Inspection Report Summary
Most inspections found deficiencies, with issues primarily related to facility maintenance, cleanliness, resident care, and safety hazards. The most recent report from September 16, 2025, substantiated complaints about uncomfortable temperatures on the second floor and a raised laminate floor in the dining room that caused a resident fall and injury. Earlier reports also cited pest infestations, unsanitary conditions, missed medical appointments due to transportation failures, and lapses in reporting financial abuse, though several complaint investigations were unsubstantiated. There were no fines or license suspensions listed in the available reports. While some deficiencies have persisted over time, the facility has addressed certain problems such as pest control and initiated repairs, but safety and maintenance concerns remain.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
57% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 52
Capacity: 92
Deficiencies: 2
Date: Sep 16, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-05-20 regarding facility temperature control and tripping hazards, among other complaints.
Complaint Details
The complaint investigation was substantiated for allegations that the facility was not maintained at a comfortable temperature and was not free of tripping hazards, resulting in a resident fall with femur fracture and surgery. Other allegations regarding staff inappropriate behavior, elevator repair, and room cleanliness were unsubstantiated.
Findings
The investigation substantiated that some second-floor rooms were uncomfortably cold due to thermostat issues and that raised laminate flooring in the dining room posed a tripping hazard causing a resident fall and injury. Other allegations related to staff behavior, elevator repair, and room cleanliness were found unsubstantiated.
Deficiencies (2)
Facility failed to maintain a comfortable temperature for residents, with some 2nd floor rooms measuring as low as 62 degrees F, controlled by a single thermostat.
Dining room laminate flooring was raised approximately 7 inches, posing a tripping hazard and risk to residents.
Report Facts
Residents interviewed: 8
Rooms inspected: 13
Raised laminate flooring height: 7
Deficiencies cited: 2
Plan of Correction due date: Oct 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
| Mario Preston | Interim Executive Director | Facility representative met during investigation and exit interview |
| Chanel Sanchez | Executive Director | New Executive Director involved in investigation discussions |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 92
Deficiencies: 0
Date: Jul 29, 2025
Visit Reason
The visit was an unannounced complaint investigation to examine the allegation that the licensee did not follow a resident's admission agreement.
Complaint Details
The complaint alleged that resident R1 was billed for services not rendered, including deposits and automatic withdrawals from a shared bank account. Interviews and record reviews showed the resident moved in November 28, 2023 and moved out March 2, 2024. A credit refund of $16,499.02 was issued to the responsible party. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation found that although the resident was billed for services, the licensee followed refund procedures and the admission agreement. There was insufficient evidence to corroborate the allegation, and the complaint was determined to be unsubstantiated.
Report Facts
Deposit amount: 5500
Invoice amount: 9962
Billed amount: 27724
Automatic withdrawal: 9962
Community fee: 2500
Monthly charges: 9962
Credit refund: 16499.02
Residents interviewed: 6
Staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager on report |
| Christina Schoech | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Mario Preston | Interim Executive Director | Arrived during investigation visit |
| Marina Verdugo | Resident Engagement Coordinator | Conducted exit interview |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 92
Deficiencies: 2
Date: Jun 26, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-05-12 regarding inadequate cleaning, odors, and pest infestation in a resident's room.
Complaint Details
The complaint investigation was substantiated based on observations, interviews, and document reviews. Allegations included inadequate cleaning, odors from pet waste, and pest infestation in resident R1's room. Staff were unaware of the cockroach infestation until shortly before the investigation. Pest control services were arranged and ongoing.
Findings
The investigation substantiated that staff did not ensure the resident's room was adequately cleaned, free from odors, or free from pests. The resident's room was found cluttered with hoarding, had a strong odor of pet feces and urine, and was infested with cockroaches. Pest control services were initiated after discovery of the infestation.
Deficiencies (2)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Resident's room infested with cockroaches, cluttered, and unsanitary conditions posing health and safety risks.
Maintenance and Operation. All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. Resident's room had strong odor of pet feces and urine.
