Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations unsubstantiated, indicating generally adequate care and compliance. However, some reports cited isolated deficiencies related to resident rights, medication administration, staffing, and admission agreements. The most recent inspection on September 12, 2025, was clean with no deficiencies found during a complaint investigation. Earlier issues included a substantiated violation for failure to ensure injections were administered by qualified staff in June 2025 and a privacy rights violation in May 2025 involving unauthorized social media posts. Overall, the facility shows improvement over time, with recent reports reflecting fewer and less severe deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 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
4
3
2
1
0
Census
Latest occupancy rate
59% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 77
Capacity: 130
Deficiencies: 0
Date: Sep 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on June 6, 2025, alleging multiple issues including staff not providing mail to residents, mismanagement of medications, failure to prevent resident harm, inadequate housekeeping, failure to safeguard personal items, delayed toileting assistance, inappropriate staff communication, and improper hand hygiene.
Complaint Details
The complaint investigation was unannounced and addressed multiple allegations including failure to provide mail, medication mismanagement, resident harm prevention, housekeeping timeliness, safeguarding personal items, toileting assistance, inappropriate staff communication, and hand hygiene. The allegation regarding mail was unsubstantiated, while all other allegations were unfounded.
Findings
After interviews with residents and staff, observations, and record reviews, all allegations were determined to be either unsubstantiated or unfounded. Residents and staff reported generally adequate services, proper medication management, respectful communication, timely housekeeping and toileting assistance, safeguarding of personal belongings, and proper hand hygiene practices. No deficiencies were cited.
Report Facts
Complaint control number: 22-AS-20250606123601
Capacity: 130
Census: 77
Number of residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Espinal | Executive Director | Assisted with the complaint investigation visit and exit interview |
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation |
| Amie Pangilinan | Nurse Consultant (similar to Health Service Director) | Monitors MedTech staff and oversees medication management and training |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 130
Deficiencies: 1
Date: Jun 19, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not ensuring that an appropriately skilled professional was assisting residents with injections.
Complaint Details
The complaint alleged that facility staff were not ensuring that an appropriately skilled professional was assisting residents with injections. The allegation was substantiated based on resident interviews and investigation findings.
Findings
The investigation found that staff denied injecting residents with insulin and the Administrator reported that registered nurses are on call but do not inject residents. Resident interviews indicated that residents self-inject insulin and staff have not injected residents in recent years. Based on the evidence, the allegation was substantiated.
Deficiencies (1)
Failure to ensure that injections are administered by an appropriately skilled professional as required by CCR 87629(b)(1).
Report Facts
Capacity: 130
Census: 72
Deficiency Type A: 1
Plan of Correction Due Date: Jul 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Vanegas | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alma Espinal | Administrator | Facility Administrator interviewed during the investigation and named in findings |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 130
Deficiencies: 0
Date: May 27, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that staff did not safeguard a resident’s personal belongings.
Complaint Details
The complaint alleged that staff did not safeguard a resident’s personal belongings. The investigation found conflicting statements and evidence, including police records and room inspection, and concluded the allegation was unsubstantiated.
Findings
The investigation included interviews, room inspection, photographs, police records, and medical records. Conflicting information was found regarding missing items, and the allegation was deemed unsubstantiated due to lack of sufficient evidence.
Report Facts
Residents interviewed: 6
Items missing reported: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Espinal | Administrator | Spoke with Licensing Program Manager during telephone visit and received report for signature. |
| Kimberley Mota | Licensing Program Analyst | Conducted the complaint investigation. |
| Carla Martinez | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 130
Deficiencies: 1
Date: May 20, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-05-15 alleging that a resident's personal rights were violated.
Complaint Details
The complaint alleged that a resident's personal rights were violated. The allegation was substantiated based on interviews, record review, and evidence of private TikTok videos with views ranging from 8 to 274, violating the facility's standards of conduct.
Findings
The investigation found that a TikTok video of a resident and a staff member dancing was posted privately on the staff member's account, with some videos having views from followers. This was determined to be a violation of the resident's personal rights and the facility's standards of conduct.
Deficiencies (1)
Failure to ensure residents' personal rights to reasonable privacy as evidenced by private TikTok videos with views posing a potential personal rights risk.
