Inspection Report Summary
Most inspections found no deficiencies, with the facility generally clean, well-maintained, and compliant with regulations. However, several complaint investigations were substantiated, including serious issues such as staff neglect causing resident injuries like fractures and a broken femur, failure to seek timely medical treatment, and not notifying responsible parties. The facility also failed to submit required incident reports and did not consistently provide transportation and laundry services as agreed. The most recent report from August 26, 2025, was clean with no deficiencies, showing improvement since earlier substantiated complaints and penalties, including immediate civil fines of $500 assessed in 2025. Other complaint investigations were unsubstantiated or involved minor environmental and care concerns that the facility addressed.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
75% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 71
Capacity: 95
Deficiencies: 0
Date: Aug 26, 2025
Visit Reason
The visit was an unannounced case management visit to check on the health, safety, and welfare of residents in care following a report received by the Department regarding Resident #1 and Staff #1.
Findings
No health and safety concerns were observed during the visit. Staff #1 was confirmed removed from the facility staff schedule as of 08-15-2025. No deficiencies or civil penalties were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Eddy | Administrator | Met with Licensing Program Analyst during the visit and discussed the report. |
| Seo Jeon | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 95
Deficiencies: 3
Date: Jun 30, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-02-22 regarding staff neglect, failure to seek medical treatment, and failure to notify the Power of Attorney (POA) of a resident fall.
Complaint Details
The complaint investigation was substantiated. Allegations included staff neglect causing a broken femur, failure to seek medical treatment, and failure to notify the POA of the resident fall. The resident sustained an unwitnessed fall on 2023-01-28, was not medically evaluated until 2023-02-02, and the POA denied being notified by the facility. An immediate civil penalty of $500 was assessed, with additional penalties pending review.
Findings
The investigation substantiated that staff neglect resulted in Resident 1 sustaining a broken femur due to improper bed rail positioning. Staff failed to seek timely medical treatment for the resident, with medical evaluation occurring five days after the fall. Additionally, the licensee did not notify the resident's POA of the fall incident, despite claims to the contrary.
Deficiencies (3)
Facility staff did not ensure bed rails were in the upright position which caused an immediate health safety and personal rights risk to persons in care.
The Licensee did not seek timely medical attention for Resident 1, posing an immediate health safety and personal risk.
The licensee did not notify Resident 1's responsible party of the incident, posing a potential health, safety and personal rights risk.
Report Facts
Capacity: 95
Census: 72
Civil penalty: 500
Days delay: 5
Plan of Correction Due Date: Jul 1, 2025
Plan of Correction Due Date: Jul 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Tammy Eddy | Executive Director | Facility representative met during investigation and exit interview |
| Melissa Polendo | Residential Services Director | Interviewed regarding notification of POA and PCP |
| Staff #1 | Medication Technician/Staff involved in notification failure and subsequent write-up |
Inspection Report
Annual Inspection
Census: 68
Capacity: 95
Deficiencies: 0
Date: May 30, 2025
Visit Reason
An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and in compliance with infection control, physical plant, food service, care and supervision, record keeping, medication management, and disaster preparedness requirements. No deficiencies were cited during the visit.
Report Facts
Staff members present: 15
Resident files reviewed: 6
Staff files reviewed: 5
Resident medications reviewed: 8
Fire extinguishers: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Eddy | Executive Director | Met with Licensing Program Analyst during inspection |
| Seo Jeon | Licensing Program Analyst | Conducted the inspection |
| Rikesha Stamps | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 95
Deficiencies: 0
Date: May 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of staff neglect resulting in a resident sustaining multiple pressure injuries.
Complaint Details
The complaint alleged that staff neglect caused a resident to sustain multiple pressure injuries. The resident had multiple wounds and skin tears documented by home health, hospice, and wound care specialists. Despite extensive wound care and services, the resident passed away on 2025-01-31. The investigation found no preponderance of evidence to substantiate the allegation.
Findings
The investigation, which included observations, interviews, and records review, found the allegation of staff neglect resulting in multiple pressure injuries to be unsubstantiated due to insufficient evidence to prove the alleged violation occurred.
Report Facts
Facility capacity: 95
Census: 71
Number of wounds: 7
Home health visit frequency: 7
Wound care agency visit frequency: 6
Hospice service period: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javina George | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Patricia Russell | Resident Services Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Tammy Eddy | Executive Director | Interviewed regarding wound care training and facility procedures |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 95
Deficiencies: 0
Date: Apr 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff neglect resulted in a resident sustaining an unexplained injury while in care.
Complaint Details
The complaint alleged staff neglect causing a resident's unexplained injury. The allegation was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation, which included observations, interviews, and records review, found the allegation to be unfounded. The resident's injury was determined to be due to mechanical function failure related to prior orthopedic hardware, not a fall or staff neglect.
