Inspection Report Summary
Most inspections found deficiencies related to resident care, staffing, medication management, and safety, with several substantiated complaints over the years. The facility has faced serious issues including failure to provide timely medical attention resulting in serious injury and a $10,000 civil penalty assessed in the most recent October 21, 2025 report, which confirmed neglect causing serious bodily harm. Other notable problems include insufficient staffing, delayed response to call buttons, medication errors, and failure to follow physician orders, with some enforcement actions such as fines and staff suspensions. Several complaint investigations were unsubstantiated, particularly those alleging abuse or poor hygiene, indicating some concerns were not confirmed. While deficiencies have persisted over time, the most recent report shows continued serious issues rather than improvement.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
110% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
76% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 140
Capacity: 185
Deficiencies: 0
Date: Oct 21, 2025
Visit Reason
Unannounced inspection to follow up on a substantiated allegation of a death report investigation related to neglect, lack of care and supervision, and failure to seek timely medical attention.
Complaint Details
The visit was complaint-related, following a substantiated allegation of neglect/lack of care and supervision and failure to seek timely medical attention resulting in serious bodily injury.
Findings
The Department determined that the facility caused serious bodily injury to a resident by failing to timely summon emergency medical care, resulting in a civil penalty. An immediate civil penalty of $500 was previously issued, and an additional penalty of $9,500 was assessed for a total of $10,000.
Report Facts
Civil penalty amount: 10000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator/Director | Met during inspection and acknowledged receipt of appeal rights. |
| Valeria Conway | Licensing Program Analyst | Conducted the unannounced inspection and signed the report. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 185
Deficiencies: 0
Date: Oct 15, 2025
Visit Reason
An unannounced Case Management visit was conducted in conjunction with a complaint investigation regarding an alleged sexual abuse incident that occurred on 10/14/2025 in the Memory Care Unit.
Complaint Details
The visit was triggered by a complaint investigation of an alleged sexual abuse incident involving Resident #1 on 10/14/2025. Law enforcement Deputy Zavala conducted an investigation. The incident report will be submitted to Community Care Licensing by the end of the day. The Executive Director is required to cross-report to appropriate agencies and notify law enforcement.
Findings
The Executive Director reported the incident and notified all responsible parties and the resident's primary physician. Law enforcement arrived to conduct an investigation. A 24-hour one-on-one private caregiver was assigned to the resident involved. Further investigation is needed regarding the alleged sexual abuse.
Report Facts
Facility capacity: 185
Resident census: 140
Incident date: Oct 14, 2025
Incident time: 1730
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Executive Director | Named in relation to the alleged sexual abuse incident and interview |
| Valeria Conway | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Zavala | Deputy | Law enforcement officer who arrived to conduct investigation |
Inspection Report
Annual Inspection
Census: 139
Capacity: 185
Deficiencies: 3
Date: Sep 4, 2025
Visit Reason
The visit was an unannounced required annual inspection to ensure the facility's compliance with Title 22 Regulations and to check for health and safety hazards.
Findings
The inspection found the facility generally compliant with regulations, including clean kitchens, well-maintained common areas, and proper storage of knives and sharps. However, deficiencies were noted including unsecured medications in resident rooms, unattended cleaning carts with accessible chemicals, and a resident without a current annual medical visit documented.
Deficiencies (3)
Medications were not properly secured in three residents' rooms where residents could not store their own medications, posing an immediate health and safety risk.
Two cleaning carts were left unattended with chemicals accessible to residents, posing a potential health and safety risk.
One resident did not have documentation of an annual routine medical visit within the required timeframe, posing a potential health and safety risk.
Report Facts
Deficiencies cited: 3
POC Due Date: Sep 8, 2025
POC Due Date: Sep 18, 2025
Census: 139
Total Capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Executive Director | Met with Licensing Program Analyst during inspection and mentioned in relation to findings. |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 185
Deficiencies: 1
Date: May 6, 2025
Visit Reason
The inspection was conducted as an unannounced Case Management Incident visit following an unusual incident report involving a resident who fell and sustained a back fracture.
Complaint Details
The visit was complaint-related due to an Unusual Incident/Injury Report received on 02/27/2025 about Resident #1 who fell on 02/25/2025 and sustained a back fracture. The deficiency was issued on 03/12/2025. No citations were issued during the current visit.
Findings
The Licensing Program Analyst conducted interviews, file reviews, and document collection related to the incident. No citations were issued at this time, but a $500 immediate civil penalty was assessed previously, with potential for additional penalties.
Deficiencies (1)
A deficiency was issued related to the incident involving Resident #1's fall and injury.
Report Facts
Civil penalty amount: 500
Number of staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Met with Licensing Program Analyst during inspection and involved in incident discussion |
| Esther Cortez | Licensing Program Analyst | Conducted the unannounced Case Management Incident inspection |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 185
Deficiencies: 1
Date: Apr 9, 2025
Visit Reason
The inspection was conducted as an unannounced Case Management Incident visit following receipt of two Unusual Incident/Injury Reports and two Self-Reports of Suspected Dependant Adult/Elder Abuse related to incidents involving residents and staff.
Complaint Details
The visit was complaint-related following reports of incidents involving residents R1 and R2 and staff S1 and S2. R1 confirmed being given dog food and feeling diminished. R2 denied rough treatment. S1 denied knowledge of the dog food and denied roughness. S1 had a prior corrective action notice for neglect. S1 was suspended and S2 received training. Incidents were reported to the ombudsman, resident, resident's family, physician, and Licensing.
Findings
The investigation confirmed that a resident was mistakenly given dog food by staff, which caused distress, and that another resident denied any rough treatment by staff. Staff member S1 was suspended and S2 received training. A deficiency was cited for failure to accord dignity to residents, and a civil penalty was issued.
Deficiencies (1)
Based on self-reported incident reports the licensee did not comply with the requirement to accord dignity to residents when a resident was given dog food, posing a potential personal rights risk.
Report Facts
Number of unusual incident/injury reports received: 2
Number of self-reports of suspected abuse received: 2
Plan of Correction due date: Apr 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Met with Licensing Program Analyst during inspection and involved in incident follow-up |
| Esther Cortez | Licensing Program Analyst | Conducted the unannounced Case Management Incident inspection |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 185
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the facility failed to provide resident records to the resident and/or their authorized person.
