Inspection Reports for Las Villas del Norte
1325 Las Villas Way, Escondido, CA 92026, United States, CA, 92026
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on May 30, 2025, which was clean with no issues cited. However, several complaint investigations substantiated isolated deficiencies related primarily to resident safety and personal rights, such as multiple incidents of residents eloping after fire alarms disarmed exit doors in early 2025, and a failure to provide timely assistance to residents pressing call buttons in 2023. Other substantiated issues involved cleanliness concerns in the memory care unit and lapses in staff training on dementia care. The facility faced civil penalties for the elopement incidents but no fines or license actions were listed in the available reports. The record shows some improvement as the latest inspection was free of deficiencies following earlier concerns, and many complaints were found unsubstantiated.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
91% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 181
Capacity: 198
Deficiencies: 0
Date: May 30, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to assess compliance with licensing requirements for the facility.
Findings
The facility was found to be in compliance with no deficiencies cited. The environment was clean and safe, with secured medications, food supplies, and fire safety equipment properly maintained and functional.
Report Facts
Fire extinguisher service date: Apr 21, 2025
Bedridden resident capacity: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the inspection visit |
| Reu Baggao | Administrative Executive Director | Met with Licensing Program Analyst during inspection and provided facility access |
Inspection Report
Complaint Investigation
Capacity: 198
Deficiencies: 1
Date: Apr 16, 2025
Visit Reason
An unannounced case management visit was conducted regarding an Unusual Incident/Injury Report submitted by the facility reporting Resident 1 eloped from the facility on 2025-04-04 after a fire alarm was pulled, disarming exit doors.
Complaint Details
The visit was complaint-related due to an incident where Resident 1 eloped from the facility after a fire alarm was pulled, disarming exit doors. Resident 1 was located by law enforcement a mile away. Resident 1 has a history of eloping and is unable to leave unassisted. The complaint is substantiated as civil penalties will be assessed.
Findings
The fire alarm near the memory care unit was pulled, causing exit doors to disarm and Resident 1 to elope without staff supervision. Resident 1 was found a mile away by law enforcement with no apparent injuries. A similar incident occurred with Resident 2 on 2025-03-30. Civil penalties will be assessed. No additional health or safety concerns were observed.
Deficiencies (1)
Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating personal rights. This requirement was not met as the fire alarm was pulled which disarmed all exit doors resulting in Resident 1 eloping with no staff supervision.
Report Facts
Capacity: 198
Caregivers present: 4
Fire alarm pull stations: 6
Incident date: Apr 4, 2025
Incident date: Mar 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Administrator | Named in relation to Resident 1 elopement incident and return of Resident 1 |
| Reu Baggao | Administrative Executive Director | Met with Licensing Program Analyst and provided information about the incident |
| Ana Ramirez | Resident Services Director | Met with Licensing Program Analyst and provided information about the incident |
| Janette Romero | Licensing Program Analyst | Conducted the unannounced case management visit and inspection |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 198
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
An unannounced case management visit was conducted regarding an Unusual Incident/Injury Report submitted by the facility reporting that Resident 1 eloped from the facility on 2025-03-30.
Complaint Details
The visit was complaint-related due to an incident where Resident 1 eloped from the facility on 2025-03-30. The complaint was substantiated as the facility failed to secure the courtyard gate, posing a potential health and safety risk.
Findings
Facility staff failed to ensure the courtyard gate was secured after all exit doors were disarmed due to a fire alarm, resulting in Resident 1 eloping from the facility without staff supervision. The resident was returned by law enforcement with no visible injuries. The facility conducted staff training and purchased a new siren alarm for the courtyard gate.
Deficiencies (1)
Facility staff failed to ensure the courtyard gate was secured after knowing all doors had been disarmed, resulting in Resident 1 eloping from the facility without staff supervision.
Report Facts
Capacity: 198
Census: 180
Plan of Correction Due Date: Apr 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Administrator | Met with Licensing Program Analyst during the visit and involved in the incident report |
| Lorena Vivar | Memory Care Director | Met with Licensing Program Analyst during the visit and involved in the incident report |
| Janette Romero | Licensing Program Analyst | Conducted the unannounced case management visit |
| Tricia Danielson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 175
Capacity: 198
Deficiencies: 0
Date: Jan 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff were not practicing proper food safety practices, following a resident's visitor falling ill after a meal provided by the facility.
Complaint Details
The complaint alleged unsanitary food practices and failure of servers to wash hands on 01/02/2025 after a resident's visitor became ill. The allegation was unsubstantiated after investigation.