Report Facts
Census: 73
Total Capacity: 130
Number of private TikTok videos viewed: 6
Number of private TikTok videos with views: 4
Deficiency Type: 1
Plan of Correction Due Date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Christine Juarez | Licensee | Facility representative met during the investigation and exit interview |
| Alice Castillo | Housekeeper | Granted entry to Licensing Program Analyst during investigation |
| Maroma Herrera | Activity Director | Informed of the purpose of the visit during investigation |
| Alma Espinal | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 130
Deficiencies: 0
Date: May 13, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility did not safeguard a resident's personal belongings.
Complaint Details
The complaint alleged that the facility did not safeguard a resident's personal belongings. The investigation was unannounced and included interviews with staff and residents, a facility tour, and review of documentation. The allegation was found unsubstantiated due to conflicting information and lack of evidence.
Findings
The investigation revealed conflicting information regarding missing items; residents and staff denied theft, and documentation showed previous accusations were unsubstantiated. Due to lack of corroborating evidence, the allegation was deemed unsubstantiated.
Report Facts
Complaint Control Number: 22-AS-20250507101501
Facility Capacity: 130
Census: 70
Date complaint received: 05/07/2025
Inspection start time: 08:00 AM
Inspection end time: 10:10 AM
Pipe repair date: 04/07/2025
Toilet unclog date: 04/08/2025
Number of prior accusations: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Alma Espinal | Administrator | Facility administrator contacted during investigation |
| Tony Ruiz | Maintenance Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 130
Deficiencies: 0
Date: Feb 19, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 09/12/2024 alleging that a resident sustained unexplained injuries and an unwitnessed fall due to lack of supervision, and that facility staff did not dispense medications as prescribed.
Complaint Details
The complaint alleged that a resident sustained unexplained injuries and an unwitnessed fall due to lack of supervision, and that medications were not dispensed as prescribed. The investigation included interviews with staff, review of medical and medication records, and police reports. The allegations regarding injuries and fall were unsubstantiated, and the medication allegation was unfounded.
Findings
The investigation found that the allegations of unexplained injuries and unwitnessed fall due to lack of supervision were unsubstantiated due to insufficient evidence. The allegation that facility staff did not dispense medications as prescribed was deemed unfounded based on staff interviews and record review.
Report Facts
Facility capacity: 130
Resident census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Tony Ruiz | Maintenance Director | Met with Licensing Program Analyst during the visit |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Plan of Correction
Census: 78
Capacity: 130
Deficiencies: 3
Date: Nov 13, 2024
Visit Reason
Unannounced Plan of Correction (POC) visit based on deficiencies cited in a prior inspection on 2024-11-06.
Findings
All previously cited deficiencies related to centrally stored medications, basic services, and TB testing have been cleared with proof of correction provided. The licensee has complied with the Plan of Correction.
Deficiencies (3)
Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications
Deficiency cited under Title 22 Regulation 87464(f)(4) pertaining to Basic Services
Deficiency cited under Title 22 Regulation 87411(f) pertaining to TB testing
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced Plan of Correction visit. |
| Alma Espinal | Administrator/Director | Facility Administrator/Director named in the report. |
Inspection Report
Annual Inspection
Census: 78
Capacity: 130
Deficiencies: 3
Date: Nov 6, 2024
Visit Reason
The visit was an unannounced annual required inspection to evaluate compliance with licensing regulations at Willow View Gardens Memory Care & Assisted Living.
Findings
The inspection found unsecured medications accessible to residents, staff files lacking proof of TB testing, and medications not administered per physician orders. The facility had deficiencies related to personnel health screening, medication storage, and medication administration.
Deficiencies (3)
Three out of six personnel records did not have a TB test result, posing a potential health and safety risk.
Multiple instances of unsecured medications observed, posing an immediate health and safety risk.
Four out of seven resident medications were not administered per physician's order or lacked documentation, posing an immediate health and safety risk.
Report Facts
Residents in assisted living: 59
Residents in memory care: 19
Residents on hospice: 10
Staff without proof of TB testing: 3
Medications not administered per physician order: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Espinal | Administrator | Facility administrator present during inspection and named in report |
| William Vanegas | Licensing Program Analyst | Conducted inspection and signed report |
| Armando J Lucero | Licensing Program Manager | Supervisor overseeing inspection and cited in deficiency section |
| Kimberly Lyman | Licensing Program Analyst | Conducted inspection |
Inspection Report
Census: 84
Capacity: 130
Deficiencies: 0
Date: Aug 28, 2024
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report submitted on 2024-05-31 involving a resident sent out for a psychiatric evaluation after making threats.