Report Facts
Capacity: 92
Census: 51
Rooms inspected: 17
Residents interviewed: 11
Staff interviewed: 5
Pest control service frequency: 2
Plan of Correction Due Date: Jun 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mario Preston | Interim Executive Director / Operations Specialist | Met with during inspection and exit interview |
| Logan Harrison | Executive Director | Agreed to submit plan of correction and staff training |
| Noemi Galarza | Licensing Program Analyst | Conducted complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 92
Deficiencies: 1
Date: Jun 6, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that facility staff do not ensure the facility showers are clean and orderly.
Complaint Details
The complaint alleged that the second floor common shower needed cleaning, had mildew, fans did not work properly, and the vanity was too large. The allegation was substantiated based on interviews and observations.
Findings
The investigation substantiated the allegation that the second floor common shower was not properly maintained, with a non-operational fan inside the shower and tile grout needing deep cleaning. Staff and resident interviews, along with a tour, confirmed these issues.
Deficiencies (1)
Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. The fan inside the shower was non-operational and the tile grout in the shower needed deep cleaning.
Report Facts
Capacity: 92
Census: 49
Plan of Correction Due Date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sanjay Kabadi | Administrator | Facility administrator named in the report |
| Logan Harrison | Executive Director | Participated in the exit interview and facility tour |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 92
Deficiencies: 1
Date: May 16, 2025
Visit Reason
The visit was a Case Management - Incident inspection to follow up on a 3rd party SOC 341 Report of Suspected Dependent Elder Abuse related to financial abuse of a resident by social media contacts.
Complaint Details
The visit was triggered by a complaint involving suspected financial abuse of resident R1 by social media 'friends'. The complaint was substantiated by findings that the resident was financially exploited and the facility failed to report the abuse to the licensing agency.
Findings
The investigation found that resident R1 had willfully gifted money to persons met via Facebook, and the facility failed to submit the required SOC 341 report to the licensing agency upon knowledge of the financial abuse. A citation was issued for this failure.
Deficiencies (1)
Failure to submit a SOC 341 report to the licensing agency within seven days of knowledge of financial abuse of resident R1.
Report Facts
Capacity: 92
Census: 51
Plan of Correction Due Date: May 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Logan Harrison | Executive Director | Met with during inspection and given a copy of the report |
| Noemi Galarza | Licensing Program Analyst | Conducted the Case Management - Incident visit and signed the report |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 92
Deficiencies: 3
Date: May 16, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that staff did not ensure a resident's room was adequately cleaned, free from odors, and free from pests.
Complaint Details
The complaint investigation was substantiated based on observations, interviews, and photographic evidence confirming the allegations of inadequate cleaning, odors, and pest infestation in resident R1's room.
Findings
The investigation found substantiated evidence of unsanitary conditions in resident R1's room, including clutter, dead and live cockroaches, pet feces and urine odors, and pest infestation. Staff were unaware of the infestation until recently, and pest control services were initiated during the visit.
Deficiencies (3)
The premises were not maintained in a state of good repair and did not provide a safe and healthful environment, evidenced by unswept floors, food on the floor/tables, clutter, and excessive personal belongings posing health and safety risks.
Waste was not located, stored, and disposed of in a manner to prevent transmission of communicable diseases or odors, posing a risk to health and safety, evidenced by strong odor of pet feces and urine in resident R1's room and patio area.
The facility was not clean, safe, sanitary, and in good repair at all times, evidenced by resident R1's room infested with dead and alive cockroaches and maggots, posing a potential health and safety risk.
Report Facts
Rooms inspected: 17
Residents interviewed: 11
Staff interviewed: 5
Plan of Correction Due Date: May 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Logan Harrison | Executive Director | Met with during the investigation and participated in exit interview |
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Annual Inspection
Census: 47
Capacity: 92
Deficiencies: 3
Date: May 6, 2025
Visit Reason
The inspection was an unannounced required 1-year visit to evaluate compliance with licensing requirements for the Residential Care For Elderly (RCFE) facility serving residents aged 60 and over.
Findings
The facility was found to have several deficiencies including water temperature exceeding the required range in some rooms, missing mattress pads in certain resident rooms, and uncovered food items in the refrigerator. Infection control supplies and operational requirements such as fire clearance and liability insurance were in place. The facility has a hospice waiver for 8 residents and provides care with 38 staff members.
Deficiencies (3)
Water temperature in 8 out of 18 rooms was above 120 degrees Fahrenheit, ranging from 125.4 to 137.6 degrees, posing an immediate health and safety risk.