Findings
The investigation found no preponderance of evidence to substantiate the allegation. Observations included proper food storage temperatures, staff wearing gloves, and safe food handling practices. Staff received training on Norovirus prevention and food safety, and the alleged victim reported no issues with the meal or facility sanitation.
Report Facts
Capacity: 198
Census: 175
Temperature: 0
Temperature: 31
Staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the complaint investigation and delivered amended findings |
| Jolene Farish | Administrator | Facility administrator interviewed and involved in the investigation |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 198
Deficiencies: 1
Date: Dec 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that the licensee did not provide healthful accommodations for a resident, staff were not properly trained in cleaning/sanitation practices, and a resident was not accorded dignity.
Complaint Details
The complaint investigation was substantiated for the allegation that the licensee did not provide healthful accommodations for a resident. The allegations that staff were not properly trained in cleaning/sanitation practices and that a resident was not accorded dignity were unsubstantiated.
Findings
The investigation substantiated that the licensee failed to provide healthful and comfortable accommodations for one resident in the memory care unit, evidenced by ants crawling on the resident and bedding. Other allegations regarding staff training and resident dignity were unsubstantiated due to lack of supporting evidence.
Deficiencies (1)
Licensee did not provide healthful and comfortable accommodations in 1 of 51 persons in the memory care unit, posing a potential Personal Rights risk.
Report Facts
Capacity: 198
Census: 172
Residents affected: 1
Memory care unit residents: 51
Plan of Correction Due Date: Jan 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the complaint investigation |
| Jolene Farish | Executive Director | Met with Licensing Program Analyst during investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 198
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
An unannounced visit was conducted to investigate allegations that staff did not ensure a resident was properly fed and that staff were mistreating a resident while in care.
Complaint Details
The complaint was unsubstantiated. Allegations included delayed meal service and staff mistreatment. Interviews with residents and staff, as well as direct observation, did not confirm the allegations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Residents reported varying wait times for meals, but none reported walking away without food or staff being rude. The Licensing Program Analyst observed timely meal service during the visit.
Report Facts
Capacity: 198
Census: 167
Number of residents interviewed: 5
Meal serving times: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Administrator | Met with Licensing Program Analyst during investigation |
| Janette Romero | Licensing Program Analyst | Conducted the complaint investigation visit |
| George Lynn Sharp | Culinary Service Director | Interviewed regarding meal service schedules and delays |
Inspection Report
Follow-Up
Census: 186
Capacity: 198
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
The visit was an unannounced case management follow-up to address concerns identified in a Non-Compliance Conference held on 2023-10-20.
Findings
During the visit, no health or safety concerns were observed. The facility was found to have working utilities, required food supply, and adequate staffing. The previous concerns identified in the Non-Compliance Conference were not observed during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Administrator | Met with Licensing Program Analyst during the inspection and informed of the purpose of the visit. |
| Ana Ramirez | Resident Care Director | Met with Licensing Program Analyst during the inspection and informed of the purpose of the visit. |
| Janette Romero | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Tricia Danielson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 187
Capacity: 198
Deficiencies: 2
Date: Aug 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 07/23/2024 regarding housekeeping and food storage issues at the facility.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure the facility was clean, specifically in the Memory Care Unit. The allegation regarding improper food storage causing residents to get sick was unsubstantiated due to lack of evidence.
Findings
The investigation substantiated the allegation that housekeeping staff did not ensure the Memory Care Unit was properly cleaned, with feces observed in multiple resident bathrooms and showers. The facility reported staffing shortages but has since hired additional housekeepers. The allegation that residents got sick from improperly stored food was unsubstantiated after inspection and interviews.
Deficiencies (2)
Surfaces such as floors, chairs, toilets, sinks, counters and tabletops were not cleaned and disinfected on a regular basis to ensure they are safe and sanitary.
Six of nine resident bedrooms/bathrooms toured appeared to have feces stuck inside the toilet bowls, on the toilet seats, on the bathroom floor, and/or on the outside bedroom door handles, posing a potential health/safety/personal rights risk to residents.
