Inspection Reports for Oakmont of San Jose
917 Thornton Way, San Jose, CA 95128, United States, CA, 95128
Back to Facility ProfileInspection Report Summary
Most inspections at this facility found no deficiencies, including the most recent annual inspection on April 11, 2025, which was perfect with no issues cited. However, several complaint investigations over the past two years substantiated deficiencies related primarily to resident care, staffing shortages, medication management, and failure to follow proper procedures such as timely medical attention and accurate recordkeeping. Notably, investigations in 2024 and 2025 found problems with delayed medication administration, inadequate response to resident call buttons, unauthorized fee increases without proper notice, and failure to report suspected abuse promptly. Some investigations also substantiated breaches of resident confidentiality and improper eviction notices, but many other complaints were unsubstantiated. The facility appears to have improved recently, with the latest reports showing no deficiencies and several prior issues addressed or resolved.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
66% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 61
Capacity: 92
Deficiencies: 0
Date: May 29, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-01-23 regarding inappropriate touching, pushing, restraint, and neglect of a resident at Oakmont of San Jose.
Complaint Details
The complaint involved multiple allegations against staff including inappropriate touching, pushing, inappropriate restraint, leaving a resident soiled, and failure to ensure toilet flushing. Interviews with the resident, staff, law enforcement, and other residents were conducted. The resident denied some allegations and staff denied all. Law enforcement found no evidence or injuries. The allegations were determined unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found the allegations unsubstantiated based on interviews, record reviews, and observations. No visible injuries or evidence supported the claims, and staff denied inappropriate conduct. No deficiencies were cited.
Report Facts
Capacity: 92
Census: 61
Resident interviews: 6
Staff interviews: 4
Resident reports of being left soiled: 1
Residents reporting no extended soiling: 5
Residents with flushed toilets observed: 5
Residents with unflushed toilets observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Kabariti | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jackie Jin | Licensing Program Manager | Oversaw the complaint investigation |
| Kippie Castronovo | Executive Director | Facility representative met during investigation and report review |
Inspection Report
Annual Inspection
Census: 66
Capacity: 92
Deficiencies: 0
Date: Apr 11, 2025
Visit Reason
An unannounced annual inspection was conducted as a required 1-year visit to evaluate compliance with licensing regulations.
Findings
The inspection found the facility to be in compliance with all applicable regulations with no deficiencies cited. The facility was observed to be well maintained, with proper safety measures, adequate staffing, and complete records.
Report Facts
Staff count: 19
Resident rooms: 67
Fire extinguisher service dates: 2
Fire drill date: Fire drill conducted on 12/31/2024
Perishable food supply duration: 2
Non-perishable food supply duration: 7
Refrigerator temperature: 32
Freezer temperature: 14
Staff records reviewed: 4
Client records reviewed: 5
Client medications reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Santino Fortes | Licensing Program Analyst | Conducted the inspection |
| Jan Krum | Marketing Director | Met with Licensing Program Analyst during inspection |
| Val Baldugo | Acting Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 1
Date: Sep 13, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received regarding fee increases without proper notice, charging fees for services not provided, and failure to notify a resident's physician of a change in condition.
Complaint Details
The complaint investigation was triggered by allegations that the facility increased resident fees without proper notice, charged fees for services not provided, and failed to notify a resident's physician of a change in condition. The fee increase allegation was substantiated, the fees for services not provided allegation was unfounded, and the failure to notify physician allegation was unsubstantiated.
Findings
The investigation substantiated that the facility increased a resident's fees without providing the required written notice within two business days. The allegation that the facility charged fees for services not provided was found to be unfounded. The allegation regarding failure to notify the resident's physician of a change in condition was unsubstantiated due to insufficient evidence.
Deficiencies (1)
Facility did not provide 2 day written notice about detailing the new rate for the charges for the new level of care.
Report Facts
Capacity: 92
Census: 62
Deficiency Type B: 1
Plan of Correction Due Date: Sep 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Kippie Castronovo | Executive Director | Met with Licensing Program Analyst during the investigation |
| Flavio Silva | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 92
Deficiencies: 2
Date: Sep 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 05/18/2022 regarding staff not following COVID-19 protocols, unsanitary medication administration, staff working while ill, failure to perform hand hygiene, and alleged misinformation about COVID-19 cases to family members.
Complaint Details
The complaint investigation was substantiated for allegations related to staff not following COVID-19 protocols and unsanitary medication administration. Allegations that staff were providing care while ill and not performing hand hygiene were unsubstantiated. The allegation that the administrator was not disclosing COVID-19 cases truthfully to family members was unfounded.
Findings
The investigation substantiated allegations that staff failed to follow COVID-19 protocols and administered medication unsanitarily, posing immediate health and safety risks. Other allegations, including staff working while ill, failure to perform hand hygiene, and administrator not disclosing COVID-19 cases truthfully, were found to be unsubstantiated or unfounded.
Deficiencies (2)
Failure to ensure residents are accorded safe, healthful and comfortable accommodations, furnishings and equipment, evidenced by staff not wearing appropriate PPE while serving food to COVID residents and not wearing masks while speaking to COVID residents.
Failure to have sufficient and competent personnel to meet resident needs, evidenced by staff administering medication that had fallen on the floor.
Report Facts
Facility capacity: 92
Census: 82
Deficiencies cited: 2
Plan of Correction due date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jackie Jin | Licensing Program Manager | Oversaw the complaint investigation |
| Sherry Theam | Memory Care Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 92
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2022-05-23 alleging that staff did not accord resident dignity and respect and did not respect resident's personal privacy.
Complaint Details
The complaint alleged that staff entered a resident's apartment without permission and did not respect the resident's privacy. Staff explained their procedures for knocking and entering when residents do not respond. The investigation found no conclusive evidence to substantiate the allegations.
