Inspection Report Summary
Most inspections found deficiencies related primarily to resident care, medication management, and facility safety, with several substantiated complaints involving inadequate supervision, improper medication administration, and failure to maintain confidential records. The facility received civil penalties for repeated issues, including an immediate safety risk when a resident eloped and was not properly reported, and for incomplete personnel records and unlocked disinfectants. Some complaints about harassment, food service, and staff conduct were unsubstantiated. The most recent report from September 18, 2025, was a complaint investigation with no deficiencies found, indicating some improvement. While issues have persisted over time, recent findings suggest the facility is addressing prior concerns.
Deficiencies (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a September 2025 inspection.
Census over time
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Maureen Lee | Memory Care Director | Met with during the investigation and involved in interview |
| Justin Zackzewski | Director of Hospitality | Received copy of the report during exit interview |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Annemarie Domizio | Executive Director | Named in relation to findings and plans of correction |
| Maureen Lee | Memory Care Director | Met with Licensing Program Analysts during inspection |
| Lisha Holmes | Licensing Program Analyst | Conducted inspection and signed report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Justin Zackzewski | Director of Hospitality | Met during the investigation and received the exit interview and report |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Justin Zackzewski | Director of Hospitality | Met with during inspection and received exit interview |
| Annemarie Domizio | Executive Director | Facility administrator mentioned in relation to findings |
| Lisha Holmes | Licensing Program Analyst | Conducted complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Justin Zackzewski | Director of Hospitality | Met with Licensing Program Analyst during inspection |
| Lisha Holmes | Licensing Program Analyst | Conducted the proof of correction inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Justin Zackzewski | Director of Hospitality | Met with Licensing Program Analyst to discuss complaint and facility operations. |
| Annmarie E Domizio | Administrator/Director | Named as facility administrator/director. |
| Tsedey Mekonnen | Concierge | Received copy of the report during exit interview. |
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection and case management visit. |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager overseeing the visit. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection and authored the report |
| Annemarie Domizio | Executive Director | Facility administrator met during inspection |
| Justin Zackzewski | Director of Hospitality | Facility staff met during inspection and involved in complaint discussion |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Annemarie Domizio | Executive Director | Met with Licensing Program Analyst and named in findings |
| Justin Zackzewski | Director of Hospitality | Met with Licensing Program Analyst during investigation |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Justin Zackzewski | Director of Hospitality | Met with Licensing Program Analyst during investigation |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Justin Zackzewski | Director of Hospitality | Met with during the investigation |
| Annemarie Domizio | Executive Director | Onboarding Executive Director met during the investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Conducted and signed the complaint investigation report |
| Lisha Holmes | Licensing Program Analyst | Conducted and signed the complaint investigation report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Justin Zackzewski | Director of Hospitality | Met during investigation and received exit interview |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Claudia Redditt | Director of Business Administration | Met during inspection and involved in review of documentation |
| Annemarie Domizio | Executive Director | Mentioned in relation to time constraints and complaint follow-up |
| Lisha Holmes | Licensing Program Analyst | Conducted inspection and signed report |
| Yvonne Flores-Larios | Licensing Program Manager | Supervisor of inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Douglas Blake | Interim Executive Director | Met with investigators during the inspection and involved in investigation findings. |
| Annemarie Domizio | Executive Director | Met with investigators during the inspection and involved in investigation findings. |
| Robert Coe | Administrator | Named as facility administrator in the report. |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation. |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Claudia Redditt | Director of Business Administration | Met with during investigation and received exit interview |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report as Licensing Program Manager |
| Robert Coe | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Claudia Redditt | Director of Business Administration | Met with during the investigation and exit interview |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Robert Coe | Administrator | Facility administrator named in the report |
| Douglas Blake | Interim Executive Director | Met with Licensing Program Analyst during investigation |
| Annemarie Domizio | Executive Director | Suggested meeting with Director of Business Administration due to time constraints |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the case management visit and inspection |
| Mary Anne Watral | Interim-Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Robert Coe | Administrator | Named as facility administrator |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation |
| Douglas Blake | Interim Executive Director | Met with Licensing Program Analyst during investigation |