Report Facts
Housekeeping staff: 5
Housekeepers assigned to MCU: 2
Housekeeping staff after hiring: 6
Resident bedrooms/bathrooms toured: 9
Resident bathrooms with feces observed: 6
Interviews conducted: 9
Interviews corroborating food allegation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Administrator | Met during inspection and reported housekeeping staffing and corrective actions. |
| Ana Ramirez | Resident Care Director | Met during inspection and provided information on housekeeping assignments. |
| Janette Romero | Licensing Program Analyst | Conducted the complaint investigation and inspection. |
| Debbie Palacios | Licensing Program Analyst | Assisted in delivering findings during the complaint investigation. |
| Nathan Condie | Regional Director | Participated in touring resident bedrooms and bathrooms during investigation. |
| George 'Lynn' Sharp | Chef | Met during kitchen tour related to food storage allegation. |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 198
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that the facility did not provide residents with hot water and that the facility was not clean or sanitized.
Complaint Details
The complaint alleged that residents were not provided with hot water and that the facility was not clean or sanitized. The investigation determined these allegations were unfounded, meaning the complaint was false or without reasonable basis.
Findings
The investigation found the allegations to be unfounded after observations, interviews with staff and residents, and record reviews showed that the facility provided hot water and was clean and sanitized with no safety concerns noted.
Report Facts
Capacity: 198
Census: 121
Number of resident rooms sampled: 5
Housekeepers: 2
Housekeeper shift hours: 8.5
Hot water heater repair date: Jun 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene M. Farish | Executive Director | Met with Licensing Program Analyst during investigation and discussed findings |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Michael Vitalli | Facility Maintenance Manager | Interviewed regarding hot water heater maintenance issue |
| Christian Herbert | Building Services Director | Interviewed regarding cleaning and sanitizing practices |
Inspection Report
Monitoring
Census: 121
Capacity: 198
Deficiencies: 0
Date: Jun 14, 2024
Visit Reason
The visit was an unannounced case management visit conducted to follow up on concerns identified in the Non-Compliance Conference held on 10/20/2023.
Findings
During the visit, no health or safety concerns were observed. The facility was found to have working utilities, required food supply, and adequate staffing. The previous concerns identified in the Non-Compliance Conference were not observed during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the unannounced case management visit and inspection. |
| Reu Baggao | Administrative Executive Director | Met with Licensing Program Analyst during the inspection and was informed of the visit purpose. |
Inspection Report
Census: 168
Capacity: 198
Deficiencies: 1
Date: Apr 22, 2024
Visit Reason
An unannounced case management deficiencies visit was conducted to review staff training compliance related to dementia care requirements.
Findings
The inspection revealed that three out of three reviewed staff did not complete the required twelve hours of dementia care training, posing an immediate health, safety, and personal rights risk to residents.
Deficiencies (1)
Training requirements for direct care staff: 12 hours of dementia care training not completed as required, including 6 hours before working independently and 6 hours within the first 4 weeks of employment.
Report Facts
Staff files reviewed: 3
Staff non-compliant: 3
Capacity: 198
Census: 168
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolina Farish | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Javina George | Licensing Program Analyst | Conducted the inspection and authored the report |
| Tricia Danielson | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Annual Inspection
Census: 168
Capacity: 198
Deficiencies: 0
Date: Apr 12, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies issued. Observations included proper safety measures, secure medication storage, adequate food supplies, and no health or safety concerns.
Report Facts
Hospice waiver residents: 28
Residents receiving hospice services: 10
Fire extinguisher service date: Mar 13, 2024
Food supply duration (perishable): 2
Food supply duration (non-perishable): 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Janette Romero | Licensing Program Analyst | Conducted the inspection visit |
| Tricia Danielson | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 198
Deficiencies: 1
Date: Jan 4, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff overcharged a resident for care fees during a hospitalization absence.
Complaint Details
The complaint alleged that staff overcharged a resident for care fees during an absence exceeding fourteen days due to hospitalization. The allegation was substantiated based on interviews and record review.
Findings
The investigation substantiated that Resident 1 was overcharged $3,400.00 in monthly care fees due to a clerical error, despite the facility not acting in bad faith. The facility failed to comply with the admission agreement's terms on pro-rated credits for absences over fourteen days.
Deficiencies (1)
The licensee did not comply with the admission agreement by overcharging Resident 1 for care, posing a potential health and safety risk.
Report Facts
Overcharge amount: 3400
Census: 155
Total capacity: 198
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Jolene Farish | Administrator | Facility administrator met during investigation and discussed findings |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 198
Capacity: 198
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
The visit was an unannounced case management Health and Safety Check conducted in response to previous information received by Community Care Licensing regarding the health and safety of the residents in care.