Complaint Details
The complaint alleged that the facility failed to provide resident records to the resident and/or their authorized representative. The investigation included interviews with the administrator and the point of contact, file reviews, and document collection. The facility faxed 228 pages on 03/28/25 and an additional 208 pages on 04/08/25. The point of contact confirmed receipt of medical records but was still awaiting billing records, which the facility stated would be sent after closing out March. The allegation was unsubstantiated.
Findings
The investigation found that the facility received a subpoena for the requested records and faxed the medical and billing records after legal review. Although there was a delay in providing the billing records, the facility was not denying production of any requested information. Therefore, the allegation was deemed unsubstantiated.
Report Facts
Pages faxed: 228
Pages faxed: 208
Capacity: 185
Census: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Interviewed regarding the complaint and investigation findings |
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 185
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
An unannounced Case Management Incident inspection was conducted following an unusual incident report regarding Resident #1 who fell during a beach outing and sustained a back fracture.
Complaint Details
The visit was complaint-related due to an unusual incident report received on 02/27/2025 about Resident #1's fall on 02/25/2025. The complaint was substantiated as the staff failed to provide the resident's assistive device during the outing.
Findings
The investigation found that Staff 1 allowed Resident #1 to go on an outing without their assistive device, resulting in a fall and injury. A deficiency was cited for failure to provide safe accommodations, and a $500 civil penalty was issued.
Deficiencies (1)
Failure to comply with Personal Rights of Residents by allowing Resident #1 to sustain a back fracture due to being taken on an outing without their assistive device.
Report Facts
Civil penalty amount: 500
Capacity: 185
Census: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Met with Licensing Program Analyst during inspection and provided information about the incident |
| Esther Cortez | Licensing Program Analyst | Conducted the unannounced Case Management Incident inspection |
| Kasandra Lopez | Licensing Program Manager | Supervisor overseeing the inspection report |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 185
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff were not responding to residents' call buttons in a timely manner.
Complaint Details
The complaint was substantiated. The allegation was that staff were not responding to residents' call buttons in a timely manner, which was confirmed through interviews, resident reports, and pendant call log reviews.
Findings
The investigation substantiated the allegation that staff did not respond to residents' call buttons promptly, with some residents waiting over 30 minutes for assistance. A review of pendant call logs showed multiple instances of delayed responses, posing a potential health and safety risk.
Deficiencies (1)
Staff did not respond to residents' calls for assistance in a timely manner, violating CCR 87468.2(a)(4) regarding residents' personal rights to care and supervision.
Report Facts
Capacity: 185
Census: 120
Pendant calls with delayed response: 21
Pendant calls answered after 30 minutes: 12
Plan of Correction Due Date: Feb 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Met with Licensing Program Analyst during the investigation |
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 185
Deficiencies: 1
Date: Jan 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were unable to provide medication as prescribed to residents during an evacuation and that the licensee did not provide an up-to-date and readily available emergency disaster plan.
Complaint Details
The complaint investigation was substantiated for failure to provide prescribed medications during an evacuation, while the allegation regarding the lack of an emergency disaster plan was unsubstantiated.
Findings
The allegation regarding the emergency disaster plan was found unsubstantiated as the facility had a current plan, conducted monthly drills, and residents and staff reported the evacuation was well handled. However, the allegation that staff failed to provide prescribed medications during the evacuation was substantiated based on interviews and a medication audit revealing that three residents did not receive their medications during the evacuation.
Deficiencies (1)
Licensee did not comply with CCR 87465(a)(4) requiring assistance with self-administered medications; staff failed to dispense prescribed medication to three residents during an evacuation, posing a potential health and safety risk.
Report Facts
Capacity: 185
Census: 126
Residents interviewed: 13
Staff interviewed: 4
Residents with medication issues: 3
Plan of Correction due date: Feb 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joeyvic Alvarado | Administrator | Facility administrator met during the investigation |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 185
Deficiencies: 1
Date: Dec 12, 2024
Visit Reason
An unannounced Case Management - Deficiencies inspection was conducted due to deficiencies observed during the investigation for Complaint control #29-AS-20240826174337, which were unrelated to the complaint allegation.
Complaint Details
The inspection was triggered by Complaint control #29-AS-20240826174337. The deficiency observed was unrelated to the complaint allegation.
Findings
The Operations Specialist/Interim Administrator was found not to be fingerprint cleared and associated with the facility, which posed an immediate health and safety risk to residents. An immediate $500 civil penalty was assessed.
Deficiencies (1)
Operations Specialist/Interim Administrator was not fingerprint cleared and associated to the facility as required by criminal record review regulations.
Report Facts
Civil penalty amount: 500
Capacity: 185
Census: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Michelle Greenberg | Business Office Manager II | Met with the Licensing Program Analyst during the inspection. |
| Lauria Gallagher | Director of Resident Services I | Met with the Licensing Program Analyst during the inspection. |
| Joeyvic Alvarado | Administrator | Facility Administrator named in the report. |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 185
Deficiencies: 1
Date: Dec 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not responding to residents' call buttons in a timely manner.
Complaint Details
The complaint was substantiated. The allegation was that staff were not responding to resident call buttons in a timely manner, with residents waiting from 15 minutes to over 30 minutes, including one instance during the investigation where a resident's pendant call was not answered after over 30 minutes.
Findings
The investigation substantiated the allegation that staff did not respond promptly to residents' call buttons, with residents waiting from 15 minutes to over 30 minutes for assistance. A review of call logs showed 26 instances on 12/01/2024 where residents waited over 30 minutes. A deficiency was cited for failure to provide timely care and supervision.
Deficiencies (1)
Staff did not respond to residents calls for assistance in a timely manner, which poses a potential health and safety risk to residents in care.
Report Facts
Residents waiting over 30 minutes for assistance: 26
Census: 122
Total Capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kasandra Lopez | Licensing Program Manager | Named in relation to the deficiency citation and report management |
| Michelle Greenburg | Business Office Manager | Interviewed during investigation and agreed to staff in-service plan |
| Lauria Gallagher | Director of Resident Service | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 185
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
The visit was conducted as a complaint investigation following an allegation received on 08/26/2024 that a staff member inappropriately touched a resident.
