Inspection Report Summary
Most inspections found multiple deficiencies related to staff training, medication management, resident rights, and recordkeeping, with some posing immediate health and safety risks. The most serious issues involved false claims by staff obtaining personal information under false pretenses and breaches of confidentiality, both substantiated in a complaint investigation on August 14, 2025. The facility was also cited repeatedly for admitting a bedridden client without proper licensing and failing to maintain required medical and personnel documentation. The most recent report from August 27, 2025, still showed several uncorrected deficiencies, indicating ongoing challenges despite some partial corrections in earlier follow-ups. Several complaint investigations were unsubstantiated, but the pattern of regulatory issues suggests the facility has not yet fully resolved key compliance problems.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
375% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
67% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 4
Capacity: 6
Deficiencies: 14
Date: Aug 27, 2025
Visit Reason
To follow up on deficiencies cited on 7/31/25, 8/5/25 and 8/14/25, the Licensing Program Analyst met with the administrator and licensee to review documents submitted as corrections.
Findings
Several deficiencies remain uncorrected, including immediate risk issues related to personal rights and false claims, as well as multiple potential risk deficiencies involving pre-admission appraisals, staff training, health screenings, medication management, and storage of client records.
Deficiencies (14)
Residents in all RCFEs shall have the personal right to be accorded safe, healthful & comfortable accommodations; client in room #5 observed with recliner chair & wheelchair next to bed preventing getting out of bed.
Facility staff obtained personal and confidential information by falsely stating it was required by state licensing; licensee failed to prevent false claims by staff.
No signed pre-admission appraisal on file for client #5 admitted 3 years ago.
No documentation that staff received training on emergency response.
Annual reappraisals for all clients missing or dated more than 12 months ago.
Facility failed to maintain current written records of care for client #4 with gall bladder stoma.
Training records not available for medication administration training.
Training records not available for dementia care training for direct care staff.
Training records not available for training on postural supports, restricted conditions, health services, and hospice care.
Six out of six staff files missing health screenings and TB test results.
Staff write on prescription labels, violating labeling requirements.
Rx medications for former client observed in kitchen cabinet, not properly disposed of or documented.
Facility records stored in client room #4, violating client's right to private use of room.
MD orders not maintained for OTC medications C3 OTC Senna and C6 Senna Plus.
Report Facts
Capacity: 6
Census: 4
Deficiencies cited: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Lu Johnson | Administrator/Director | Met with Licensing Program Analyst during inspection |
| Audrey Jeung | Licensing Program Analyst | Conducted inspection and signed report |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 2
Date: Aug 14, 2025
Visit Reason
This case management visit was initiated in response to information obtained during a phone call with a resident's responsible party, as deficiencies of the California Code of Regulations, Title 22, occurred.
Complaint Details
The visit was complaint-related, initiated due to information from a resident's responsible party. The report documents substantiated Type A deficiencies posing immediate risks.
Findings
The facility was found to have committed Type A deficiencies including making false claims by staff obtaining personal and confidential information through false statements, and failure to safeguard resident records confidentiality by sharing unsolicited personal information via text to another client's responsible party, posing immediate health, safety, or personal rights risks to clients in care.
Deficiencies (2)
False claims: Facility staff obtained personal and confidential information by falsely stating that the information was required by state licensing, posing an immediate health, safety, or personal rights risk to clients in care.
Resident records: Staff shared unsolicited personal and confidential client information via text to another client's responsible party, failing to ensure confidentiality and posing an immediate health, safety, or personal rights risk to clients in care.
Report Facts
Capacity: 6
Census: 5
Plan of Correction Due Date: Aug 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Program Analyst | Initiated the case management visit and signed the report |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Follow-Up
Census: 5
Capacity: 6
Deficiencies: 14
Date: Aug 14, 2025
Visit Reason
To follow up on deficiencies cited on 7/31/25 and 8/5/25, including review of corrections submitted to the licensing office on 8/13/25.
Findings
Some deficiencies cited previously were corrected and acknowledged, including updates to medical reports, postural supports, resident records, personnel requirements, and incidental medical care. However, several deficiencies cited on 7/31/25 and 8/5/25 still exist as plans of correction were not submitted to the licensing agency.