Findings
The facility appeared clean, safe, and sanitary during the visit. Residents were observed relaxing and eating lunch. The incident involved a resident with a psychiatric hold who has not returned to the facility.
Report Facts
Incident report date: May 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Sam Haddadin | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Erick Gonzalez | Met with during the inspection visit |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 130
Deficiencies: 0
Date: May 7, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of illegal eviction at Willow View Gardens Memory Care & Assisted Living.
Complaint Details
The complaint alleged illegal eviction. The investigation revealed that Resident 1 was served an eviction notice on 04/17/2024 for alcohol usage in violation of house rules. The department approved the eviction notice as legal. The allegation was deemed unfounded.
Findings
The investigation found that the eviction notice served to Resident 1 for violation of house rules related to alcohol usage was legal and approved by the department. The allegation of illegal eviction was deemed unfounded based on interviews and record review.
Report Facts
Facility capacity: 130
Census: 82
Complaint control number: 22-AS-20240502094405
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 130
Deficiencies: 0
Date: May 1, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not provide comfortable living accommodations for a resident.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.
Findings
The investigation revealed that two residents who became roommates were unhappy with the living situation, but the facility took steps to separate them into different rooms. The allegation was deemed unfounded as it was false or without reasonable basis.
Report Facts
Capacity: 130
Census: 80
Complaint Control Number: 22-AS-20240426103500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Michael Tea | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Alma Espinal | Administrator | Facility administrator involved in addressing the complaint |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 130
Deficiencies: 0
Date: May 1, 2024
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations that staff did not assist residents with meeting dining needs, providing adequate activities, and toileting needs.
Complaint Details
The complaint investigation was initiated based on allegations received on 04/18/2024. The allegations included staff not assisting residents with dining needs, inadequate activities, and not assisting with toileting needs. The dining and activities allegations were found unfounded, while the toileting allegation was unsubstantiated.
Findings
The investigation found the allegations regarding dining assistance and activities to be unfounded based on resident interviews and observations. The allegation regarding toileting assistance was deemed unsubstantiated due to conflicting information and lack of sufficient evidence.
Report Facts
Residents interviewed: 6
Staff interviewed: 3
Staff working lunch shift: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted complaint investigation |
| Michael Tea | Licensing Program Analyst | Conducted complaint investigation |
| Alma Espinal | Administrator | Facility administrator present during investigation |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 130
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not seek timely medical attention for a resident.
Complaint Details
The complaint alleged that staff did not seek timely medical attention for a resident. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that a resident admitted with Parkinson's Disease was observed on the ground but had no injuries. The resident was agitated due to missing medications, and was sent out for agitation and confusion unrelated to the fall. Due to conflicting information, the allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 130
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alma Espinal | Administrator | Facility administrator interviewed during investigation |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 130
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-04-05 regarding staff not providing a resident an admission agreement, staff yelling at a resident, and staff threatening a resident.
Complaint Details
The complaint involved allegations that staff did not provide a resident an admission agreement, staff yelled at a resident, and staff threatened a resident. The admission agreement allegation was unfounded. The yelling and threatening allegations were unsubstantiated due to conflicting statements and insufficient evidence.
Findings
The investigation found the allegation that staff did not provide a resident an admission agreement to be unfounded based on documentation and interviews. The allegations that staff yelled at or threatened a resident were deemed unsubstantiated due to conflicting information and lack of sufficient evidence.
Report Facts
Capacity: 130
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Espinal | Administrator | Met with during investigation and involved in findings regarding allegations |
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
Inspection Report
Plan of Correction
Census: 88
Capacity: 130
Deficiencies: 1
Date: Apr 16, 2024
Visit Reason
Unannounced Plan of Correction (POC) visit based upon deficiencies cited in LIC form 809 D on 04/08/2024.
Findings
The deficiency cited under Title 22 Regulation 87458(a) regarding Medical Assessment has been cleared. Licensee provided proof of medical assessment for Resident 1 and has complied with the POC. Licensee was advised to remain in compliance with previously cited items.