Beds in rooms 204, 205, and 209 did not have mattress pads, posing a potential health and safety risk.
Eleven chocolate pudding glass cups were observed uncovered in the refrigerator, posing a potential health and safety risk.
Report Facts
Residents receiving hospice services: 3
Residents receiving home health services: 15
Staff members providing care: 38
Rooms with water temperature above 120 degrees Fahrenheit: 8
Rooms without mattress pads: 3
Uncovered pudding cups in refrigerator: 11
Facility capacity: 92
Facility census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Logan Harrison | Executive Director | Met with during inspection and named in findings |
| Lisa Hicks | Licensing Program Manager | Named in report as licensing program manager |
| Noemi Galarza | Licensing Program Analyst | Conducted inspection and named in report |
Inspection Report
Census: 67
Capacity: 92
Deficiencies: 0
Date: Jan 10, 2025
Visit Reason
Unannounced case management visit regarding the relocation of 22 residents from Brookdale Santa Monica Gardens to Brookdale Central Whittier due to mandatory evacuation orders from a Fire Advisory.
Findings
The relocated residents were found to have designated rooms with necessary supplies and medical equipment. Staffing and medication administration were maintained by staff from the original facility. The facility had sufficient food supplies and accommodations for all residents. No deficiencies or violations were noted.
Report Facts
Number of relocated residents: 22
Facility capacity: 92
Current census: 67
Last routine fire inspection date: Jul 15, 2024
Last fire drill date: Dec 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Logan Harrison | Executive Director | Met with Licensing Program Analyst during inspection and provided information |
| Noemi Galarza | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 92
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations including failure to respond in writing to resident council concerns, lack of posting of 'Rights of Resident Councils', facility disrepair, and inadequate housekeeping services.
Complaint Details
The complaint investigation was unsubstantiated for all allegations after interviews with residents and staff, physical inspection of the facility, and review of documentation.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Resident council concerns were addressed verbally and in writing, 'Rights of Resident Councils' were posted prominently, the facility was observed to be in good repair, and housekeeping services were provided weekly as scheduled.
Report Facts
Capacity: 92
Census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation |
| Logan Harrison | Executive Director | Facility representative interviewed during investigation |
| Sanjay Kabadi | Administrator | Facility administrator listed in report header |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 92
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not ensure a resident was provided transportation as agreed to in the Admission Agreement.
Complaint Details
The complaint alleged that staff did not ensure transportation for resident R1 as agreed, causing missed medical appointments. The allegation was substantiated after investigation.
Findings
The investigation found that the facility did not have a staff bus driver for over six months, causing resident R1 to miss at least two necessary pre-surgery medical appointments in the past week and a total of six appointments in the last six months. Transportation arrangements with sister communities were inconsistent, and no contract was in place with home care agencies. The allegation was substantiated based on interviews, record reviews, and observations.
Deficiencies (1)
Failure to provide transportation to medical appointments as specified in the Residency Agreement, resulting in missed appointments and potential health and safety risks.
Report Facts
Residents present: 48
Total licensed capacity: 92
Missed medical appointments: 6
Missed pre-surgery appointments: 2
Residents requiring transportation: 5
Plan of Correction due date: Dec 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
| Logan Harrison | Interim Administrator | Interviewed during investigation and participated in exit interview |
| Denise Bartley | Wellness Director | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 92
Deficiencies: 1
Date: Oct 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not maintaining laundry equipment in good repair.
Complaint Details
The complaint was substantiated. The allegation was that the 2nd floor dryer was in disrepair, making loud noises that disturbed residents and delayed laundry. Staff and residents confirmed the issue, and observations corroborated the allegation.
Findings
The investigation confirmed that the 2nd floor Resident Laundry Room dryer and the basement washer were in disrepair for approximately 4 weeks, causing delays in residents' laundry routines and posing a potential health and safety risk. A new washer and dryer have been ordered and are expected to arrive soon.
Deficiencies (1)
Maintenance and Operation. Facilities which have machines and do their own laundry shall have adequate supplies available and equipment maintained in good repair. This requirement was not met as the 2nd floor dryer and basement washer were in disrepair.