Findings
No health or safety issues were identified during the visit. The facility had sufficient staff for supervision, residents' rooms met regulatory furnishing requirements, and medications were being properly distributed. No deficiencies were observed or cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Normalin Paulo | Residential Care Coordinator | Met with during the visit and received a copy of the report. |
| Venus Mixson | Licensing Program Analyst | Conducted the unannounced case management Health and Safety Check. |
| Jazmond D Harris | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 198
Deficiencies: 0
Date: Dec 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation regarding allegations that the facility did not have an adequate food supply and that staff did not ensure a resident was provided fluids resulting in dehydration.
Complaint Details
Two complaints were investigated: 1) Facility does not have adequate food supply, which was found to be unfounded. 2) Staff did not ensure resident was provided fluids resulting in dehydration, which was found to be unsubstantiated.
Findings
The investigation found the allegation of inadequate food supply to be unfounded based on interviews, observations, and record reviews showing ample food supply. The allegation regarding dehydration due to lack of fluids was unsubstantiated, as staff reported providing sufficient fluids but documentation was lacking to confirm this.
Report Facts
Residents interviewed: 5
Staff interviewed: 5
Capacity: 198
Census: 160
Grocery receipt supply months: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Shaw Ross | Licensing Program Analyst | Conducted the complaint investigation |
| Jolene Farish | Executive Director | Facility representative met during investigation |
Inspection Report
Census: 151
Capacity: 198
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
An unannounced collateral visit was conducted to aid in an investigation occurring at another licensed care facility.
Findings
No deficiencies were observed or cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Executive Director | Met during the visit and participated in the exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced collateral visit. |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 198
Deficiencies: 1
Date: Sep 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations received on 2023-05-18 regarding resident neglect, lack of supervision, irregular feeding, and unsafe/unclean environment at the facility.
Complaint Details
The complaint investigation was triggered by allegations including severe neglect, unsupervised resident, irregular feeding, and unsafe/unclean environment. The allegations of neglect, supervision, and feeding were unsubstantiated. The unsafe and unclean environment allegation was substantiated.
Findings
The investigation found the allegations of severe neglect, unsupervised resident, and irregular feeding to be unsubstantiated due to lack of sufficient evidence. However, the allegation that the facility did not provide a safe and clean environment was substantiated based on the presence of a soiled mattress stored in a resident's bathroom, posing health and safety risks.
Deficiencies (1)
The licensee did not ensure personal rights were maintained for residents. Resident #1 was found injured sitting on top of a mattress stored in their bathroom, which was soiled and posed an immediate health, safety, and personal rights risk.
Report Facts
Weight loss: 13
Staff interviewed: 6
Capacity: 198
Census: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Ana Cruz | Resident Services Director | Met with the Licensing Program Analyst during the investigation. |
| Jolene Farish | Administrator | Facility administrator named in the report. |
| Reyna Lacey | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Rikesha Stamps | Licensing Program Manager | Named as Licensing Program Manager in relation to deficiency citation. |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 198
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff were not providing a resident with a refund.
Complaint Details
The complaint alleged that staff were not providing a refund to Resident 1 for monthly care fees overcharged during the resident's absence. The investigation found no preponderance of evidence to prove the violation occurred, and the allegation was unsubstantiated.
Findings
The allegation that staff did not provide a refund to the resident was found to be unsubstantiated. The facility issued a refund check directly to the resident, but the individual handling the resident's finances was not authorized, which delayed the refund. The facility provided a refund and a $100 credit to the resident's account as accommodation.
Report Facts
Capacity: 198
Census: 157
Refund credit: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Romero | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Jolene Farish | Administrator | Facility administrator met during the investigation and involved in refund discussion |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 166
Capacity: 198
Deficiencies: 0
Date: May 23, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to allegations of staff neglect resulting in a resident falling and sustaining a hip fracture, and a resident being pushed out of a wheelchair resulting in a shoulder fracture.
Complaint Details
The complaint involved allegations of staff neglect causing a resident to fall and sustain a hip fracture, and a resident being pushed out of a wheelchair causing a shoulder fracture. The investigation included interviews and record reviews, and concluded the allegations were unsubstantiated.
Findings
The investigation found that although the allegations may have happened or are valid, there was no preponderance of evidence to prove the alleged violations did or did not occur. The allegations were therefore unsubstantiated. Facility staff responded appropriately to incidents and no evidence of neglect was found.
Report Facts
Facility capacity: 198
Census: 166
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation |
| Jazmond D Harris | Licensing Program Manager | Oversaw the complaint investigation |
| Ana Cruz | Resident Care Director | Interviewed during investigation regarding allegations |
| Klarrisa Romero | Memory Care Director | Interviewed during investigation regarding allegations |
Inspection Report
Complaint Investigation
Census: 159
Capacity: 198
Deficiencies: 1
Date: Feb 16, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation of a Personal Rights Violation regarding residents not receiving their mail.
