 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-05-24 regarding resident food quality and failure to itemize a resident's bill.
Complaint Details
The complaint investigation addressed two allegations: 1) Resident food was not of quality, which was unsubstantiated. 2) Facility did not itemize resident's bill, which was unfounded.
Findings
The investigation found the allegation of poor food quality unsubstantiated due to lack of evidence and resident/staff interviews confirming good food quality. The allegation that the facility did not itemize a resident's bill was unfounded based on billing records and staff interviews showing proper billing procedures and timely provision of itemized statements.
Report Facts
Capacity: 185
Census: 86
Bill amount: 6000
Complaint received date: May 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisela Garcia-Centeno | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| John Rante | Licensing Program Manager | Oversaw the complaint investigation |
| Maritza Maezze | Business Director | Facility representative met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 185
Deficiencies: 8
Date: Jun 6, 2023
Visit Reason
An unannounced complaint investigation visit was conducted due to multiple allegations including insufficient staffing, staff neglect, medication errors, failure to provide healthful accommodations, intimidation of residents, and failure to follow reporting requirements.
Complaint Details
The complaint investigation was triggered by multiple allegations including insufficient staffing, staff neglect, failure to administer medication as prescribed, failure to provide healthful accommodations, intimidation of residents, failure to follow reporting requirements, unsecured medications, and lack of staff training. One allegation of staff working under the influence of marijuana was unsubstantiated.
Findings
The investigation substantiated multiple allegations including insufficient staffing, medication errors leading to health risks for a resident, failure to provide basic care and healthful accommodations, intimidation of residents by management, and failure to provide required staff training. One allegation regarding staff working under the influence of marijuana was found unsubstantiated due to lack of evidence.
Deficiencies (8)
Facility personnel did not provide basic care services to one resident, posing an immediate health risk.
Facility personnel did not administer medication as prescribed to one resident, posing an immediate health risk.
Facility personnel were not sufficient in numbers and competent to meet resident needs, posing a potential health risk.
Facility did not accord healthful accommodations to one resident, posing a potential personal rights risk.
Licensee did not submit written reports to licensing for one resident, posing a potential health and safety risk.
Staff spoke in an intimidating manner to residents, posing a potential personal rights risk.
Facility did not keep medications in a safe and locked place, posing a potential safety risk to residents.
Staff who assist residents with personal activities of daily living did not receive initial and annual training, posing a potential health risk.
Report Facts
Residents present: 85
Total licensed capacity: 185
Medication doses missed: 4
Medication hold duration: 8
Residents assessed at care level 0: 40
Residents assessed at care level 1: 17
Residents assessed at care levels 2-5: 23
Residents affected by unsecured medications: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maritza Maezza | Community Business Director | Facility representative met during investigation and exit interview |
| Omar Zamudio | Maintenance Director | Facility representative met during investigation |
| Simon Jacob | Licensing Program Manager | Oversaw the licensing program and signed the report |
| Jennifer Lott | Licensing Program Manager | Oversaw deficiency information and plan of correction |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 185
Deficiencies: 0
Date: May 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not deliver residents' mail in a timely manner.
Complaint Details
The complaint alleged that staff did not deliver resident's mail in a timely manner. Interviews and records review showed mail was typically delivered by the next day. The allegation was unsubstantiated.
Findings
The investigation found that mail delivery to residents' rooms generally occurred no later than the day after mail was received by the facility. There was no contractual agreement for mail delivery to rooms, and the one-day delay did not support the alleged violation. The complaint was determined to be unsubstantiated due to lack of corroborating evidence.
Report Facts
Capacity: 185
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation and exit interview |
| Maritza Maezze | Community Business Director | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 185
Deficiencies: 1
Date: May 25, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 05/19/2023 alleging that staff did not ensure that resident records and personal information remained confidential.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation involved a breach of confidentiality where Resident1 was given another resident's confidential documents.
Findings
The investigation substantiated the allegation that staff failed to safeguard confidential resident records, confirmed by an interview, observation, and record review. One out of 85 residents was affected, posing a potential personal rights violation.
Deficiencies (1)
Staff did not safeguard confidential resident records as required by CCR 87506(c)(1), revealing confidential information without proper consent.
Report Facts
Residents affected: 1
Census: 85
Total capacity: 185
Plan of Correction due date: Jun 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Julia Lopez | Executive Director | Facility representative met during the investigation and named in findings. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 185
Deficiencies: 0
Date: May 12, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to a complaint alleging the facility was in disrepair, specifically regarding the heating, ventilation, and air conditioning (HVAC) system not working properly.