Complaint Details
The complaint alleged that Staff #1 sexually abused Resident #1 by touching the resident's vagina. The allegation was investigated through interviews, document reviews, and a facility tour. Staff #1 was suspended and later terminated pending investigation. The allegation was deemed unsubstantiated due to lack of evidence and inconsistent statements.
Findings
The investigation did not find sufficient evidence to substantiate the allegation of sexual abuse by the staff member. The resident's statements changed during the investigation, there were no witnesses, and the staff member denied the allegation. The case was closed by the Los Angeles County Sheriff's Department with no further action.
Report Facts
Facility capacity: 185
Resident census: 122
Complaint received date: Aug 26, 2024
Investigation interview dates: Sep 26, 2024
Investigation interview dates: Oct 24, 2024
Investigation interview dates: Nov 5, 2024
Resident's physician report date: Sep 14, 2022
Incident report date: Aug 17, 2024
Staff termination date: Aug 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Joeyvic Alvarado | Administrator | Facility administrator at the time of the investigation |
| Michelle Greenburg | Business Office Manager | Met with Licensing Program Analyst during the visit |
| Lauria Gallagher | Director of Resident Services I | Met with Licensing Program Analyst during the visit |
| Christine Ferris | Investigator | Assigned to investigate the complaint allegation |
| Diane Lugar | Operations Specialist/Interim Administrator | Met with Licensing Program Analyst and Investigator during investigation |
Inspection Report
Annual Inspection
Census: 106
Capacity: 185
Deficiencies: 5
Date: Sep 10, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with Title 22 regulations and ensure health and safety standards at the facility.
Findings
The inspection found several deficiencies including lack of warning signs for hot water taps above 125°F, improper storage of disinfectants and medications accessible to residents, hot water temperatures above 120°F in multiple resident rooms, and inoperable or missing smoke detectors in two resident rooms. The facility was cited for these violations and plans of correction were agreed upon.
Deficiencies (5)
No warning sign observed for hot water taps delivering water at 129.9 degrees Fahrenheit in the kitchen sink of assisted living.
Disinfectants, cleaning solutions, and poisons stored in four resident rooms and one unlocked storage room accessible to residents.
Medications stored in three resident rooms where residents cannot store or manage medications per physician's report.
Hot water temperature above 120 degrees Fahrenheit in seven resident rooms.
Smoke detector inoperable in resident room #274 and missing in resident room #103.
Report Facts
Census: 106
Total Capacity: 185
Deficiencies cited: 5
Hot water temperature: 129.9
Hot water temperature range: 108.9-125.6
Hot water temperature violations: 7
Resident rooms with smoke detector issues: 2
Resident rooms with improper storage: 4
Resident rooms with medication storage issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kasandra Lopez | Licensing Program Manager | Supervisor overseeing the inspection |
| Jeff Labelle | Executive Director | Facility Executive Director present during inspection |
| Diane Lugar | Operation Specialist | Met with Licensing Program Analyst during inspection |
| Joeyvic Alvarado | Administrator/Director | Facility Administrator/Director named in report header |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 185
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that the facility was not preventing the spread of COVID-19.
Complaint Details
The complaint alleged that on August 16, 2024, there was a COVID-19 outbreak and the facility was not testing residents or preventing spread. The allegation was deemed unsubstantiated after investigation including interviews, file review, and facility tour.
Findings
The investigation found that the allegation was unsubstantiated. The facility had an approved infection control plan, adequate PPE supplies, and protocols in place. Residents and staff were informed of COVID-19 cases, exposed or symptomatic residents were tested and isolated, and mass testing was not required by public health guidance.
Report Facts
Capacity: 185
Census: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Kasandra Lopez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Joeyvic Alvarado | Administrator | Facility Administrator named in report |
| Jeff Labelle | Executive Director | Met with Licensing Program Analyst during inspection |
| Diane Lugar | Operation Specialist | Met with Licensing Program Analyst during inspection |
Inspection Report
Capacity: 185
Deficiencies: 0
Date: Aug 14, 2024
Visit Reason
The visit was conducted to gather additional information about a death report (LIC 624) submitted on 2024-08-05 concerning a resident who had a fall on 2024-08-03 and subsequently died at the hospital.
Findings
The inspection involved interviews with facility staff and requests for pertinent records. The cause of death remains unclear, and further investigation is needed. The family had not yet provided the death certificate at the time of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator/Director | Named as facility administrator/director |
| Shari Lefevre | Regional Director of Operations | Met with during the visit and involved in the inspection |
| Guadalupe Santos | Memory Care Director | Interviewed regarding the death report and case |
| Diane Lugar | Operations Specialist | Interviewed regarding the death report and case |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 1
Date: Aug 14, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff were not following a resident's physician's order regarding the use of bed rails.
Complaint Details
The complaint alleged that staff were not following a resident's physician's order to use half bed rails due to the facility's policy prohibiting bed rails. The complaint was substantiated after investigation.
Findings
The investigation found that the facility staff temporarily removed the resident's half bed rails despite a physician's order, failed to inform the resident's responsible parties about the facility's bed rail policy, and did not follow the physician's order. The allegation was substantiated and citations were issued.
Deficiencies (1)
Failure to comply with CCR 87608(a)(5)(A) as the resident's half bed rails were removed, posing a potential health and safety risk.
Report Facts
Capacity: 185
Census: 96
Deficiencies cited: 1
Plan of Correction Due Date: Aug 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Kasandra Lopez | Licensing Program Manager | Named in the report as Licensing Program Manager overseeing the investigation |
| Joeyvic Alvarado | Administrator | Facility administrator mentioned in the report |
| Shari Lefevre | Regional Director of Operations | Interviewed during the investigation |
| Ruth Austin | Divisional Director Health & Wellness | Interviewed during the investigation |
| Diane Lugar | Operations Specialist | Met with LPAs during the investigation |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 185
Deficiencies: 0
Date: Mar 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-07 concerning multiple allegations including resident injury, medication protocol violations, delayed response to call pendants, disrespectful staff behavior, unclean resident rooms, malodorous conditions, and failure to safeguard resident property.