Deficiencies (1)
Deficiency cited under Title 22 Regulation 87458(a) regarding Medical Assessment
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced Plan of Correction visit. |
| Alma Espinal | Administrator/Director | Facility administrator met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 130
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
An unannounced case management visit was conducted in conjunction with complaint #22-AS-20240402090752 to investigate the complaint.
Complaint Details
Complaint #22-AS-20240402090752 was investigated and substantiated by the finding of a missing physician medical assessment for Resident 1.
Findings
The investigation found that Resident 1's file did not have a physician report on file, resulting in a cited deficiency per Title 22 Division 6 of the California Code of Regulations.
Deficiencies (1)
Failure to obtain and keep on file a medical assessment signed by a physician made within the last year prior to a person's acceptance as a resident.
Report Facts
Capacity: 130
Census: 89
Plan of Correction Due Date: Apr 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Supervisor and named in the report |
| Alma Espinal | Administrator | Facility Administrator who was met during the inspection and discussed the report |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 130
Deficiencies: 0
Date: Mar 12, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff did not follow proper eviction procedures.
Complaint Details
The allegation that staff did not follow proper eviction procedures was investigated and found to be unfounded.
Findings
The investigation found that the resident moved out voluntarily with family and durable power of attorney, who provided a 30-day notice but moved the resident out the same day. The allegation was deemed unfounded based on interviews and record review.
Report Facts
Capacity: 130
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Alma Espinal | Administrator | Met with during the investigation and confirmed findings |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 130
Deficiencies: 0
Date: Feb 27, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations including inappropriate placement of a resident on a 72-hour hold, failure to provide resident with keys timely, lack of activities for residents, and restricting a resident from leaving the facility.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Kimberly Lyman. Allegations were investigated through interviews, facility tour, and document review. Allegations related to involuntary hold, keys, activities, and resident freedom to leave were found unfounded. Allegations regarding provision of facility rules and resident records were unsubstantiated due to conflicting information.
Findings
The investigation found the allegations to be unfounded or unsubstantiated. Resident was appropriately placed on a 72-hour hold due to grave disability, keys were replaced timely, activities were provided and confirmed by residents, and residents were not denied leaving the facility. Conflicting information prevented substantiation of allegations regarding provision of facility rules and resident records.
Report Facts
Facility capacity: 130
Resident census: 74
Complaint control number: 22-AS-20240215130307
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alma Espinal | Administrator | Facility administrator met with during investigation and provided information |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 130
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff does not serve dinner at an appropriate time, food is not served warm, and staff have communication barriers with residents.
Complaint Details
The complaint was unsubstantiated due to lack of sufficient evidence to prove the alleged violations occurred.
Findings
The investigation found adequate food supply and warm food delivery processes. Six out of seven residents reported food was served warm and dinner delivery times were generally between 4-5 PM, with personalization available. Communication issues were denied by six out of seven residents and not observed by the investigator. Due to conflicting information, the allegations were deemed unsubstantiated.
Report Facts
Residents interviewed: 7
Residents denying communication issues: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alma Espinal | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 130
Deficiencies: 2
Date: Dec 13, 2023
Visit Reason
An unannounced case management visit was conducted in conjunction with a complaint investigation (complaint visit 22-AS-20231122171857) to evaluate compliance and investigate issues related to resident care and facility management.
Complaint Details
The visit was complaint-related, investigating issues including improper handling of resident's power of attorney documentation, lack of notification to responsible parties regarding hospice enrollment, and unauthorized release of resident personal information by the hospice agency. Resident was disenrolled from hospice after responsible party was notified via a third party.
Findings
The investigation found that the facility administrator was not qualified and was unaware of important resident information, including mismanagement of private information and improper handling of hospice care enrollment. Deficiencies were cited under Title 22 Division 6 of the California Code of Regulations.
Deficiencies (2)
The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). Knowledge of the requirements for providing care and supervision appropriate to the residents is not being met.
Licensee failed to ensure facility has a qualified administrator. Facility administrator is not aware of what is occurring in facility and not managing resident's private information, posing an immediate health and safety risk to residents in care.
Report Facts
Capacity: 130
Census: 58
Deficiencies cited: 2
Plan of Correction Due Date: Dec 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Espinal | Administrator | Facility administrator interviewed and named in findings regarding lack of qualifications and management |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management and complaint investigation visit |
| Alisa Ortiz | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 130
Deficiencies: 1
Date: Dec 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not allowing a resident to participate in the planning of their care and that staff did not ensure the resident was protected from financial abuse while in care.