Report Facts
Capacity: 92
Census: 43
Deficiency Type B count: 1
Plan of Correction Due Date: Oct 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Logan Harrison | Interim Administrator | Met with during investigation and named in findings regarding approval of new laundry equipment order |
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Annual Inspection
Census: 43
Capacity: 92
Deficiencies: 2
Date: Apr 19, 2024
Visit Reason
The inspection was an unannounced required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with regulatory requirements.
Findings
The inspection found deficiencies related to water temperature exceeding the allowed range in multiple resident rooms and food safety violations involving improper thawing and storage of food. Other areas such as infection control, staffing, resident records, and physical plant safety were reviewed with some pending corrections noted.
Deficiencies (2)
Water temperature in resident rooms exceeded the required 105-120 degrees Fahrenheit range, posing an immediate health and safety risk.
Food service violation observed with an open package of hot dogs thawed in the kitchen sink where dirty dishes are rinsed and uncovered plates of pie desserts in the refrigerator, posing an immediate health and safety risk.
Report Facts
Staff count: 37
Resident files reviewed: 7
Rooms inspected: 17
Fire clearance capacity: 74
Hospice waiver residents: 12
Hospice waiver residents: 8
Residents receiving hospice services: 2
Residents receiving home health services: 10
Medications reviewed: 7
Food supply duration: 2
Food supply duration: 7
Liability insurance per occurrence: 1000000
Liability insurance total aggregate: 3000000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sanjay Kabadi | Executive Director | Met during inspection and mentioned in exit interview |
| Valerie Mendez | Resident Engagement Coordinator | Present during inspection and visit purpose explained to her |
| Denise Bartley | Health and Wellness Director | Arrived shortly after inspection began |
| Lisa Hicks | Supervisor | Named in report as supervisor and in exit interview |
| Noemi Galarza | Licensing Evaluator | Conducted inspection and signed report |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 92
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff placed a resident on hospice against their wishes and that staff were not following a resident's legal documentation.
Complaint Details
The complaint alleged that staff placed a resident on hospice against their wishes and did not follow the resident's legal documentation. The investigation included interviews, record reviews, and a facility tour. It was found that the POA made the hospice care decision and the facility adhered to all legal documents. The allegations were unsubstantiated.
Findings
The investigation found that the resident was placed in hospice care by their legally appointed Power of Attorney (POA) in accordance with the resident's Advance Health Care Directive and POLST orders. The facility followed the legal documents and POA's decisions. The allegations were determined to be unsubstantiated due to lack of evidence proving violations.
Report Facts
Facility capacity: 92
Census: 50
Number of staff interviewed: 4
Number of residents enrolled in hospice: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sanjay Kabadi | Executive Director | Met with during investigation and exit interview |
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 92
Deficiencies: 4
Date: Jan 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-12-13 regarding inadequate incontinence care, grooming neglect, unclean linens, and hazardous items accessible to a resident.
Complaint Details
The complaint investigation was substantiated. Allegations included staff not meeting incontinence care needs, neglecting grooming, not providing clean linens, and failing to make hazardous items inaccessible to the resident. Evidence included interviews with residents and staff, photographs, and observations during the visit.
Findings
The investigation substantiated multiple allegations including failure to meet incontinence care needs, neglect of grooming, failure to provide clean linens, and failure to remove hazardous items from a resident's bed. Photographic evidence and interviews supported these findings, indicating risks to resident health, safety, and personal rights.
Deficiencies (4)
Failure to provide personal assistance and care as needed by the resident, including incontinence care.
Failure to provide assistance in dressing, grooming, bathing, and other personal hygiene.
Failure to accord residents safe, healthful, and comfortable accommodations, furnishings, and equipment.
Failure to protect residents against hazards by not removing hazardous items such as toothpicks and plastic knives from resident's bed.
Report Facts
Capacity: 92
Census: 50
Plan of Correction Due Date: Jan 25, 2024
Number of staff interviewed: 7
Number of residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sanjay Kabadi | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Noemi Galarza | Licensing Program Analyst | Conducted complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 92
Deficiencies: 0
Date: Dec 7, 2023
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that a resident sustained a fracture while in care.
Complaint Details
The complaint alleged that a resident was rough handled by a caregiver resulting in a fracture. After interviews with staff, administrator, and review of medical records, there was no sufficient evidence to support the allegation. The finding was unsubstantiated.