Report Facts
Facility capacity: 95
Resident census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Polendo | Corporate Director of Dementia Services | Interviewed denying resident sustained any falls |
| Tammy Eddy | Executive Director | Met with Licensing Program Analyst during the visit and received report |
| Javina George | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tricia Danielson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 95
Deficiencies: 1
Date: Feb 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that a resident sustained an arm fracture due to neglect/lack of care and supervision, staff did not ensure toileting assistance was provided, and staff did not ensure medications were dispensed as prescribed.
Complaint Details
The complaint was substantiated. The resident sustained an arm fracture due to neglect/lack of care and supervision. Staff left the resident unattended on the toilet, resulting in a fall and fracture. Medication was discontinued without a formal physician's order, and staff failed to seek timely medical treatment for stroke symptoms, resulting in delayed care and serious injury.
Findings
The investigation substantiated that the resident sustained an arm fracture due to staff neglect and lack of supervision, including leaving the resident unattended on the toilet leading to a fall. The allegation that staff did not ensure toileting assistance was unsubstantiated. The allegation that medications were not properly dispensed was substantiated due to medication discontinuation without formal physician order and failure to seek timely medical treatment for stroke symptoms. An immediate civil penalty of $500 was assessed, with potential additional penalties pending review.
Deficiencies (1)
Staff neglect caused serious injuries to resident while in care, posing an immediate health and safety risk.
Report Facts
Resident falls: 14
Civil penalty amount: 500
Medication discontinuation period: 5
Plan of Correction due date: Mar 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jazmond D Harris | Licensing Program Manager | Oversaw the complaint investigation |
| Tammy Eddy | Executive Director | Met with Licensing Program Analyst during investigation |
| Melissa Polendo | Administrator | Provided information regarding medication and staff training |
| Patricia Russell | Resident Service Director | Could not find physician's order for medication discontinuation |
| Staff 1 | Left resident unattended on toilet leading to fall and injury | |
| Staff 2 | Recognized stroke symptoms correctly | |
| Staff 3 | Incorrectly treated resident for seizure and delayed notification of POA |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 95
Deficiencies: 1
Date: Feb 28, 2025
Visit Reason
The inspection was conducted as a case management visit regarding the health, safety, and welfare of residents, triggered by a complaint investigation for complaint control number #18-AS-20240515085438.
Complaint Details
The visit was complaint-related under complaint control number #18-AS-20240515085438. The deficiency was substantiated as the facility failed to submit required serious incident reports.
Findings
The facility failed to submit a serious incident report to the department regarding a resident's fall on 08/13/22, violating Title 22 Regulations Reporting Requirements. The facility showed no proof of attempts to notify the department of the incident. No immediate concerns for residents were observed during the visit.
Deficiencies (1)
Failure to submit a written serious incident report within 7 days regarding R1's elopement from the facility, posing a potential threat to the health, safety, and personal rights of the resident.
Report Facts
Deficiencies cited: 1
Capacity: 95
Census: 74
Plan of Correction Due Date: Mar 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Eddy | Executive Director | Named in relation to the deficiency regarding failure to submit serious incident reports |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Jazmond D Harris | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 95
Deficiencies: 3
Date: Feb 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-12-24 regarding multiple allegations about staff not abiding by admission agreements, inadequate transportation, untimely vehicle repairs, and unmet resident laundry needs.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not abide by the admission agreement, failed to provide adequate transportation for residents' scheduled appointments, did not timely repair the facility vehicle, and did not ensure resident laundry needs were met. Other allegations about incident reporting, care and supervision, and staffing sufficiency were unsubstantiated.
Findings
The investigation substantiated allegations that staff failed to provide transportation and laundry services as required by the admission agreement, including the facility bus being out of service for two months and laundry services being skipped during staff vacation. Other allegations regarding incident reporting, care and supervision, and staffing levels were unsubstantiated.
Deficiencies (3)
Licensee did not comply with Section 87208 Plan of Operation (a) regarding operating the facility according to the plan of operation.
Licensee did not comply with Section 87465(a)(2) regarding providing assistance in meeting necessary medical and dental needs including transportation.
Licensee did not comply with Section 87307(a)(3)(F) regarding providing basic laundry service and ensuring coverage when assigned attendant is absent.
Report Facts
Capacity: 95
Census: 70
Deficiencies cited: 3
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Seo Jeon | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rikesha Stamps | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Tammy Eddy | Executive Director | Met with Licensing Program Analyst during the investigation and provided information regarding facility operations |
| Melissa Polendo | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 72
Capacity: 95
Deficiencies: 0
Date: May 16, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted by the Licensing Program Analyst to assess compliance with state regulations.
Findings
The facility was found to be clean, well-maintained, and in compliance with all applicable regulations. No deficiencies were observed during the inspection.