Complaint Details
The complaint investigation was substantiated regarding failure to allow resident participation in care planning due to lack of consultation with the responsible party before hospice enrollment. The allegation of financial abuse was investigated and deemed unfounded.
Findings
The investigation substantiated that staff failed to consult the resident's responsible party before enrolling the resident in hospice care, violating personal rights and posing a potential health and safety risk. The allegation of financial abuse was found to be unfounded.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have personal rights including having their representatives regularly informed by the licensee of activities related to care or services. This requirement was not met as Licensee failed to ensure R1's responsible party was consulted before hospice enrollment.
Report Facts
Capacity: 130
Census: 58
Deficiency count: 1
Plan of Correction Due Date: Dec 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Alma Espinal | Administrator | Facility administrator acknowledged findings and was met during the investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 130
Deficiencies: 1
Date: Oct 26, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility illegally evicted a resident.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The facility illegally evicted a resident by issuing an eviction notice for an invalid reason.
Findings
The investigation found that the facility issued a thirty-day eviction notice to a resident for refusing to log in personal valuables, which contradicted the facility's admission agreement. The eviction notice was determined to be not legal per department guidelines, and the allegation was substantiated.
Deficiencies (1)
Licensee failed to ensure eviction notice was provided for a valid reason; eviction reason contradicted admission agreement, posing a potential health and safety risk to residents.
Report Facts
Capacity: 130
Census: 76
Deficiencies cited: 1
Plan of Correction Due Date: Nov 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Alma Espinal | Administrator | Facility administrator met during investigation and recipient of report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 130
Deficiencies: 0
Date: Oct 9, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2023-10-03 regarding medication administration errors, insufficient staffing, cigarette odor in resident rooms, and meal service issues.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included incorrect medication administration, insufficient staffing, cigarette odor in resident rooms, and issues with meal service. Conflicting information and evidence led to the conclusion that there was not a preponderance of evidence to prove violations. The allegations were ultimately deemed unsubstantiated or unfounded.
Findings
The investigation found no substantiated violations. Allegations related to medication errors, staffing levels, cigarette odor, and meal service quality and timing were deemed unsubstantiated or unfounded after interviews, facility tours, and document reviews.
Report Facts
Facility capacity: 130
Resident census: 70
Staffing levels: 4
Staffing levels: 1
Resident confirmations: 6
Staff confirmations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Alma Espinal | Administrator | Facility administrator involved in investigation and interviews |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 130
Deficiencies: 4
Date: Aug 21, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to allegations including inadequate staffing, untimely resident care, lack of activities, and inadequate shower assistance.
Complaint Details
The complaint was substantiated based on evidence including resident interviews, staff interviews, observations, and documentation review. Allegations of inadequate staffing, delayed care response, lack of activities, and missed showers were confirmed. Allegations regarding elevator maintenance, carpet cleaning, and staff disrespect were unsubstantiated.
Findings
The investigation substantiated that the facility had insufficient staffing with caregivers performing multiple roles, delayed response to resident call cords, lack of resident activities, and missed showers for some residents. Additional allegations regarding elevator maintenance, carpet cleaning, and staff respect were found unsubstantiated.
Deficiencies (4)
Facility failed to ensure residents are cared for by sufficient numbers of staff; staff performing dining room service and activity coordination duties.
Facility staff failed to respond to resident pendant pulls in a timely manner.
Facility failed to ensure activities are provided to residents; only bingo observed in the afternoon.
Facility failed to ensure residents receive shower assistance as required.
Report Facts
Capacity: 130
Census: 66
Deficiency count: 4
Plan of Correction Due Dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
| Alma Espinal | Administrator | Facility administrator interviewed during investigation and named in findings |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 130
Deficiencies: 2
Date: May 16, 2023
Visit Reason
An unannounced complaint investigation was conducted based on allegations received on 2023-04-14 regarding overcharging residents, lack of itemized financial costs, outdated emergency disaster plan, poor communication, failure to schedule medical appointments, and failure to provide bedroom necessities.
Complaint Details
The complaint investigation was substantiated for allegations of overcharging a resident and failure to provide an itemized list of financial costs. Other allegations related to emergency disaster plan, phone answering, scheduling medical appointments, communication with responsible party, and provision of bedroom necessities were found to be unfounded or unsubstantiated.