Findings
The investigation found insufficient evidence to determine if the facility caregiver caused the resident's fracture. Medical records showed no evidence of suspected abuse or neglect. Therefore, the allegation was found to be unsubstantiated.
Report Facts
Capacity: 92
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Wong | Licensing Program Analyst | Conducted the complaint investigation visit |
| David Sicairos | Licensing Program Manager | Named in report as Licensing Program Manager |
| Barbara Tyler | Administrator | Facility administrator involved in investigation |
| Sanjay Kababi | Met with during visit and received exit interview |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 92
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that the facility did not provide a refund to a resident's authorized representative.
Complaint Details
Allegation: Facility did not provide refund to representative. The complaint involved a resident who never physically moved in, and the authorized representative claimed the refund was not properly issued. After review, the refund was issued as a good faith gesture, and no financial discrepancies were found. The allegation was unsubstantiated.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, resulting in the allegation being unsubstantiated. A refund was issued as a good faith gesture, exceeding the expected amount.
Report Facts
Capacity: 92
Census: 49
Community Fee rate: 2750
Pro rated rent: 1695.75
Refund amount issued: 3303.02
Expected refund amount: 1100
Good faith refund amount: 2200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sanjay Kabadi | Executive Director | Met with during investigation and involved in refund agreement |
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 92
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
The inspection visit was conducted in response to a complaint alleging that the facility evicted a resident without assisting with alternative housing and care options.
Complaint Details
The complaint alleged that the facility evicted resident #1 without assisting with alternative housing and care options. The investigation included interviews with the Executive Director, staff, and the resident, as well as review of documents. The allegation was found unsubstantiated.
Findings
The investigation found that the facility did provide assistance to the resident in finding new housing, including help with phone calls and involvement of the resident's nurse practitioner. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 92
Census: 52
Eviction notice date: May 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation |
| Sanjay Kabadi | Executive Director | Interviewed during investigation |
| Barbara Tyler | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 46
Capacity: 92
Deficiencies: 5
Date: May 18, 2023
Visit Reason
The inspection was an unannounced required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with regulatory requirements.
Findings
The facility was inspected across multiple domains including infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, planned activities, food service, incident medical and dental, disaster preparedness, and residents with special health needs. Several deficiencies were cited related to water temperature regulation, facility maintenance, staff training, and medication administration.
Deficiencies (5)
Water temperature in rooms 229, 235, 243, 251, 252, and 257 exceeded the maximum allowed temperature of 120 degrees Fahrenheit.
Kitchen sink faucets measured below 125 degrees Fahrenheit and lacked warning signs for taps delivering water at 125 degrees or above.
Room 117 entrance wall was in disrepair.
One staff member did not have current 1st Aid/CPR training on file.
Resident medications were not administered as prescribed; missing medications were identified for residents R1 and R2.
Report Facts
Residents receiving hospice care: 2
Staff members: 33
Staff files reviewed: 7
Resident files reviewed: 10
Resident medications reviewed: 7
Residents receiving home health services: 11
Resident rooms: 73
Plan of Correction due dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Bartley | Health/Wellness Director | Met with during the inspection and exit interview. |
| Barbara Tyler | Administrator | Facility administrator; noted that a new administrator began May 15, 2023. |
| Lisa Hicks | Supervisor | Named in relation to findings and plans of correction. |
| Noemi Galarza | Licensing Evaluator | Conducted the inspection and signed the report. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 92
Deficiencies: 1
Date: May 2, 2023
Visit Reason
The visit was conducted as a complaint investigation following allegations that staff failed to meet residents' hygiene needs, failed to give resident medication timely, and staff members spoke inappropriately to residents.
Complaint Details
The complaint investigation was unannounced and conducted following a complaint received on 04/28/2020. Allegations included staff failing to meet residents' hygiene needs, failing to give medication timely, and inappropriate staff behavior. The allegation of inappropriate staff behavior was substantiated; the others were unsubstantiated.
Findings
The investigation substantiated the allegation that a staff member (S1) spoke inappropriately and was rough and aggressive towards residents, resulting in disciplinary actions and termination. The allegations regarding failure to meet hygiene needs and timely medication administration were unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
Failure to accord dignity in personal relationships with staff, residents, and others, evidenced by staff member S1 being rough, aggressive, and inappropriate towards residents.