Deficiencies (14)
Section 87204 Limitations - Capacity & Ambulatory Status: Updated MD report for Client #1 states client is Non-ambulatory
Section 87608 Postural Supports: MD orders for half bed rails for clients #1, #3, #5, #6 were sent to CCLD
Section 87506 Resident Records: Emergency information for clients #1, #2, #4 were sent to CCLD
Section 87411 Personnel Requirements: Proof of current first-aid training for staff #2, #3, #4, #5, #6 sent to CCLD
Section 87465 Incidental Medical Care: First-aid manual is observed at facility
CCR 87457(c) Pre-Admission Appraisal: Appraisal for client #5 not completed, signed, and dated by client or representative and facility representative
Health and Safety Code 1569.695(b) and 1569.695(c) deficiencies still exist
87463(a) Reappraisals: Appraisals for all clients not completed, signed, and dated by client or representative and facility representative
CCR 87611(b)(1-3) General Requirements for Allowable Health Conditions deficiencies still exist
CCR 87412(a)(1-13) Personnel Records deficiencies still exist
CCR 87468.1(a)(1) Personal Rights: Affirmation that clients have the right to NOT be confined in bed was not submitted
Health and Safety Code 1569.69(a), 1569.626(a), 1569.696(a) deficiencies still exist
CCR 87411(f): Health screenings were not submitted for 6 staff
CCR 87618(b)(1)(B), CCR 87465(h)(1)(4), CCR 87468.1(a)(13), CCR 87465(i)(1-4), CCR 87465(e)(1-4) deficiencies still exist
Report Facts
Civil penalty amount: 700
Civil penalty daily amount: 100
Census: 5
Total capacity: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Johnson | Administrator | Advised about failure to correct cited deficiencies and civil penalty assessment |
| Audrey Jeung | Licensing Program Analyst | Reviewed corrections submitted and signed report |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Follow-Up
Census: 6
Capacity: 6
Deficiencies: 2
Date: Aug 5, 2025
Visit Reason
To follow up on deficiencies cited during the annual inspection on 2025-07-31, to verify corrections were made by 2025-08-04.
Findings
One deficiency related to Administrator Qualifications & Duties was corrected, confirming the administrator holds a current RCFE certificate. However, a deficiency regarding the facility serving a bedridden client, which it is not licensed to serve, still exists and a civil penalty is being assessed.
Deficiencies (2)
Section 87405 Administrator Qualifications & Duties - corrected
Section 87204 Limitations - Capacity & Ambulatory Status - facility serving bedridden client not licensed to do so
Report Facts
Civil penalty amount: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Johnson | Administrator/Director | Named in relation to Administrator Qualifications deficiency and facility representation during inspection |
| Audrey Jeung | Licensing Program Analyst | Reviewed deficiencies during follow-up inspection |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 10
Date: Aug 5, 2025
Visit Reason
To complete the annual inspection of 7/31/25, including review of centrally stored medication records and staff training records, although training records were not available for review.
Findings
Multiple and repeated deficiencies were cited related to staff training documentation, health screenings, medication administration, personal rights, and storage of medications and records. These deficiencies pose potential or immediate health, safety, or personal rights risks to clients in care.
Deficiencies (10)
Licensee failed to maintain documentation that staff have received medication training, which poses a potential health, safety or personal rights risk.
Licensee failed to maintain documentation that staff have received dementia training, which poses a potential health, safety or personal rights risk.
Licensee failed to maintain documentation that staff have received training on postural supports, restricted health conditions, and hospice care, posing a potential health, safety or personal rights risk.
Licensee failed to ensure health screenings and TB test results were maintained for all staff, posing a potential health, safety or personal rights risk.
No 'No Smoking-Oxygen in Use' signs were posted, posing a potential health, safety or personal rights risk.
Staff wrote on prescription labels, which is not permitted and poses a potential health, safety or personal rights risk.
Client in room #5 was observed with recliner chair and wheelchair placed next to bed, preventing safe egress, posing an immediate health, safety or personal rights risk.