Findings
The investigation substantiated that a resident was overcharged and the admission agreement lacked a breakdown of basic service rates, resulting in a refund of $353. Other allegations including outdated emergency plan, phone answering, scheduling medical appointments, communication with responsible parties, and provision of bedroom necessities were found to be unfounded or unsubstantiated.
Deficiencies (2)
Resident was charged for the entire month of March without proration for prior days not admitted; refund of $353 was provided.
Admission agreement did not specify payment provisions including basic service rate.
Report Facts
Refund amount: 353
Capacity: 130
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Alma Espinal | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 130
Deficiencies: 1
Date: May 9, 2023
Visit Reason
An unannounced case management visit was conducted in conjunction with a complaint investigation regarding the facility's compliance with regulations.
Complaint Details
The visit was conducted in conjunction with complaint visit 22-AS-20230414121958. The complaint was substantiated by the finding that the admission agreement was not signed within the required timeframe.
Findings
The facility failed to ensure that the admission agreement for a resident was signed within seven days of admission, which poses a potential health and safety risk to residents in care. Deficiencies were cited based on this finding.
Deficiencies (1)
Admission agreements shall be signed and dated by the resident or representative and the licensee no later than seven days following admission. This requirement was not met as the admission agreement was signed late.
Report Facts
Capacity: 130
Census: 65
Plan of Correction Due Date: May 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Supervisor and named in the report |
| Alma Espinal | Administrator | Facility administrator involved in the discussion of findings |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 130
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-11-22 regarding administrator presence, medically prescribed diets, nutritional meals, and adequacy of facility staff.
Complaint Details
The complaint investigation addressed allegations that the administrator was not present for sufficient hours, residents were not receiving medically prescribed diets or nutritional meals, and facility staff was inadequate to meet residents' needs. All allegations were found to be unsubstantiated or unfounded based on observations, interviews, and documentation review.
Findings
The investigation found the allegations to be unsubstantiated or unfounded. The administrator was confirmed to be present for sufficient hours, residents reported no issues with prescribed diets or meals, and staffing levels were adequate despite a shortage of dining staff with caregivers filling in during meal times.
Report Facts
Residents in memory care: 9
Residents in assisted living: 34
Facility capacity: 130
Census: 43
Caregivers in assisted living: 2
Caregivers in memory care: 2
Med techs: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Espinal | Administrator | Administrator present during the investigation and confirmed to be working long hours |
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kristine Juarez | Licensee | Present during the investigation and interviewed |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Original Licensing
Census: 42
Capacity: 130
Deficiencies: 2
Date: Oct 25, 2022
Visit Reason
An announced pre-licensing inspection was conducted to evaluate the facility's readiness for initial licensing as a Residential Care Facility for the Elderly.
Findings
The facility was toured and found to have appropriate structure, safety features, emergency supplies, and adequate resident accommodations. Minor issues such as discolored doors and discarded boxes were noted for correction.
Deficiencies (2)
Multiple doors in the facility are discolored; require cleaning/repainting and proof to be forwarded by 11/01/2022.
Discarded boxes on side of facility need to be disposed of.
Report Facts
Capacity: 130
Census: 42
Temperature range: 105.6-117.1
Date of application: Aug 3, 2022
Fire clearance approval date: Aug 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Espinal | Executive Director | Met during inspection and discussed visit purpose |
| Kristine Juarez | Licensee | Met during inspection and discussed visit purpose |
| Tony Ruiz | Maintenance Director | Participated in facility tour during inspection |
| Kimberly Lyman | Licensing Program Analyst | Conducted the announced pre-licensing inspection |
| Alisa Ortiz | Licensing Program Manager | Named in report header and signature |
Inspection Report
Original Licensing
Census: 41
Capacity: 130
Deficiencies: 0
Date: Sep 19, 2022
Visit Reason
The visit was conducted as a change of ownership evaluation and pre-licensing readiness assessment for the Residential Care Facility for the Elderly.
Findings
The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and reporting.
Report Facts
Capacity: 130
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alma Espinal | Administrator | Facility administrator participating in COMP II interview |
| Kristine Juarez | Participant in COMP II interview | |
| Jude De La Concepcion | Licensing Program Manager | Named in report header |
| Bethany Hunter | Licensing Program Analyst | Named in report header and analyst conducting COMP II |
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