Complaint Details
The complaint investigation was unsubstantiated for all allegations including resident injury, medication protocol noncompliance, delayed response to call pendants, disrespectful staff behavior, unclean and malodorous resident room, and failure to safeguard resident property.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. The resident's injury was not supported by evidence, medication protocols were followed appropriately, staff response times to call pendants were generally timely, staff treated residents with respect, housekeeping maintained cleanliness, and there was no evidence of missing resident property.
Report Facts
Facility capacity: 185
Resident census: 100
Response time: 15
Response time: 10
Complaint received date: Jan 7, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Joeyvic Alvarado | Executive Director | Met with Licensing Program Analyst during inspection |
| Matan Burstyn | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 185
Deficiencies: 0
Date: Mar 21, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 09/07/2023 regarding inadequate wound care for a resident and failure to ensure the facility was free of insects.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not adequately caring for a resident's wound and staff not ensuring the facility was free of insects. The resident had a chronic wound with maggot infestation discovered at hospital admission, but the resident did not report the wound or infection to staff. No insects were observed in the facility during inspection, and pest control was regularly conducted.
Findings
The investigation found insufficient evidence to support the allegations. Resident #1 was independent and capable of reporting their wound, which was not reported to staff prior to hospital admission. No insects or flies were observed during the facility walkthrough, and pest control measures were in place. Therefore, both allegations were deemed unsubstantiated.
Report Facts
Facility capacity: 185
Census: 100
Complaint receipt date: Sep 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Joeyvic Alvarado | Executive Director | Met with Licensing Program Analyst during inspection |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 185
Deficiencies: 0
Date: Mar 21, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 12/18/2023 regarding retaliation against a resident, failure to bathe a resident, failure to clean a resident's room, and untimely response by the administrator to a responsible party.
Complaint Details
The complaint included allegations that the licensee retaliated against a resident, facility staff failed to bathe a resident, failed to clean a resident's room, and that the administrator did not respond timely to a responsible party. The investigation included interviews with staff, residents, family members, and review of records. All allegations were found unsubstantiated based on the evidence.
Findings
The investigation found insufficient evidence to support any of the allegations. All allegations including retaliation, failure to bathe, failure to clean the resident's room, and untimely administrator response were deemed unsubstantiated. No citations were issued.
Report Facts
Facility capacity: 185
Census: 100
Complaint control number: 29-AS-20231218160810
Dates of visits: Initial visit on 2023-12-22, subsequent visit on 2024-02-29, and complaint investigation visit on 2024-03-21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Executive Director | Met with during inspection and involved in investigation |
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visits |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 185
Deficiencies: 1
Date: Dec 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of insufficient staffing at the facility.
Complaint Details
The complaint alleged insufficient staffing leading to numerous falls in the memory care unit. The investigation included interviews, record reviews, and surveillance footage review. The allegation was substantiated based on staff interviews confirming insufficient staffing at times.
Findings
The investigation found that although there was insufficient evidence that staffing shortages directly caused resident falls, staff interviews confirmed that there are times when only two caregivers are on shift, which is insufficient to meet residents' needs. The allegation of insufficient staffing was substantiated.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. Interviews revealed there are times when only two caregivers are on duty in the memory care unit with 28 residents, posing a potential health and safety risk.
Report Facts
Capacity: 185
Census: 100
Memory care census: 28
Caregivers on shift: 2
Caregivers on shift: 3
Plan of Correction due date: Dec 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Interviewed regarding staffing and resident fall incident |
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 185
Deficiencies: 0
Date: Dec 22, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations including questionable death, medications not administered as prescribed, and insufficient staffing at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included questionable death of Resident #1, improper medication administration to Resident #2, and insufficient staffing. After review of records, interviews, and observations, the Department found insufficient evidence to support these allegations.
Findings
The investigation found insufficient evidence to substantiate the allegations of questionable death, insufficient staffing, and medication errors. The resident's death was not linked to staff neglect, staffing levels were deemed adequate, and medication administration was found to be correct despite documentation issues with an outside company.
Report Facts
Facility capacity: 185
Census: 100
Complaint received date: Jan 21, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joeyvic Alvarado | Executive Director | Facility representative interviewed during the investigation |
| Matan Burstyn | Administrator | Facility administrator who submitted the death report |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 185
Deficiencies: 1
Date: Dec 22, 2023
Visit Reason
The visit was an unannounced complaint investigation to deliver findings for an investigation initiated on 2021-11-01 regarding multiple allegations including staff hitting a resident, resident biting another resident's leg, failure to notify family of incidents, insufficient staffing, and failure to report staff abusing resident to proper agencies.
Complaint Details
The complaint investigation involved allegations of staff hitting a resident, a resident biting another resident's leg, failure to notify resident's family of an incident, insufficient staffing, and failure to report staff abusing resident to proper agencies. All allegations except the failure to report abuse were found unsubstantiated. The failure to report abuse allegation was substantiated.
Findings
The investigation found insufficient evidence to substantiate allegations that staff hit a resident, a resident bit another resident's leg, the facility failed to notify resident's family of an incident, and insufficient staffing. However, the allegation that the facility failed to report staff abusing a resident to proper agencies was substantiated, resulting in a cited deficiency for failure to submit required written reports.
Deficiencies (1)
Failure to submit a written report to the licensing agency and responsible persons within seven days of an alleged abuse incident between Staff #3 and Resident #1, which is a potential health and safety risk to residents.
Report Facts
Capacity: 185
Census: 100
Deficiencies cited: 1
Plan of Correction Due Date: Dec 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Joeyvic Alvarado | Executive Director | Met with Licensing Program Analyst during inspection |
| Joann Gange | Regional Director | Interviewed regarding allegations and investigation findings |
| Walter Cline | Assistant Administrator | Participated in physical plant tour and interviews during investigation |
| Alex Alvarado | Health and Wellness Director | Interviewed during subsequent inspection |
Inspection Report
Annual Inspection
Census: 96
Capacity: 185
Deficiencies: 1
Date: Sep 25, 2023
Visit Reason
The inspection was a required unannounced annual visit to evaluate compliance with Title 22 Regulations and ensure health and safety standards at the facility.