Complaint Details
The complaint was substantiated based on evidence that residents #1 and #2 did not receive their mail for approximately four months, violating their personal rights.
Findings
The investigation found that residents #1 and #2 had accumulated approximately four months of mail that was not provided to them or their responsible parties, substantiating the allegation of a Personal Rights Violation.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have the right to send and receive unopened correspondence in a prompt manner. This requirement was not met as residents #1 and #2 were not provided their mail nor was it provided to their responsible party for at least 4 months.
Report Facts
Census: 159
Total Capacity: 198
Deficiency Type Count: 1
Months of Mail Accumulated: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation |
| Jolene Farish | Executive Director | Facility representative met during investigation |
| Ana Cruz | Memory Care Director | Interviewed during investigation |
| Deborah Mullen | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 166
Capacity: 198
Deficiencies: 1
Date: Jan 25, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 09/22/2022 regarding resident care issues at the facility.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not answer the resident's call button in a timely manner, with documented response times of 35 and 39 minutes. Other allegations regarding multiple falls due to lack of supervision, unsafe environment, failure to assist with changing clothes, and medication dispensing were unsubstantiated or unfounded.
Findings
The investigation substantiated that staff did not respond to a resident's call button in a timely manner, posing a potential health and safety risk. Other allegations including lack of supervision leading to falls, unsafe environment, failure to assist with changing clothes, and medication dispensing were found unsubstantiated or unfounded.
Deficiencies (1)
Resident's call button was not answered in a timely manner, with staff response times exceeding 30 minutes on two occasions.
Report Facts
Call button activations: 6
Call button response time (minutes): 35
Call button response time (minutes): 39
Resident stay duration (days): 23
Direct staff supervision instances: 125
Alprazolam doses provided: 76
Maximum doses per 24 hours: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Ana Cruz | Memory Care Director | Met with the Licensing Program Analyst during the investigation. |
| Deborah Mullen | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 166
Capacity: 198
Deficiencies: 1
Date: Jan 25, 2023
Visit Reason
The visit was an unannounced case management inspection to address a deficiency observed during the investigation of a complaint related to multiple falls experienced by Resident #1.
Complaint Details
The visit was triggered by complaint control number 18-AS-20220922143233. The deficiency was substantiated as the facility failed to address the resident's change in condition and reassess for fall precautions.
Findings
The facility failed to reassess Resident #1 or implement fall precautions after the resident experienced six falls within less than 48 hours, indicating a failure to address a change in the resident's condition and posing a risk to resident safety.
Deficiencies (1)
The licensee did not ensure Resident #1 was provided assistance following a change in condition, including reassessment and fall precautions after multiple falls.
Report Facts
Falls experienced by Resident #1: 6
Facility capacity: 198
Resident census: 166
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report. |
| Deborah Mullen | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
| Ana Cruz | Memory Care Director | Facility staff member met during the inspection. |
Inspection Report
Complaint Investigation
Census: 166
Capacity: 198
Deficiencies: 0
Date: Jan 24, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 06/02/2022 regarding staff supervision, assistance with medical devices, and safeguarding of resident's personal belongings.
Complaint Details
The complaint included allegations that staff did not properly supervise residents, did not assist a resident with a medical device (CPAP machine), and did not safeguard a resident's personal belongings. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation found that memory care residents were supervised with assigned staff ratios, residents received assistance with medical devices such as CPAP machines, and measures were in place to safeguard personal belongings. However, the allegations could not be substantiated due to lack of preponderance of evidence.
Report Facts
Residents per caregiver: 10
Residents per caregiver: 12
Residents per caregiver: 10
Residents per caregiver: 15
Additional staff: 4
Additional staff: 3
Additional staff: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation |
| Ana Cruz | Memory Care Director | Met with Licensing Program Analyst during investigation |
| Deborah Mullen | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 198
Deficiencies: 1
Date: Jan 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations including staff not responding to a resident's call for assistance in a timely manner, staff not providing an ADA compatible room, and staff not meeting a resident's hygiene needs.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not respond timely to Resident #1's call lights. The allegations regarding the ADA compatible room and hygiene needs were found to be unfounded and unsubstantiated respectively.