Complaint Details
The complaint alleged the facility was in disrepair due to HVAC issues causing temperature discomfort. Investigation included interviews with staff and resident, review of work orders, and direct observation of the HVAC unit. The resident preferred room temperatures between 80-83 degrees Fahrenheit, and the unit was functioning within that range despite a missing dash on the digital display.
Findings
Based on observations, record reviews, and interviews, there was no preponderance of evidence to prove the alleged violation occurred; the complaint was found to be unsubstantiated.
Report Facts
Facility capacity: 185
Resident census: 84
Complaint receipt date: May 8, 2023
Work order dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| John Rante | Licensing Program Manager | Oversaw the complaint investigation |
| Julia Lopez | Executive Director | Facility representative interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 185
Deficiencies: 1
Date: Apr 20, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following complaints received on 2023-04-12 regarding the lack of non-skid mats in showers and the placement of grab bars in required locations.
Complaint Details
The complaint alleging the facility did not provide non-skid mats for showers was substantiated. The complaint alleging the facility did not place grab bars in required locations was unsubstantiated.
Findings
The investigation substantiated the complaint that the facility did not provide non-skid mats or strips in showers for two residents, posing a safety risk. However, the complaint regarding the placement of grab bars was unsubstantiated as all resident bathrooms contained grab bars as required.
Deficiencies (1)
Licensee did not provide non-skid mats or strips in bathtubs or showers for 2 of 81 persons in care, posing a safety risk.
Report Facts
Persons in care without non-skid mats: 2
Total census: 81
Total capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation and facility inspection |
| John Rante | Licensing Program Manager | Oversaw the complaint investigation |
| Maritza Maezee | Business Director | Facility representative interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 185
Deficiencies: 0
Date: Feb 16, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility did not assist a resident in obtaining medical and dental care.
Complaint Details
The complaint alleged that the licensee did not assist Resident 1 in obtaining medical and dental care. The allegation was found to be unsubstantiated due to lack of evidence.
Findings
The investigation found that prior to the resident's relocation to a higher level care facility, the resident was independent in self-care and regularly received medical and dental care. There was no evidence to corroborate the allegation, and the complaint was unsubstantiated.
Report Facts
Capacity: 185
Census: 80
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Segura | Licensing Program Analyst | Conducted the complaint investigation |
| Julia Lopez | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 185
Deficiencies: 2
Date: Sep 20, 2022
Visit Reason
The visit was an unannounced case management inspection conducted to discuss an incident report received on September 14, 2022, regarding a resident injury caused by a cabinet falling in a private bathroom.
Complaint Details
The visit was triggered by an incident report received on September 14, 2022, indicating that Resident #1 sustained a head injury when a cabinet in their private bathroom was not properly secured and fell off the wall.
Findings
The facility was found to have a deficiency related to maintenance and operation, specifically failing to maintain good repair in one out of 82 resident rooms, posing a potential safety risk to residents.
Deficiencies (2)
Maintenance and Operation (a) The facility shall be safe and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Based on an interview with the Executive Director (ED) the facility did not maintain good repair to 1 out of 82 resident rooms. This posed a potential safety risk to residents in care.
Report Facts
Resident rooms with maintenance issues: 1
Census: 82
Total capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Lopez | Executive Director | Interviewed during the visit and involved in the exit interview |
| Debbie Correia | Licensing Program Analyst | Conducted the unannounced case management visit |
| Simon Jacob | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 185
Deficiencies: 0
Date: Apr 27, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2020-03-12 regarding failure of staff to address scabies, changes in resident's medical condition, and failure to provide appropriate transportation.
Complaint Details
The complaint investigation was unsubstantiated due to lack of corroborating evidence despite multiple allegations including failure to address scabies, failure to address resident's change in medical condition, and failure to provide transportation as per the Admission Agreement.
Findings
The investigation found that although there were allegations of staff failing to address scabies, medical condition changes, and transportation issues for Resident 1, the evidence was insufficient to substantiate these claims. Facility staff implemented universal precautions after scabies diagnosis, but documentation and coordination issues were noted.
Report Facts
Complaint Control Number: 08-AS-20200312094050
Facility Capacity: 185
Census: 86
Number of allegations: 9
Assessment levels: Care level scale ranges from 0 to 4, with R1 assessed at levels 0, 1, 2, and 3 at various times
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Julia Lopez | Executive Director | Facility representative who met with the investigator during the visit |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 185
Deficiencies: 1
Date: Dec 21, 2021
Visit Reason
An unannounced subsequent case management visit was conducted to cite a deficiency identified during a prior investigation related to inappropriate sexual touching between a staff member and residents.