Report Facts
Staff present: 20
Client records reviewed: 10
Employee records reviewed: 10
Food supply duration: 1
Food supply duration: 2
Facility temperature: 75
Water temperature: 107
Fire extinguishers: 28
Last emergency drill date: Jan 18, 2024
Last fire inspection date: Aug 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Eddy | Executive Director | Met with Licensing Program Analyst during inspection and participated in facility tour |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the annual inspection |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on report |
| Melissa Polendo | Administrator/Director | Facility Administrator/Director listed on report |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 95
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 09/08/2023 alleging that staff did not ensure a safe and healthful environment by failing to assist a resident with incontinence needs.
Complaint Details
The complaint was substantiated. Staff failed to assist Resident #1 with incontinence needs, leaving the resident unattended for over 20 hours, resulting in soaked bedding and odors. The facility implemented a revised care plan with increased monitoring.
Findings
The investigation found that Resident #1 was not attended to for over 20 hours on September 8th, 2023, resulting in soaked bedding and chucks. The allegation was substantiated, posing health and safety risks to residents. The facility revised the care plan to increase checks on the resident to every hour.
Deficiencies (1)
Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors.
Report Facts
Capacity: 95
Census: 63
Deficiency Type: 1
POC Due Date: Jan 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tammy Eddy | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Patrica Russell | Resident Care Manager | Addressed concerns and revised Resident #1's care plan |
| Jazmond D Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 65
Capacity: 95
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
The visit was conducted as a follow-up for an Immediate Exclusion letter concerning a former employee named Adriana Silva.
Findings
No health and safety concerns were identified during the unannounced case management visit, and no deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Russell | Resident Service Director | Met with Licensing Program Analyst during the visit and discussed the report. |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Jazmond D Harris | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 95
Deficiencies: 2
Date: Jun 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including the facility not ensuring the shower/tub was kept in a state of repair and the resident's shower seat was not fixed properly, as well as a complaint about food quality.
Complaint Details
The complaint investigation was substantiated for the allegations that the shower/tub was not kept in a state of repair and the shower seat was loose and not fixed properly. The food quality complaint was unsubstantiated.
Findings
The investigation substantiated the allegations regarding the shower/tub disrepair and loose shower seat, posing a potential personal rights risk to residents. The food quality complaint was unsubstantiated as most residents reported the food was of the right temperature and alternatives were available.
Deficiencies (2)
Personal Rights of Residents in All Facilities: Residents were not accorded safe, healthful and comfortable accommodations as evidenced by the loose shower seat posing a personal rights risk.
Maintenance and operation: The facility was not clean, safe, sanitary and in good repair at all times as evidenced by the disrepair of the shower/tub area.
Report Facts
Capacity: 95
Census: 66
Deficiencies cited: 2
Plan of Correction Due Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Polendo | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joel Esquivel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 95
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility did not issue a refund to a resident and did not safeguard the resident's personal belongings.
Complaint Details
The complaint involved two allegations: 1) the facility did not issue a refund to a resident, and 2) the facility did not safeguard the resident's personal belongings. Both allegations were found to be unsubstantiated after investigation.
Findings
The investigation found that the facility issued the 80% refund within the required 30 days as per the Admission Agreement, and the allegation was unsubstantiated. Regarding the safeguarding of personal belongings, the resident's glasses were moved but not lost, and no belongings were claimed damaged, lost, or stolen; this allegation was also unsubstantiated.
Report Facts
Refund percentage: 80
Refund issuance timeframe: 30
Facility capacity: 95
Resident census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation |
| Melissa Polendo | Executive Director | Facility representative met during investigation and named in findings |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 72
Capacity: 95
Deficiencies: 0
Date: May 16, 2022
Visit Reason
The inspection was an unannounced annual inspection limited to infection control conducted by Licensing Program Analyst Crystal Colvin.
Findings
The facility demonstrated compliance with COVID-19 infection control best practices, including adequate PPE supplies, staff training, symptom monitoring, and visitor screening. One public bathroom was found to be out of paper towels, but this resulted only in a Technical Assistance Advisory Note rather than a deficiency.
Report Facts
PPE supply duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Stansbury | Administrator | Met with Licensing Program Analyst during inspection and confirmed infection control practices |
| Crystal Colvin | Licensing Program Analyst | Conducted the annual infection control inspection |
| Joel Esquivel | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 63
Capacity: 95
Deficiencies: 0
Date: May 21, 2021
Visit Reason
Licensing Program Analysts conducted an unannounced annual inspection with an emphasis on infection control at the facility.
Findings
The inspection found proper infection control measures including signage, hand hygiene supplies, cleaning provisions, and PPE use. No deficiencies were cited during the visit.
Report Facts
Staff present: 18
Residents present: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Polendo | Memory Care Director | Met with Licensing Program Analysts during the inspection and explained the purpose of the visit |
Report
February 17, 2026
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