Findings
The investigation substantiated that staff did not respond to Resident #1's call lights in a timely manner, posing a potential health, safety, and personal rights risk. The allegation that staff did not provide an ADA compatible room was found to be unfounded. The allegation that staff did not meet the resident's hygiene needs was unsubstantiated due to lack of sufficient evidence.
Deficiencies (1)
Resident's call light alarms were not answered in a timely manner, posing a potential health, safety and personal rights risk.
Report Facts
Call light activations by Resident #1: 37
Call lights responded to within 15 minutes: 14
Call lights responded to in 16-20 minutes: 8
Call lights responded to in 21-30 minutes: 5
Call lights responded to in 31-45 minutes: 6
Call lights responded to in 51 minutes: 1
Call lights responded to beyond 1 hour: 3
Scheduled staff assisted showers for Resident #1: 6
Days Resident #1 went without a shower (alleged): 12
Residents interviewed: 10
Residents reporting timely call light response: 9
Residents receiving assistance with showers: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jolene Farish | Executive Director | Facility representative met during the investigation |
| Deborah Mullen | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 198
Deficiencies: 0
Date: Jan 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations including insufficient staffing to meet residents' needs, lack of supplies, and inadequate food service at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included insufficient staffing, lack of supplies, and inadequate food service. Interviews and observations did not support these claims, and the allegations were determined to be unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with residents and staff, as well as observations during the visit, indicated that staffing levels were adequate, supplies were sufficiently stocked, and no expired or spoiled food was served.
Report Facts
Memory care residents interviewed: 6
Memory care staff interviewed: 5
Staff scheduled AM shift: 4
Staff scheduled PM shift: 3
Staff scheduled NOC shift: 2
Facility capacity: 198
Facility census: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jolene Farish | Executive Director | Met with Licensing Program Analyst during the investigation |
| Deborah Mullen | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 198
Deficiencies: 1
Date: Nov 16, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation of physical abuse of a resident at the facility.
Complaint Details
The complaint investigation was substantiated based on interviews with residents and staff, observations, and records reviewed. The allegation involved physical abuse of a resident by a staff member, which was confirmed by multiple witnesses and evidence.
Findings
The investigation substantiated the allegation of physical abuse by Staff #1 towards Resident #1. Interviews with residents and staff, along with observations, confirmed the abuse and rough handling of residents by the staff member, posing an immediate health, safety, and personal rights risk.
Deficiencies (1)
Failure to ensure Resident #1 was free from physical abuse while in care, violating personal rights of residents to be free from punishment, humiliation, intimidation, abuse, or other actions interfering with daily living functions.
Report Facts
Capacity: 198
Census: 178
Deficiency count: 1
Plan of Correction due date: Dec 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Executive Director | Met with Licensing Program Analyst during investigation |
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation |
| Deborah Mullen | Licensing Program Manager | Named in report as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 198
Deficiencies: 1
Date: Oct 27, 2022
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff were not maintaining a clean bathroom for a resident, not meeting the resident's needs, not assisting with hearing aids, and not safeguarding the resident's personal property.
Complaint Details
The complaint was substantiated regarding unclean bathroom floors for Resident #1, with evidence including observations and interviews confirming staff did not address urine on the bathroom floor. Other allegations about unmet resident needs, hearing aid assistance, and safeguarding personal property were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation substantiated that staff failed to maintain a clean bathroom for Resident #1, posing a potential health and safety risk. Other allegations regarding unmet needs, hearing aid assistance, and safeguarding personal property were unsubstantiated due to insufficient evidence.
Deficiencies (1)
Floor surfaces in bath, laundry and kitchen areas were not maintained in a clean, sanitary, and odorless condition.
Report Facts
Capacity: 198
Census: 171
Deficiency Type: 1
Plan of Correction Due Date: Nov 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ana Cruz | Generations Program Director | Facility representative involved in the investigation and plan of correction |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 198
Deficiencies: 0
Date: Jul 12, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the facility refrigerator was not maintained in working condition.
Complaint Details
Complaint was regarding the facility refrigerator not being maintained in working condition. The complaint was found to be unfounded.
Findings
The investigation found that the main walk-in refrigerator had intermittent issues starting July 3, 2022, but temporary repairs were made and perishable foods were relocated to other refrigerators and the walk-in freezer. The complaint was determined to be unfounded as the allegations were false or without reasonable basis.
Report Facts
Facility capacity: 198
Census: 198
Complaint received date: Jul 8, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Danielson | Licensing Program Analyst | Conducted the complaint investigation |
| Jolene Farish | Executive Director | Interviewed during the investigation |
| Deborah Mullen | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 166
Capacity: 198
Deficiencies: 1
Date: Jun 29, 2022
Visit Reason
An unannounced complaint investigation was conducted following an allegation of neglect and lack of supervision resulting in sexual abuse of residents by a stranger.