Facility records were stored in client room #4, which is not for staff use, posing a potential health, safety or personal rights risk.
Rx medications for a former client were observed in the kitchen cabinet, posing a potential health, safety or personal rights risk.
MD orders were not maintained for OTC medications (C3 OTC Senna and C6 Senna Plus), posing a potential health, safety or personal rights risk.
Report Facts
Census: 6
Total Capacity: 6
Deficiencies cited: 10
Plan of Correction Due Date: Aug 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Lu Johnson | Administrator/Director | Facility administrator named in report |
| Audrey Jeung | Licensing Program Analyst | Conducted inspection and signed report |
| April Cowan | Licensing Program Manager | Oversaw licensing program for inspection |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 13
Date: Jul 31, 2025
Visit Reason
The inspection was a required unannounced 1-year annual evaluation visit to assess compliance with licensing requirements for the George Anne Home facility.
Findings
Multiple Type B deficiencies were cited related to licensing compliance including operation beyond licensed capacity limits, missing pre-admission appraisals, lack of staff training documentation, incomplete emergency drill records, missing physician orders for postural supports, outdated or missing medical reappraisals, incomplete resident emergency contact information, inadequate resident medical records, lack of certified administrator, incomplete personnel records, insufficient first aid training for staff, and absence of a first aid manual in the facility.
Deficiencies (13)
Facility operated beyond licensed capacity by admitting a bedridden client without proper license.
No signed pre-admission appraisal on file for client admitted 3 years ago.
No documentation that staff received training on responding to emergencies.
Documentation of emergency drills does not clearly indicate what was done.
No MD orders maintained for 4 out of 6 clients who have half bed rails.
MD assessments for 3 out of 6 clients were done over 3 years ago or not maintained.
Annual reappraisals for all clients are missing or dated more than 12 months ago.
No emergency contact information maintained for 3 out of 6 clients.
Incomplete resident medical records, including lack of documentation for gall bladder stoma care.
No proof of certified RCFE administrator available.
Personnel records for all staff missing job applications, health screenings, and criminal record statements.
Five out of six staff lack proof of current first aid training.
No first-aid manual available in the facility.
Report Facts
Census: 6
Total Capacity: 6
Deficiencies cited: 13
Plan of Correction Due Dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Lu Johnson | Administrator/Director | Facility administrator without valid RCFE administrator certification |
| Audrey Jeung | Licensing Program Analyst | Conducted facility tour and inspection |
| April Cowan | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 15
Date: Sep 3, 2024
Visit Reason
The inspection was a required unannounced 1-year annual inspection to evaluate compliance with California Code of Regulations and facility licensing requirements.
Findings
Multiple deficiencies were cited related to maintenance, medication storage, personnel health screenings, staff training, client records, emergency preparedness, and facility safety. Plans of correction were requested with due dates for all deficiencies.
Deficiencies (15)
Hot water temperature tested at 128 degrees in rear common bathroom, exceeding allowed maximum.
Cleaning liquids stored where accessible to clients in bathroom #1, common bathroom, kitchen cabinet, and backyard gazebo.
Clients' medications stored in unlocked cabinets in hallway and kitchen, accessible to residents.
No health screening and TB test results for 3 out of 6 staff files reviewed.
No documentation that staff received 4 hours of training on postural supports, restricted health conditions, and hospice care.
No documentation that staff who handle or manage medications have received required medication training.
Personal rights forms incomplete or missing for 2 out of 6 client files reviewed.
No appraisal on file for client #5 admitted over 2 years ago.
Staff have not received training on responding to emergencies.
No documentation of emergency drills conducted quarterly for each shift.
All clients have half bed rails on beds but no physician orders on file.
No evidence that staff have received required dementia training.
MD reports and appraisals for clients #1, #3, #4, #6 diagnosed with dementia are dated more than 12 months ago.
A chair used to weigh clients is stored in client room #4 due to lack of common storage area.
Discarded walkers, mattresses, furniture, and 13 oxygen tanks observed in backyard posing safety risk.