Report Facts
Capacity: 92
Census: 54
Corrective actions: 3
Plan of Correction Due Date: May 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jewel Baptiste | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Tami Ojiwang | Administrator | Facility administrator named in the report |
| Denise Bartley | LVN | Met with Licensing Program Analyst during inspection |
| Barbara Tyler | Executive Director | Interviewed during investigation regarding staff behavior and allegations |
| S1 | Staff member substantiated for inappropriate and aggressive behavior towards residents; received three corrective actions and was terminated |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 92
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 04/22/2021 regarding resident shower assistance, lack of grab bars in showers, untimely cleaning of soiled towels, and safeguarding of resident belongings.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of shower assistance, absence of grab bars, untimely cleaning of soiled towels, and failure to safeguard resident belongings. Interviews with staff and residents, document reviews, and observations did not support the allegations.
Findings
The investigation found insufficient evidence to substantiate the allegations. Residents requiring shower assistance were accommodated per schedule, grab bars were present in showers, laundry services including soiled towels were provided weekly and handled appropriately, and resident belongings were safeguarded. The allegations were therefore unsubstantiated.
Report Facts
Facility capacity: 92
Census: 53
Number of allegations: 4
Number of staff interviewed: 5
Number of residents interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Gonzalez | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Barbara Tyler | Executive Director | Facility representative interviewed during investigation |
| Amy Rogers | Health & Wellness Director | Interviewed during investigation regarding resident care |
| Steven Sciurba | Administrator | Facility administrator listed in report header |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 92
Deficiencies: 0
Date: Jan 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident sustained a fracture while in care.
Complaint Details
The complaint alleged that a resident sustained a fracture while in care. The investigation included interviews with staff, residents, the resident's relative, and review of medical and hospital records. It was found that the resident had ongoing medical issues and it was unclear if the fracture occurred at the facility or elsewhere. No evidence of abuse or neglect was found, and the allegation was unsubstantiated.
Findings
The investigation found no sufficient evidence to substantiate the allegation of abuse or neglect related to the resident's fracture. The facility was found clean and in good repair, and no immediate health or safety concerns were noted. The allegation was determined to be unsubstantiated.
Report Facts
Facility capacity: 92
Resident census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Wong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Barbara Tyler | Administrator | Facility administrator involved in the investigation |
| David Sicairos | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 92
Deficiencies: 2
Date: Jan 13, 2023
Visit Reason
Unannounced case management visit to cite deficiencies related to a complaint investigation regarding resident pain and facility response.
Complaint Details
Complaint investigation related to resident R1's pain complaints and facility's delayed medical response. The complaint was accepted by the CCL IB investigation Unit and included interviews with resident's relative, staff, residents, administrator, physical therapist, and review of hospital and police reports. The complaint was substantiated with cited deficiencies.
Findings
The investigation found that resident R1 complained of right-side and chest pain which was not promptly addressed by the facility, resulting in a delayed hospital visit where R1 was diagnosed with a rib fracture and elevated potassium level. Deficiencies were cited for failure to observe and document changes in resident condition and for the administrator's failure to follow up on the resident's condition.
Deficiencies (2)
Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The requirement was not met as evidenced by R1 was not sent to hospital in a timely manner.
Administrator - Qualifications and Duties - The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). The requirement was not met as evidenced by Administrator did not follow up with staff about R1's condition.
Report Facts
Facility capacity: 92
Resident census: 52
Deficiency count: 2
Plan of Correction Due Date: Jan 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Tyler | Administrator | Met during visit and named in findings related to failure to follow up on resident condition |
| Christine Wong | Licensing Program Analyst | Conducted unannounced case management visit and authored report |
| David Sicairos | Supervisor | Supervisor overseeing licensing evaluation |
| IB Investigator Garcia | Conducted complaint investigation including interviews and evidence collection |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 92
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation of unlawful eviction of a resident.
Complaint Details
The allegation was that on 6/9/22 a resident was issued a 30-day eviction notice for heavy alcohol drinking in their private room. The resident had multiple incident reports related to alcohol intoxication and posed health and safety risks. Staff denied the allegation of unlawful eviction. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the resident had a long history of alcohol abuse violating the facility's residency agreement, but there was insufficient evidence to substantiate the allegation of unlawful eviction. The resident was still residing at the facility with a verbal extension to move out.