Findings
The facility was generally found to be in compliance with regulations, including clean and operable kitchens, safe common areas, proper record keeping, and adequate infection control measures. However, a deficiency was cited for unlocked personal hygiene items accessible to residents with dementia, posing an immediate health and safety risk.
Deficiencies (1)
Personal hygiene items were found unlocked and accessible to residents in the memory care unit, posing an immediate health, safety, or personal rights risk.
Report Facts
Expired food items: 4
Resident files reviewed: 8
Personnel files reviewed: 8
Residents interviewed: 2
Staff interviewed: 6
Hot water temperature measurements: 13
Fire inspection date: Aug 15, 2023
Fire and earthquake drills: Aug 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Executive Director | Met with Licensing Program Analysts and involved in entrance interview and plan of correction. |
| Alex Alvarado | Health and Wellness Director | Met with Licensing Program Analysts during the inspection. |
| Martha Arroyo | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Desaree Perera | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not allow residents to have visitors.
Complaint Details
The complaint alleged that the facility did not allow residents to have visitors. The allegation was unsubstantiated after review of visitation logs, interviews, and documentation showing visitation continued with safety protocols during the COVID outbreak.
Findings
The investigation found that family members were allowed to visit residents daily after a reported COVID outbreak, with visitation conducted by appointment in outdoor settings only if no symptoms were present. The allegation was deemed unsubstantiated due to insufficient evidence supporting the claim that residents were not allowed visitors.
Report Facts
Capacity: 185
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Met during the investigation and provided information regarding visitation policies |
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Alex Alvarado | Health and Wellness Director | Met during the investigation and assisted with plant tour and interviews |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 185
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-11-08 regarding physical abuse and neglect at the facility.
Complaint Details
The complaint involved multiple allegations including staff hitting, pushing, and pulling residents' hair; rough and untimely incontinent care; resident isolation and neglect; lack of dignity and respect; failure to assist with ADLs; unexplained injuries; and management not following up on abuse reports. The investigation included interviews with staff, residents, former staff, and law enforcement. No evidence was found to substantiate the allegations.
Findings
The investigation found insufficient evidence to substantiate any of the allegations including physical abuse, rough incontinent care, neglect, lack of dignity and respect, failure to assist with ADLs, unexplained injuries, and management not following up on abuse reports. All allegations were deemed unsubstantiated.
Report Facts
Complaint Control Number: 29-AS-20221108114659
Capacity: 185
Census: 94
Inspection Start Time: 10:00 AM
Inspection End Time: 04:05 PM
Date Complaint Received: Nov 8, 2022
Date of Initial Complaint Inspection: Nov 9, 2022
Date of Interviews: 2022-12-30 to 2023-02-10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Met with during inspection and named in investigation |
| Kasandra Lopez | Licensing Program Analyst | Conducted complaint investigation and inspection |
| Michelle Greenburg | Business Office Manager | Met with during complaint visit |
| Edward Hector | Investigator | Conducted initial complaint investigation |
| Alex Alvarado | Health and Wellness Director | Met with during inspection and interviewed |
| Guadalupe De Los Santos | Memory Care Director | Interviewed during inspection |
| S1 | Staff member named in abuse allegations and interviewed | |
| S2 | Staff member named in abuse allegations and interviewed | |
| S5 | Staff member who reported alleged abuse to management |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 185
Deficiencies: 2
Date: Jul 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including failure to timely report a resident's change of condition to the responsible party, insufficient staffing, and verbal abuse by staff to residents.
Complaint Details
The complaint investigation was substantiated for two allegations: 1) Licensee did not report resident's change of condition to the responsible party timely, and 2) Insufficient staffing. The allegation that staff were verbally abusive to residents was unsubstantiated.
Findings
The investigation substantiated that the licensee failed to timely notify the responsible party of a resident's change of condition and that insufficient staffing occurred resulting in late medication delivery. The allegation of staff verbally abusing residents was unsubstantiated.
Deficiencies (2)
Failure to ensure residents are regularly observed for changes in condition and timely notification to responsible party.
Failure to maintain sufficient and competent staff to meet resident needs, resulting in late medication delivery.
Report Facts
Capacity: 185
Census: 96
Deficiencies cited: 2
Plan of Correction Due Date: Jul 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Michelle Greenberg | Business Office Manager | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Matan Burstyn | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 185
Deficiencies: 4
Date: May 12, 2023
Visit Reason
The visit was a Case Management - Incident investigation conducted to issue final findings and citations related to a prior incident involving the death of Resident #1 on 02/13/2020, following up on a death report submitted to the Department.
Complaint Details
The visit was complaint-related, triggered by a death report of Resident #1. The investigation substantiated that facility staff failed to seek timely medical attention, contributing to the resident's death.
Findings
The investigation found that the facility staff failed to provide timely medical treatment to Resident #1, who was found unresponsive and later pronounced deceased. Deficiencies included failure to immediately call 911, failure to update medical assessments and care plans after condition changes, and medication administration by an unqualified med tech. A $500 immediate civil penalty was assessed.
Deficiencies (4)
Failure to immediately telephone 911 when an injury or circumstance posed an imminent threat to resident health, resulting in delayed medical treatment for Resident #1.
Failure to comply with diabetes care requirements; Resident #1 needed assistance with glucose testing and medication administration by an unqualified med tech.
Failure to update medical assessment for Resident #1 after condition changed when moved from Assisted Living to Memory Care Unit.
Failure to develop and update care plan for Resident #1 to meet changing needs, posing potential health and safety risk.
Report Facts
Civil penalty amount: 500
Deficiency count: 4
Plan of Correction due date: May 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joey Alvarado | Administrator | Met with Licensing Program Analyst during the visit. |
| Troy Byington | Administrator/Executive Director | Interviewed during investigation related to the incident. |
| Staff #1 | Med tech involved in medication administration and incident; written up for failure to call 911 promptly. | |
| Kasandra Lopez | Licensing Program Analyst | Conducted the Case Management - Incident visit and authored the report. |
| Desaree Perera | Licensing Program Manager | Supervised the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 185
Deficiencies: 2
Date: May 12, 2023
Visit Reason
The visit was a Case Management - Incident investigation to issue final findings and citations related to a previous incident involving a resident's fall and subsequent death, following a complaint and death report submitted to the Department.