Complaint Details
The visit was complaint-related, triggered by a licensee self-report of inappropriate sexual touching by Staff Member 1 (S1) against Resident 1 (R1) and Resident 2 (R2). The complaint was substantiated by interviews, records, and S1's own admission. S1 was arrested and pled guilty to a felony.
Findings
The investigation revealed that a staff member engaged in sexual abuse and conduct inimical to residents, including non-consensual sexual acts with two residents and a consensual sexual relationship with a third resident, which violated fiduciary duties. The staff member was arrested, terminated, and a deficiency was cited.
Deficiencies (1)
Licensee’s staff caused sexual abuse on 2 residents, posing an immediate personal rights risk to persons in care.
Report Facts
Census: 94
Total Capacity: 185
Bail Amount: 25000
Plan of Correction Due Date: Jan 20, 2022
Residents Abused: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Rebecca Hedgecock | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
| Julie Wiese | Regional Vice President | Facility representative involved in the exit interview and plan of correction development |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 185
Deficiencies: 1
Date: Dec 21, 2021
Visit Reason
An unannounced subsequent case management visit was conducted to cite a deficiency identified during a prior investigation regarding alleged inappropriate sexual comments and touching by a staff member towards a resident.
Complaint Details
The visit was complaint-related, triggered by a licensee self-report of alleged inappropriate sexual comments and touching by Staff Member 1 against Resident 1 on April 5, 2021. The complaint was substantiated based on interviews, records, and police findings.
Findings
The investigation determined that Staff Member 1 engaged in sexual harassment of Resident 1, violating the resident's personal rights and dignity. The staff member was terminated and a deficiency was cited for violation of California Code of Regulations, Title 22.
Deficiencies (1)
Licensee’s staff, through sexual harassment, violated the dignity of 1 resident, posing an immediate personal rights risk.
Report Facts
Census: 94
Total Capacity: 185
Deficiency Count: 1
Plan of Correction Due Date: Jan 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Rebecca Hedgecock | Licensing Program Manager | Supervisor and named in the report |
| Julie Wiese | Regional Vice President | Met with Licensing Program Analyst during visit and involved in plan of correction |
| Irma Arteaga | Administrator | Facility administrator who received Resident 1's report |
Inspection Report
Annual Inspection
Census: 94
Capacity: 185
Deficiencies: 0
Date: Dec 21, 2021
Visit Reason
The inspection was an unannounced required 1-year visit to evaluate the facility's compliance with regulatory standards, including infection control measures related to COVID-19.
Findings
No deficiencies were cited during this inspection. The Licensing Program Analyst conducted a tour, observed staff and residents, and reviewed the facility's COVID-19 Mitigation Plan implementation.
Report Facts
Capacity: 185
Census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and evaluation |
| Julie Wiese | Regional Vice President | Met with the Licensing Program Analyst during the inspection |
Inspection Report
Census: 97
Capacity: 185
Deficiencies: 0
Date: Aug 30, 2021
Visit Reason
An unannounced Case Management Visit was conducted to follow up on two unusual incident reports regarding residents who were absent without leave from the facility.
Findings
The Licensing Program Analyst toured the facility, performed welfare checks on the residents involved, interviewed relevant staff and residents, and reviewed care records. No deficiencies were cited during the visit.
Report Facts
Incident reports: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management Visit |
| Kris Waluzsko | Interim Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 0
Date: Apr 8, 2021
Visit Reason
The visit was an unannounced case management inspection conducted due to a self-reported incident involving unwelcome verbal comments and touching between a staff member and a resident on 2021-04-05.
Complaint Details
The complaint involved unwelcome verbal comments and touching between Staff Member 1 and Resident 1. Staff Member 1 was suspended pending investigation.
Findings
The Licensing Program Analyst conducted a welfare check on the resident involved, interviewed the administrator, and reviewed relevant records. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Brennan | Facility Administrator | Met with Licensing Program Analyst during the visit and involved in the incident report. |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Rebecca Hedgecock | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 93
Capacity: 185
Deficiencies: 0
Date: Mar 12, 2021
Visit Reason
The visit was an unannounced case management tele-virtual visit conducted due to the COVID-19 pandemic, following a self-reported incident involving inappropriate touching between a staff member and a resident.
Findings
No deficiencies were cited during the visit. The facility had suspended and subsequently terminated the employment of the staff member involved in the incident.
Report Facts
Incident date: Jan 29, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Brennan | Facility Administrator | Met with Licensing Program Analysts during the visit and received report and appeal rights |
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