Report Facts
Incident reports in 2021: 7
Incident reports total: 20
Eviction notice days: 30
Extension move-out date: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation visit |
| Barbara Tyler | Executive Director | Met with during investigation and exit interview |
| Lisa Hicks | Licensing Program Manager | Named in report |
Inspection Report
Annual Inspection
Census: 62
Capacity: 92
Deficiencies: 2
Date: May 17, 2022
Visit Reason
An unannounced required 1-year visit focusing on COVID-19 Infection Control Practices was conducted to evaluate the facility's compliance with health and safety regulations.
Findings
The inspection found plumbing issues in rooms #211 and #201, broken vertical blinds in room #231, and medication errors involving missing and undocumented medications for residents. COVID-19 infection control practices were observed and found to be in place, including signage and staff mask usage.
Deficiencies (2)
Room #211 and #201 had plumbing issues, and room #231 had broken vertical blinds, posing potential health, safety, or personal rights risks.
Resident R1 was missing medication Acetaminophen 325 mg; Resident R2 had prescribed medications not listed on the Medication Administration Report, with no documentation of refusal and Acetaminophen 500 mg present but not listed on the MAR.
Report Facts
Resident rooms inspected: 21
Resident medication records reviewed: 7
Hospice waiver residents: 8
Plan of Correction Due Date: May 24, 2022
Plan of Correction Due Date: May 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Tyler | Administrator | Met with Licensing Program Analysts during inspection and named in findings |
| Lisa Hicks | Supervisor | Named as supervisor in deficiency and plan of correction sections |
| Noemi Galarza | Licensing Evaluator | Conducted inspection and signed report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 92
Deficiencies: 2
Date: Dec 17, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not inform the authorized representative of a resident's fall resulting in injury and that staff would not itemize the resident's bill.
Complaint Details
The complaint was substantiated. Staff failed to inform the authorized representative of a resident's fall on 10/10/21 resulting in bruising and scrapes. The authorized representative was not notified due to incorrect phone numbers. The second fall on 10/27/21 was properly reported. Staff also delayed providing an itemized bill to the authorized representative, who only received it after multiple requests and an in-person visit.
Findings
The investigation substantiated that a resident sustained two falls, one of which was not reported to the authorized representative or Community Care Licensing due to incorrect contact information. Additionally, the facility delayed providing an itemized bill to the resident's authorized representative, and the Residency Agreement did not list additional personal service fees that were charged.
Deficiencies (2)
Failure to report a resident fall resulting in injury to the authorized representative and Community Care Licensing within required timeframes.
Failure to provide an itemized bill to the resident's authorized representative within two business days as required.
Report Facts
Capacity: 92
Census: 67
Additional Personal Service Charges: 897
Deficiencies cited: 2
POC Due Date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Tyler | Executive Director | Met with during investigation and exit interview |
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 92
Deficiencies: 0
Date: Dec 17, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff failed to follow an authorized representative's directive to reject flu shot administration.
Complaint Details
The complaint alleged that staff failed to follow the authorized representative's directive to reject flu shot administration for resident (R1). The investigation found insufficient evidence to substantiate the allegation, concluding it was unsubstantiated.
Findings
Based on document review and interviews, the allegation was found to be unsubstantiated due to insufficient evidence to prove the alleged violation occurred. Resident (R1) signed the flu shot consent form thinking it was for the COVID-19 booster shot, and staff stated the resident willingly accepted the flu shot.
Report Facts
Residents interviewed: 9
Facility capacity: 92
Facility census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation visit and findings |
| Barbara Tyler | Executive Director | Facility representative met during the investigation and exit interview |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 92
Deficiencies: 1
Date: Jun 2, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2021-01-07 alleging that the facility was in disrepair.
Complaint Details
The complaint was substantiated based on observations and interviews. Residents reported plumbing and maintenance issues since late 2020, including clogged toilets and broken fixtures. Staff confirmed plumbing problems affecting laundry areas and other parts of the facility. Repairs were ongoing as of the inspection date.