Complaint Details
The visit was triggered by a death report submitted on 02/21/2020 related to Resident #1 who sustained a fall after leaving the facility unattended on 01/30/2020 and died on 02/18/2020. The investigation included interviews and record reviews and was substantiated with findings of lack of supervision.
Findings
The investigation found that the facility failed to provide proper supervision to Resident #1, who left the facility unattended, resulting in a fall, injuries, hospitalization, and death. The former Administrator was unaware of the resident's physician report restricting unsupervised leaving, indicating a lack of care and supervision.
Deficiencies (2)
Failure to provide proper supervision to Resident #1, who left the facility unassisted leading to a fall and hospitalization, posing an immediate health and safety risk.
Administrator (former) was unaware of Resident #1’s physician report indicating the resident was not allowed to leave the facility unattended, posing an immediate health and safety risk.
Report Facts
Immediate civil penalty: 500
Capacity: 185
Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Facility Administrator at time of inspection, named in relation to findings. |
| Troy Byington | Facility Executive Director (former) | Named in investigation as unaware of resident's physician report restricting unsupervised leaving. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 185
Deficiencies: 1
Date: Feb 24, 2023
Visit Reason
The inspection was conducted due to an Unusual Incident/Injury Report received regarding Resident #1 who sustained an injury from hot water used by Staff #1 during bathing. The visit was an unannounced Case Management - Incident inspection.
Complaint Details
The complaint was substantiated based on evidence that Resident #1 sustained injury from hot water used by Staff #1. Staff #1 was terminated and corrective actions were taken including moving Resident #1 to another room and conducting staff training.
Findings
The investigation found that Staff #1 used untested hot water to bathe Resident #1, causing a burn injury. The facility failed to maintain safe water temperature in Resident #1's room, which was being addressed. Staff #1 was placed on leave and subsequently terminated. A deficiency was cited for failure to provide safe accommodations.
Deficiencies (1)
Failure to accord safe, healthful and comfortable accommodations as Resident #1 sustained injury due to Staff #1 using hot water when bathing.
Report Facts
Water temperature in Resident #1's current room: 121.6
Water temperature in Resident #1's prior room: 106
Census: 90
Total capacity: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Provided incident report and information about staff termination |
| Alex Alvarado | Health and Wellness Director | Investigated incident and notified physician |
| Michelle Greenberg | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervised the inspection |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 185
Deficiencies: 1
Date: Sep 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that Staff #1 had inappropriate interactions with residents.
Complaint Details
The complaint was substantiated. Staff #1 was found to have inappropriate interactions with residents including kissing, massaging, and other boundary violations. Multiple staff and residents provided statements supporting these findings. The facility did not report the incidents to Community Care Licensing or law enforcement in a timely manner.
Findings
The investigation substantiated that Staff #1 engaged in multiple inappropriate interactions with residents, including kissing, massaging, and other personal boundary violations. The facility failed to take timely disciplinary action or report the incidents to the licensing authority or law enforcement.
Deficiencies (1)
Failure to accord residents dignity in their personal relationships with staff, residents, and other persons, as evidenced by Staff #1's inappropriate interactions with multiple residents.
Report Facts
Capacity: 185
Census: 87
Deficiency Type A: 1
Plan of Correction Due Date: Oct 4, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joey Alvarado | Administrator | Facility administrator met during inspection and exit interview |
| Matan Burstyn | Former Administrator | Former administrator involved in internal investigation and interviews |
| Michelle Greenberg | Business Office Manager | Interviewed during investigation |
| Vanessa Jewel | Former Executive Director | Mentioned in relation to prior disciplinary actions and internal investigations |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 185
Deficiencies: 2
Date: Sep 21, 2022
Visit Reason
An unannounced Case Management - Deficiencies inspection was conducted due to deficiencies observed during the investigation for Complaint control #29-AS-20211008085239 which were unrelated to the complaint allegation.
Complaint Details
The visit was complaint-related due to deficiencies observed during the investigation of Complaint control #29-AS-20211008085239. The complaint was substantiated by findings that former Administrators failed to report suspected elder abuse.
Findings
The investigation revealed that two former Administrators had knowledge of suspected elder abuse involving Staff #1 and residents but failed to report it to the Community Care Licensing Division, local law enforcement, and the Long Term Care Ombudsman, posing an immediate health and safety risk to residents.
Deficiencies (2)
Administrator did not have the required knowledge and ability to conform to applicable laws, rules, and regulations, as two former Administrators failed to comply, posing an immediate health and safety risk to residents.
Failure to report suspected physical abuse to the local ombudsman, licensing agency, and law enforcement within 24 hours as required by W&I Code Section 15630(b)(1), by former Administrators Vanessa Jewel and Matan Bursytn.
Report Facts
Census: 87
Total Capacity: 185
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewel | Former Administrator | Named in failure to report suspected abuse |
| Matan Bursytn | Former Administrator | Named in failure to report suspected abuse |
| Joey Alvarado | Current Administrator | Met during inspection and exit interview |
Inspection Report
Annual Inspection
Census: 95
Capacity: 185
Deficiencies: 1
Date: Sep 14, 2022
Visit Reason
The inspection was an unannounced Required - 1 Year annual inspection with a specific emphasis on infection control practices and procedures.
Findings
The facility was generally found to be in compliance with health and safety regulations, including operational smoke alarms, carbon monoxide detectors, and fire extinguishers. However, a deficiency was cited for unsecured over-the-counter medications in a memory care resident's unlocked room, posing an immediate health and safety risk to residents with dementia.
Deficiencies (1)
Over-the-counter medications were stored in an unlocked memory care unit resident room accessible to residents with dementia, posing an immediate health and safety risk.
Report Facts
Residents in memory care: 29
Deficiency count: 1
POC Due Date: Sep 19, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joey Vic Alvarado | Administrator | Met with Licensing Program Analyst during inspection and involved in findings discussion |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 185
Deficiencies: 0
Date: Sep 14, 2022
Visit Reason
The inspection was conducted as an unannounced Case Management - Incident visit following a self-reported incident of suspected adult/elder abuse involving Resident #1 and Staff #1.