Complaint Details
The complaint was substantiated based on police reports, interviews with residents and staff, and facility observations. The alleged neglect/lack of supervision led to sexual abuse of three residents by a stranger who accessed the facility through unlocked doors.
Findings
The investigation substantiated that three residents were sexually abused by a stranger who gained entry through unlocked lobby doors. The facility failed to ensure residents were free from sexual abuse, posing an immediate health and safety risk. Multiple facility doors were found unlocked, and staff reported previous unauthorized entries.
Deficiencies (1)
Failure to ensure residents were free from sexual abuse, violating residents' personal rights as evidenced by sexual abuse incidents involving three residents.
Report Facts
Residents sexually abused: 3
Census: 166
Total capacity: 198
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Executive Director | Met with during investigation and involved in plan of correction discussions. |
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation. |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Annual Inspection
Census: 195
Capacity: 198
Deficiencies: 0
Date: May 24, 2022
Visit Reason
The inspection was an unannounced annual inspection with emphasis on infection control conducted by the Licensing Program Analyst.
Findings
The facility was found to be in compliance with infection control regulations, including appropriate COVID-19 postings, sufficient hygiene supplies, PPE usage, and staff training. No deficiencies were observed during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Executive Director | Met with Licensing Program Analyst during inspection. |
| Lorena Vivar | Assistant Executive Director | Interviewed regarding infection control measures during inspection. |
| Tricia Danielson | Licensing Program Analyst | Conducted the annual inspection. |
| Deborah Mullen | Licensing Program Manager | Named in report header. |
Inspection Report
Census: 195
Capacity: 198
Deficiencies: 0
Date: May 24, 2022
Visit Reason
The visit was an unannounced case management visit regarding a recently reported incident involving Resident #1 that occurred on May 6, 2022.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst interviewed staff, reviewed documents related to the incident, and conducted an exit interview with the facility's Executive Director.
Report Facts
Residents present: 195
Total licensed capacity: 198
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Executive Director | Met with Licensing Program Analyst during the visit |
| Tricia Danielson | Licensing Program Analyst | Conducted the case management visit |
| Deborah Mullen | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 196
Capacity: 198
Deficiencies: 1
Date: Apr 29, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not assist a resident from a fall in a timely manner.
Complaint Details
The complaint was substantiated. The allegation that staff did not assist the resident from a fall in a timely manner was confirmed through record review and interviews. The resident pressed their call pendant at 5:41pm on 4/24/22, but assistance was not provided until 911 arrived at 6:35pm. Staff were unable to answer after-hours phone lines during this time.
Findings
The investigation substantiated the allegation that staff failed to assist a resident (R1) promptly after a fall on 4/24/22. The resident pressed their pendant call at 5:41pm but was not assisted until 911 responded nearly an hour later. Staff were unable to answer after-hours phone calls during this time, and the facility was cited for deficiencies related to insufficient staffing and delayed response to resident calls.
Deficiencies (1)
Failure to provide care, supervision, and services that meet individual needs and are delivered by sufficient staff, resulting in delayed assistance to a resident who pressed their call button for help.
Report Facts
Census: 196
Total Capacity: 198
Deficiency Type: 1
Plan of Correction Due Date: May 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Colvin | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Lorena Vivar | Assistant Executive Director | Facility representative interviewed during the investigation and received the report. |
| Joel Esquivel | Licensing Program Manager | Named in the report as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 198
Deficiencies: 1
Date: Mar 22, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not provide timely medical treatment for a resident and that the facility did not have sufficient staff to answer telephones.
Complaint Details
The complaint investigation was substantiated regarding failure to provide timely medical treatment to Resident #1. The facility did not seek timely medical treatment for R1, who was not evaluated until approximately 21 hours after observation of right-sided weakness and leaning to their right side, along with facial droop. The allegation regarding insufficient staffing to answer telephones was unsubstantiated.
Findings
The investigation substantiated that the facility failed to provide timely medical treatment to Resident #1 in two separate incidents, posing an immediate health and safety risk. However, the allegation regarding insufficient staffing to answer telephones was found to be unsubstantiated after review of staffing schedules and interviews.
Deficiencies (1)
The licensee did not immediately telephone 9-1-1 when an injury or other circumstance resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis.