Report Facts
Facility capacity: 6
Census: 6
Oxygen tanks: 13
Staff files reviewed: 6
Staff files non-compliant: 3
Client files reviewed: 6
Client files with incomplete personal rights forms: 2
Client files missing appraisal: 1
Clients with dementia: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Lu Johnson | Administrator/Director | Certified RCFE administrator overseeing facility operations |
| Audrey Jeung | Licensing Program Analyst/Evaluator | Conducted inspection and authored report |
| April Cowan | Licensing Program Manager/Supervisor | Supervisor of licensing evaluation |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were denying POA visits to the facility and that residents were required to go to bed early.
Complaint Details
The complaint alleged staff were denying POA visits and forcing residents to go to bed early. The investigation determined these allegations to be unfounded.
Findings
The investigation found the allegations to be unfounded after interviews and records review. POA visits were not denied, though visit frequency and duration had changed, and residents were not forced to go to bed early; most preferred early bedtimes.
Report Facts
Facility capacity: 6
Census: 6
Complaint received date: Nov 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Maria Johnson | Administrator | Facility administrator met during investigation |
| Cara Smith | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Date: Nov 21, 2023
Visit Reason
The visit was conducted as a Case Management - Annual Continuation to review client records and continue the annual inspection from 7/17/23.
Findings
No deficiencies related to client records were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Johnson | Administrator | Met with during the inspection visit. |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 1
Date: Jul 17, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations received on 2022-01-27 regarding staff handling, feeding, medication administration, and resident care.
Complaint Details
The complaint investigation was triggered by allegations including rough handling of a resident, improper feeding, unauthorized medication administration, failure to meet resident needs, and making a video of a resident without consent. Most allegations were unsubstantiated except the video recording without consent, which was substantiated.
Findings
The investigation found most allegations unsubstantiated based on client records and staff interviews, except for one substantiated allegation where the administrator recorded a resident's behavior without consent and sent the video to a medical professional without written consent from the responsible party, violating confidentiality rights.
Deficiencies (1)
Failure to protect confidentiality of client's personal information by making and sending a video recording without consent, posing a potential personal rights risk.
Report Facts
Capacity: 6
Census: 6
Plan of Correction Due Date: Jul 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Johnson | Administrator | Named in relation to the substantiated finding of unauthorized video recording |
| Audrey Jeung | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Cara Smith | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 5
Date: Jul 17, 2023
Visit Reason
The inspection was a required unannounced 1-year visit to evaluate compliance with regulations for the George Anne Home facility.
Findings
The inspection identified multiple deficiencies including hot water temperature exceeding regulatory limits, unsafe storage of chemicals and medications accessible to clients, presence of staff without criminal record clearance, and a lack of personal privacy due to storage of equipment in a client's room. Plans of correction were submitted with due dates and some deficiencies were corrected during the visit.
Deficiencies (5)
Hot water temperature tested at 125 degrees F in middle common bathroom, exceeding the allowed maximum of 120 degrees F.
Two cans of paint and lighter fluid stored in unlocked rear storage shed accessible to clients.
Staff member J.G. present without criminal record clearance; civil penalty assessed.
Clients' refrigerated medications stored in unlocked refrigerator and excess medications in unlocked drawer accessible to clients.
Facility equipment (chair used to weigh clients) stored in a client's room, compromising personal privacy.
Report Facts
Civil penalty amount: 500
Capacity: 6
Census: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Lu Johnson | Administrator | Certified RCFE administrator overseeing facility operations. |
| J.G. | Staff member present without criminal record clearance. |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 0
Date: Feb 3, 2022
Visit Reason
The visit was conducted as a complaint investigation to review facility conditions and client files.
Complaint Details
The visit was complaint-related, but no deficiencies were cited and the complaint was not substantiated.
Findings
No deficiencies were cited during the investigation. Observations included the designation of a former office as a private client room, renovation of the garage into a staff apartment with two bunk beds in the main living area, and two unsecured detached storage sheds in the backyard.
Report Facts
Capacity: 6
Census: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Licensing Program Analyst | Observed facility conditions during complaint investigation |
| Julio Montes | Licensing Program Manager | Named in report header |
Report
January 13, 2026
Report
August 27, 2025
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