Complaint Details
The complaint involved suspected verbal abuse by Staff #1 towards Resident #1, reported on 08/27/2022 and self-reported to the licensing agency on 09/01/2022. The allegation was investigated internally and cross-reported to law enforcement and the long term care ombudsman. The complaint was not substantiated with citations at this time.
Findings
The investigation included review of video footage and interviews with staff and the resident. Staff #1 was placed on administrative leave and subsequently terminated after an internal investigation. No citations were issued at this time, but a follow-up visit may occur if needed.
Report Facts
Facility capacity: 185
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Met with Licensing Program Analyst and conducted internal investigation |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection |
| Guadalupe de Los Santos | Memory Care Health Services Director | Reported verbal abuse incident and interviewed during inspection |
| Alex Alvarado | Health and Wellness Director | Observed video footage and involved in placing Staff #1 on administrative leave |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 185
Deficiencies: 0
Date: Mar 8, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2021-03-12 regarding staff yelling at a resident and failure to ensure a resident had water.
Complaint Details
The complaint involved allegations that facility staff yelled at residents and did not ensure residents had water. After multiple interviews with residents, staff, and a family member, the allegations were deemed unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations that staff yelled at residents or failed to ensure residents had water. Resident and staff interviews, as well as observations, indicated appropriate and respectful care with no observed verbal abuse or neglect regarding water provision.
Report Facts
Capacity: 185
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Joey Alvarado | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Kawana Anthony | Administrator | Facility administrator named in the report header |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 185
Deficiencies: 0
Date: Mar 8, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of unexplained bruising observed on residents in the memory care unit.
Complaint Details
The complaint alleged unexplained bruising on residents possibly due to neglect or abuse. The investigation found insufficient evidence to substantiate the claim, and the allegation was unsubstantiated.
Findings
The investigation found that residents had bruising likely due to skin integrity issues, medication side effects, or accidental causes, with no evidence of neglect or abuse. Staff documented and reported bruises per protocol, and residents denied abuse. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 185
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Joey Alvarado | Executive Director | Met with Licensing Program Analyst during the visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report signature |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 185
Deficiencies: 1
Date: Dec 5, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that medications were not being administered to residents per doctor's orders, staff were not meeting residents' needs, staff lacked proper supplies for resident oxygen, and a manager was not always available for assistance.
Complaint Details
The complaint investigation was substantiated regarding medication administration errors, including a December 2019 incident and a November 28, 2021 incident where 28 residents missed their 5:00 p.m. medication dose. Other complaints about staff care, oxygen supplies, and manager availability were unsubstantiated.
Findings
The investigation substantiated the allegation that medications were not administered per doctor's orders, including a medication error affecting 28 residents on 11/28/2021. Other allegations regarding staff meeting residents' needs, availability of oxygen supplies, and manager availability were found unsubstantiated.
Deficiencies (1)
87465(a)(5) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by residents not receiving medication timely and missing evening medications on 11/28/2021, posing an immediate health and safety risk.
Report Facts
Residents affected by medication error: 28
Facility capacity: 185
Census: 88
Plan of Correction due date: Dec 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
| Lauria Gallagher | Community Relations Director | Met with the Licensing Program Analyst during the investigation |
| Troy Byington | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 185
Deficiencies: 2
Date: Dec 5, 2021
Visit Reason
This was an unannounced complaint investigation visit triggered by allegations of staff mishandling medication and failure to report unusual incidents.
Complaint Details
The complaint investigation was substantiated. Allegations included staff mishandling medication and failure to report unusual incidents. Evidence showed a medication error affecting 28 residents and failure to submit incident reports for bruising and hospitalizations. The facility was found non-compliant with reporting and medication administration regulations.
Findings
The investigation substantiated that staff mismanaged medication on 11/28/2021 when approximately 28 residents did not receive their 5:00 p.m. medication dose, and that the facility failed to report unusual incidents including unexplained bruising and hospitalizations as required by regulations.
Deficiencies (2)
Failure to assist residents with self-administered medications as needed, resulting in residents not receiving evening medication dose on 11/28/2021.
Failure to submit written reports of unusual incidents to the licensing agency within seven days as required.
Report Facts
Residents affected by medication error: 28
Facility capacity: 185
Census: 88
Plan of Correction due date: Dec 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
| Lauria Gallagher | Community Relations Director | Met with the Licensing Program Analyst during the investigation |
| Kawana Anthony | Administrator | Facility administrator involved in the investigation and plan of correction |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 185
Deficiencies: 0
Date: Nov 22, 2021
Visit Reason
The visit was an unannounced complaint investigation to conclude an investigation initiated on 09/17/2020 regarding allegations of staff neglecting Resident #1 and insufficient staffing in the dining area.
Complaint Details
The complaint alleged that facility staff neglected Resident #1, resulting in a fall due to improperly placed dining chairs, and that there was insufficient staffing in the dining area. Both allegations were deemed unsubstantiated based on investigation findings.
Findings
The investigation found insufficient evidence to substantiate the allegations of staff neglect causing Resident #1 to fall and insufficient staffing in the dining area. Interviews and reviews indicated adequate staffing and mindful staff behavior regarding chair placement.
Report Facts
Staffing levels: 4
Staffing levels: 6
Facility capacity: 185
Resident census: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Guzman-Chavez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
| Joeyvic Alvarado | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 185
Deficiencies: 1
Date: Nov 10, 2021
Visit Reason
The inspection was conducted due to a deficiency observed during a complaint investigation related to an incident between two residents on 10/21/2021.
Complaint Details
The visit was triggered by a complaint investigation control number 29-AS-20211102115349 regarding an incident on 10/21/2021 where Resident #1 accused Resident #2 of pushing. The facility failed to timely complete and submit the required licensing report.
Findings
The licensee failed to submit a written report of the incident to licensing within seven days as required, resulting in a citation being issued.
Deficiencies (1)
Failure to submit a written report to the licensing agency within seven days of the occurrence as required by reporting requirements.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joeyvic Alvarado | Administrator | Met with Licensing Program Analyst during inspection; named in report findings |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor named in report |
| Walter Cline | Operations Specialist | Completed the Suspected Dependent Adult/Elder Abuse form related to the incident |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 185
Deficiencies: 0
Date: Nov 10, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that a resident was hit by another resident and did not receive medical treatment for their injury.