Report Facts
Resident census: 160
Total licensed capacity: 198
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Executive Director | Met with during investigation and discussed complaint findings |
| Lorena Vivar | Assistant Executive Director | Discussed complaint findings with Licensing Program Analyst |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Lizzette Tellez | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Census: 157
Capacity: 198
Deficiencies: 0
Date: Sep 29, 2021
Visit Reason
An unannounced case management visit was conducted following a self-reported incident where a resident left the facility unattended and was returned by staff.
Findings
No health or safety risks were observed during the visit and no deficiencies were cited.
Report Facts
Capacity: 198
Census: 157
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Executive Director | Interviewed during the visit and involved in the incident report |
| Liliana Silveira | Licensing Program Analyst | Conducted the unannounced case management visit |
| Denise Powell | Licensing Program Manager | Conducted the unannounced case management visit |
Inspection Report
Census: 157
Capacity: 198
Deficiencies: 0
Date: Sep 29, 2021
Visit Reason
The visit was a case management visit conducted to obtain additional information on a self-reported death report of Resident 1 (R1).
Findings
A health and safety check of the residents was conducted, R1's file was reviewed, and copies of resident records were obtained. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Executive Director | Met with Licensing Program Analyst and Licensing Program Manager during the visit; involved in exit interview. |
| Liliana Silveira | Licensing Program Analyst | Conducted the case management visit and health and safety check. |
| Denise Powell | Licensing Program Manager | Conducted the case management visit and health and safety check. |
Inspection Report
Annual Inspection
Census: 165
Capacity: 198
Deficiencies: 0
Date: May 21, 2021
Visit Reason
An unannounced annual required licensing inspection was conducted to verify compliance with statutes, regulations, and infection control practices, including COVID-19 mitigation measures.
Findings
The facility was found to be in compliance with infection control practices and COVID-19 mitigation strategies. No deficiencies were observed during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Administrator | Met during inspection and involved in review of COVID-19 mitigation plan. |
| Adam Hamer | Licensing Program Analyst | Conducted the inspection. |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 166
Capacity: 198
Deficiencies: 0
Date: Apr 15, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident was sexually abused while in care.
Complaint Details
The complaint alleged that a resident was sexually abused by an unknown staff member. The resident reported the incident with inconsistent details and was found to have medical conditions causing confusion and hallucinations. Law enforcement could not prove a crime occurred due to lack of physical evidence, witnesses, or suspects. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff, the resident, outside sources, and review of facility, medical, and law enforcement records. The allegation was found to be unsubstantiated due to lack of evidence, inconsistencies in the resident's statements, and no staff matching the description of the alleged perpetrator.
Report Facts
Complaint Control Number: 08-AS-20200518110655
Facility Capacity: 198
Census: 166
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Hamer | Licensing Program Analyst | Conducted the complaint investigation |
| Jolene Farish | Administrator | Facility administrator met during investigation |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 152
Capacity: 236
Deficiencies: 0
Date: Feb 10, 2021
Visit Reason
The visit was a Case Management tele-visit initiated by the licensee to discuss and inspect a Change of Capacity application and conduct a Fire Safety Inspection requested by the Department.
Findings
No immediate health and safety concerns or deficiencies were observed during the tele-visit. The facility was found to be clean, well-maintained, and compliant with safety measures including smoke and carbon monoxide detectors. The facility sketch/floor plan was consistent with the current layout.
Report Facts
Old capacity: 236
New capacity: 198
Non-ambulatory residents allowed: 112
Bedridden residents allowed: 86
Hot water temperature: 109.2
Hot water temperature: 106.6
Ambient air temperature: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Administrator | Met with Licensing Program Analyst during the inspection and discussed the purpose of the visit |
| Adam Hamer | Licensing Program Analyst | Conducted the Case Management tele-visit and inspection |
| Denise Powell | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 236
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
The visit was conducted as a follow-up on an Incident Report received on 11/24/2020. The Licensing Program Analyst conducted an unannounced Case Management tele-visit via FaceTime due to COVID-19.
Complaint Details
The visit was triggered by an Incident Report received on 11/24/2020. No deficiencies were cited during the follow-up visit.
Findings
During the visit, the Licensing Program Analyst interviewed the Administrator and requested copies of resident and staff records. No deficiencies were cited on this date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jolene Farish | Administrator | Interviewed during the visit and involved in the exit interview. |
| Adam Hamer | Licensing Program Analyst | Conducted the unannounced Case Management tele-visit. |
| Denise Powell | Licensing Program Manager | Named in the report header. |
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