| Mary Anne Watral | Operations Specialist | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Douglas Blake | Executive Director | Met with Licensing Program Analyst during inspection and discussed Resident #1's case |
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection and investigation |
| Yvonne Flores-Larios | Licensing Program Manager / Supervisor | Named as supervisor and licensing program manager overseeing the inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Douglas Blake | Interim-Executive Director | Met with Licensing Program Analyst during investigation and provided information related to complaint |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Douglas Blake | Interim-Executive Director | Met with Licensing Program Analyst during inspection |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Douglas Blake | Interim-Executive Director | Facility representative met during the investigation |
| Robert Coe | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Douglas Blake | Interim-Executive Director | Met with Licensing Program Analyst during investigation |
| Robert Coe | Administrator | Facility administrator named in report header |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Douglas Blake | Executive Director | Met during inspection and involved in reporting the AWOL incident. |
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection and interviews. |
| Yvonne Flores-Larios | Licensing Program Manager | Supervised the inspection and signed the report. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Douglas Blake | Executive Director | Met with Licensing Program Analyst during investigation |
| Keoni Myles | Director of Health and Wellness | Met with Licensing Program Analyst during investigation |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Douglas Blake | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Robert Coe | Administrator | Named as the facility administrator |
| Douglas Blake | Executive Director | Met during the investigation and interview |
| Mary Anne Watral | Operations Specialist | Met during the investigation and interview |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Robert Coe | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Robert Coe | Administrator/Executive Director | Named in deficiency for lacking criminal record clearance |
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection and authored the report |
| Mary Anne Watral | Operations Specialist | Met with Licensing Program Analyst during inspection |
| Douglas Blake | Executive Director | Met with Licensing Program Analyst during inspection; noted as not having criminal record clearance on file |
| Yvonne Flores-Larios | Licensing Program Manager | Supervisor of the licensing evaluation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Robert Coe | Executive Director | Met with Licensing Program Analyst during investigation and named in findings related to failure to provide resident records |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Robert Coe | Executive Director | Met with Licensing Program Analyst during inspection and involved in reporting the elopement incident |
| Lisha Holmes | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Robert Coe | Executive Director | Met during the investigation and named in findings |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| LaTiana James | Director of Health and Wellness | Met with during inspection and discussed findings |
| Andrew Badoud | Administrator | Facility administrator named in report header |
| Alicia Delmundo | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Bennett Fong | Licensing Program Manager | Oversaw investigation and signed report |
| Jeremy Fong | Licensing Program Manager | Conducted subsequent investigation |
| Robert Coe | Executive Director | Voicemail left during inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Robert Coe | Executive Director | Met with during investigation and named in findings |
| Tea James | Director of Health and Wellness | Interviewed during investigation and named in findings |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Robert Coe | Executive Director | Met with during inspection and named in findings |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mary Anne Watral | Interim Executive Director | Met with Licensing Program Analyst during investigation |
| Andrew Badoud | Administrator | Facility Administrator notified of findings during investigation |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Mary Anne Watral | Interim-Executive Director | Met with Licensing Program Analyst during inspection; named in deficiency for lack of criminal record clearance |
| Sergio Lepez | Director of Maintenance | Accompanied Licensing Program Analyst during facility tour |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Andrew Badoud | Executive Director | Met with Licensing Program Analyst during the inspection and received the exit interview. |
| Claudia Lopes | Director of Business Administration | Met with Licensing Program Analyst during the inspection. |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Andrew Badoud | Administrator | Met with Licensing Program Analyst during the visit |
| Catherine Lin | Licensing Program Analyst | Conducted the unannounced case management visit |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| Andrew Badoud | Executive Director | Met with Licensing Program Analysts during inspection and named in report |
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| Andrew Badoud | Executive Director | Met with Licensing Program Analysts during the pre-licensing inspection and received the report. |
| Nicole Dockson | Vice President | Participated in the Component III presentation during the pre-licensing inspection. |
| Angelica Gonzalez-Gillam | Director of Health and Wellness | Participated in the Component III presentation during the pre-licensing inspection. |
Inspection Report
Original LicensingReport
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