Complaint Details
The complaint involved allegations that a resident was hit by another resident and did not receive medical treatment for their injury. Both allegations were deemed unsubstantiated based on interviews, record reviews, and follow-up medical care.
Findings
The investigation found insufficient evidence to substantiate the allegations. The incident between residents was confirmed, but there was no evidence of lack of supervision or failure to provide medical treatment. The resident was offered emergency services but declined, and later received medical care after obtaining a new physician.
Report Facts
Capacity: 185
Census: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Joeyvic Alvarado | Administrator | Facility administrator involved in the inspection and exit interview |
| Michelle Greenberg | Business Manager | Met with Licensing Program Analyst during inspection |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 185
Deficiencies: 1
Date: Oct 4, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-06-09 alleging insufficient staffing at the facility.
Complaint Details
The complaint alleged insufficient staffing. The allegation was substantiated based on interviews with staff, residents, collateral agencies, and management, confirming chronic understaffing and related care delays.
Findings
The investigation found substantiated evidence of insufficient staffing, with staff regularly transferring residents alone despite the need for two-person assistance for many residents. The facility was aware of staffing shortages and was in the process of hiring additional caregivers.
Deficiencies (1)
87411(a) Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by staffing challenges posing an immediate health and safety risk to residents.
Report Facts
Memory care residents requiring extensive assistance: 32
Residents requiring two-person assist: 10
Care staff on shift as communicated: 3
Care staff often available: 2
Deficiency Plan of Correction due date: Oct 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in relation to the investigation and report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 185
Deficiencies: 1
Date: Oct 4, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including insufficient staffing to meet residents' needs, residents not getting meals, and the facility not being well-lit.
Complaint Details
The complaint investigation was substantiated for insufficient staffing to meet residents' needs. It was found that out of 32 memory care residents, many required extensive assistance, including two-person transfers, but staffing was often insufficient. The facility was aware and in the process of hiring additional caregivers. The allegations regarding residents not getting meals and the facility being poorly lit were unsubstantiated.
Findings
The investigation substantiated the allegation of insufficient staffing, finding that the facility often had fewer care staff than required, posing an immediate health and safety risk. The allegations that residents were not getting meals and that the facility was not well-lit were found to be unsubstantiated based on observations and interviews.
Deficiencies (1)
Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by staffing challenges posing an immediate health and safety risk.
Report Facts
Memory care residents: 32
Residents requiring two-person assist: 10
Care staff on shift: 3
Care staff available: 2
Capacity: 185
Census: 91
Plan of Correction due date: Oct 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
| Michelle Greenberg | Facility representative met during the investigation | |
| Lorrie Marcott | Administrator | Facility administrator mentioned in the report |
Inspection Report
Annual Inspection
Census: 89
Capacity: 185
Deficiencies: 0
Date: Aug 19, 2021
Visit Reason
An unannounced required 1-year inspection was conducted to evaluate compliance with licensing requirements and infection control practices at the facility.
Findings
No deficiencies were observed during the inspection. The facility was found to have proper infection control, adequate food storage, functional smoke alarms, operational fire extinguishers, and proper medication storage and administration.
Report Facts
Licensed capacity: 185
Resident census: 89
Inspection duration: 4.67
Fire extinguisher last serviced date: Feb 25, 2021
Licensing fees due date: Sep 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matan Burstyn | Administrator | Met with Licensing Program Analysts during inspection and discussed inspection findings |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection |
| Martha Guzman-Chavez | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 185
Deficiencies: 2
Date: Apr 13, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations that the facility neglected a resident resulting in infections and failure to meet the resident's needs, including grooming and physician orders.
Complaint Details
The complaint investigation was substantiated for neglect resulting in infections and failure to meet resident needs, including grooming and dietary orders. The allegation that the facility did not notify the resident's representative of the decline in health was unsubstantiated.
Findings
The investigation substantiated that the facility neglected Resident #1, who developed multiple infections and was not provided proper care including personal grooming and physician-ordered dietary needs. The facility failed to follow up on a urinalysis order and did not adequately address changes in the resident's condition. However, the allegation that the facility failed to notify the resident's representative of the decline in health was unsubstantiated.
Deficiencies (2)
87464(f)(1) Basic Services. The facility did not ensure that Resident #1's care needs were met, posing an immediate health and safety risk.
87466 Observation of the Resident. The facility staff did not document or report Resident #1's grooming and hygiene changes to management, physician, or representatives, posing an immediate health and safety risk.
Report Facts
Capacity: 185
Census: 78
Deficiencies cited: 2
Plan of Correction Due Date: Apr 16, 2021
Plan of Correction Training Due Date: Apr 26, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
| Matan Burstyn | Executive Director | Facility representative met during virtual inspection |
| Vanessa Jewell | Administrator | Facility administrator named in the report |
| Edward Hector | Investigator | Assigned investigator who reviewed medical records and conducted interviews |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 185
Deficiencies: 2
Date: Feb 16, 2021
Visit Reason
An unannounced complaint investigation was conducted following allegations that a resident sustained a broken bone while in care and that the facility failed to seek timely medical attention for the resident.
Complaint Details
The complaint was substantiated for allegations that the resident sustained a broken bone while in care and that the facility failed to seek timely medical attention. Other allegations including questionable death, malnourishment, severe dehydration, and severe infection leading to sepsis were unsubstantiated.
Findings
The investigation substantiated that the resident sustained a broken bone while in care and that the facility failed to seek timely medical attention. However, allegations regarding neglect causing malnourishment, severe dehydration, severe infection leading to sepsis, and questionable death were unsubstantiated due to insufficient evidence.
Deficiencies (2)
Basic services requirement not met as resident suffered a broken bone unknown to staff, posing immediate health and safety risk.
Failure to properly report or document resident's falls, swelling, bruising, and broken bone unknown to staff, posing immediate health and safety risk.
Report Facts
Civil Penalty: 500
Civil Penalty: 250
Capacity: 185
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Kawana Anthony | Executive Director | Facility administrator interviewed during investigation. |
| Laura Garcia | Investigator | Community Care Licensing Division’s Investigations Branch Investigator assigned to the case. |
Report
June 16, 2025
Report
March 12, 2025
Report
December 12, 2024
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