Findings
The investigation substantiated the allegation that the facility was in disrepair, with multiple plumbing issues and maintenance problems reported by residents and confirmed by inspections. The facility had ongoing plumbing problems since late 2020, including clogged toilets, broken fixtures, and a temporarily closed main entrance due to major plumbing repairs.
Deficiencies (1)
87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary 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. This requirement was not met due to plumbing issues and disrepair in multiple resident rooms and common areas.
Report Facts
Capacity: 92
Census: 73
Deficiency count: 1
Plan of Correction Due Date: Jul 7, 2021
Resident interviews: 10
Staff interviews: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
| Barbara Tyler | Administrator | Facility administrator interviewed during investigation and exit interview |
| Steven Sciurba | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 92
Deficiencies: 0
Date: Jun 2, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility does not provide residents with an adequate quantity of food.
Complaint Details
The complaint alleged that the facility does not provide residents with an adequate quantity of food. After investigation including virtual and in-person tours, interviews with residents and staff, and meal observations, the allegation was determined to be unsubstantiated.
Findings
Based on observations, interviews, and meal service reviews, the facility provides approved measured servings of food according to Brookdale Menu Manager guidelines, with residents able to request second servings or alternative menu items. The allegation was found to be unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 92
Census: 73
Residents interviewed: 10
Staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Barbara Tyler | Administrator | Facility Administrator met during the investigation and exit interview |
Inspection Report
Annual Inspection
Census: 68
Capacity: 92
Deficiencies: 2
Date: May 26, 2021
Visit Reason
An unannounced required 1-year visit focusing on COVID-19 Infection Control Practices was conducted to evaluate compliance with health and safety regulations.
Findings
The inspection found that five out of fourteen resident rooms lacked hand sanitizer, and five out of eight reviewed resident medication records showed missing medications. COVID-19 infection control practices were generally observed, including mask use by staff and social distancing during dining.
Deficiencies (2)
Five resident rooms did not have hand sanitizer, posing a potential health, safety, or personal rights risk.
Five residents were missing prescribed medications during medication review.
Report Facts
Rooms inspected: 14
Rooms missing hand sanitizer: 5
Medication records reviewed: 8
Residents missing medications: 5
Facility capacity: 92
Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Tyler | Administrator | Met with Licensing Program Analyst during inspection |
| Noemi Galarza | Licensing Program Analyst | Conducted the inspection |
| Lisa Hicks | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 92
Deficiencies: 0
Date: Apr 11, 2021
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff left residents in soiled clothing for extended periods, residents' rooms smelled like urine, and residents were denied incontinence products.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff leaving residents in soiled clothing, rooms smelling like urine, and denial of incontinence products. Interviews and records review did not support these claims.
Findings
The investigation found no substantiation for the allegations. Residents and staff interviews indicated residents were changed frequently, rooms did not have urine odors, and no residents were denied incontinence products. No deficiencies were cited.
Report Facts
Capacity: 92
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda M Almaraz | Licensing Program Analyst | Conducted the complaint investigation |
| Christine Yee | Licensing Program Manager | Oversaw the complaint investigation |
| Steven Sciurba | Administrator | Facility administrator mentioned in report |
| Barbara Tyler | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 92
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
This complaint investigation was conducted in response to a complaint received on 03/18/2020 alleging staff intimidation, threats of eviction, mishandling of resident belongings and medication, improper feeding, and other concerns at Brookdale Central Whittier facility.
Complaint Details
The complaint investigation was unsubstantiated due to lack of sufficient evidence to prove the alleged violations occurred. Allegations included staff intimidation, threats of eviction, mishandling of personal belongings and medication, and improper feeding.
Findings
The investigation included interviews with residents, staff, and the administrator, and review of records. All allegations were denied by staff and residents, with no sufficient evidence found to substantiate the claims. The complaint was determined to be unsubstantiated.
Report Facts
Capacity: 92
Census: 72
Staff interviewed: 10
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Wong | Licensing Program Analyst | Conducted the complaint investigation |
| Steven Sciurba | Administrator interviewed during investigation | |
| Tami Ojiwang | Administrator | Facility administrator named in report |
| Christine Yee | Licensing Program Manager | Named as Licensing Program Manager on report |
Report
March 17, 2026
Report
March 17, 2026
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