Findings
Based on interviews with staff and review of records, the department determined that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegations were unsubstantiated.
Report Facts
Facility capacity: 92
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kippie Castronovo | Executive Director | Met with investigators during the visit |
| Flavio Silva | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 92
Deficiencies: 2
Date: Aug 26, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not maintain accurate resident records and disclosed resident confidential records to unauthorized persons.
Complaint Details
The complaint investigation was substantiated based on interviews and records review. Allegations included inaccurate resident records and unauthorized disclosure of confidential resident information.
Findings
The investigation substantiated that the facility failed to maintain accurate resident records for a resident (R1), including incorrect primary physician information and missing diagnosis. Additionally, staff disclosed confidential COVID-19 test results of another resident (R2) to an unauthorized person, posing immediate health, safety, or personal rights risks.
Deficiencies (2)
Resident records did not contain correct primary physician information, posing an immediate health, safety or personal rights risk.
Confidentiality of resident records was breached by unauthorized disclosure of COVID-19 test results.
Report Facts
Facility Capacity: 92
Census: 65
Deficiencies cited: 2
Plan of Correction Due Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted investigation and cited deficiencies |
| Jackie Jin | Licensing Program Manager | Oversaw complaint investigation |
| Kippie Castronovo | Executive Director | Met with investigators during the visit |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 92
Deficiencies: 1
Date: Aug 26, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that the facility did not adhere to the residents' admission agreement.
Complaint Details
The complaint was substantiated based on interviews and records review showing the facility increased fees after move-in contrary to the admission agreement.
Findings
The investigation substantiated that the facility changed the agreed-upon fee after the resident moved in, increasing the rate from $3,179 to $4,148 effective 2/1/2019, which violated the admission agreement requirements.
Deficiencies (1)
Facility did an initial assessment after resident's move-in which changed the agreed upon rate in the admission agreement, violating CCR 87507(g)(3)(B).
Report Facts
Deficiencies cited: 1
Census: 65
Total Capacity: 92
Fee increase: 969
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
| Kippie Castronovo | Executive Director | Met with investigators during complaint investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 92
Deficiencies: 1
Date: Aug 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-12-11 regarding staff response times to resident alerts, food temperature, staff supervision, environment comfort, medication training, and staff qualifications.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not respond timely to residents' alert calls, with evidence including call logs showing numerous calls with response times over 10 minutes and resident interviews confirming delayed responses. Other allegations were unsubstantiated or unfounded based on interviews, observations, and record reviews.
Findings
The investigation substantiated that staff did not respond timely to resident call alerts due to insufficient staffing, resulting in a cited deficiency. Other allegations including cold food, staff sleeping on duty, leaving residents unattended, uncomfortable environment, and improper medication training were unsubstantiated with no deficiencies cited. An allegation regarding staff performing duties without appropriate skilled professional present was also unfounded.
Deficiencies (1)
Facility personnel were not sufficient in numbers to respond timely to resident call buttons, posing immediate health, safety, and personal rights risks.
Report Facts
Calls with response time 10 minutes or more: 801
Calls with response time 10 minutes or more: 383
Calls with response time 10 minutes or more: 4
Residents interviewed: 10
Staff interviewed: 7
MedTech medication training hours: 24
MedTech in-service training dates: 5
Facility capacity: 92
Facility census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kippie Castronovo | Executive Director | Met with Licensing Program Analysts during inspection and involved in findings review |
| Christine Dolores | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Grace Donato | Licensing Program Analyst | Assisted in complaint investigation and findings delivery |
| Paula Spanek | Administrator | Facility administrator mentioned in report header |
| S8 | Staff member with LVN license | Alleged to perform duties without appropriate skilled professional present; denied allegations |
| Sarah Yip | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 92
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-12-05 regarding unexplained bruising, rough handling, inappropriate staff behavior, and staff inability to meet resident needs due to injury.
Complaint Details
The complaint involved allegations that a resident sustained an unexplained bruise, staff handled the resident roughly, staff spoke and yelled inappropriately, and staff with a sprained arm was unable to meet resident needs. Interviews with staff and residents, record reviews, and police reports were conducted. The allegations were found unsubstantiated due to lack of evidence and conflicting accounts.
Findings
The investigation found the allegations unsubstantiated based on interviews, record reviews, and observations. No deficiencies were cited. The bruise on the resident was possibly caused by the wheelchair, and staff behavior allegations were denied by all interviewed staff and residents. Staff with a sprained arm was not assigned caregiving duties.
Report Facts
Capacity: 92
Census: 65
Staff interviewed: 10
Staff interviewed: 11
Residents interviewed: 2
Staff interviewed: 9
Date complaint received: Dec 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Grace Donato | Licensing Program Analyst | Arrived unannounced to deliver findings |
| Kippie Castronovo | Executive Director | Met with Licensing Program Analysts during investigation |
| Paula Spanek | Administrator | Facility administrator named in report header |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 92
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 07/12/2022 alleging that staff engaged in a verbal altercation in the presence of residents.
Complaint Details
The complaint alleged that staff engaged in a verbal altercation in the presence of residents. The investigation included interviews with residents and staff, who denied witnessing or hearing any altercation. The allegation was unsubstantiated.
Findings
After interviewing multiple residents and staff, including the reporting party and witnesses, the department found no preponderance of evidence to substantiate the allegation of a verbal altercation between staff and a resident/family member. The allegation was determined to be unsubstantiated.
Report Facts
Complaint received date: Jul 12, 2022
Facility capacity: 92
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kippie Castronovo | Executive Director | Met with investigators during the visit |
| Flavio Silva | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 1
Date: Jul 18, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident was unlawfully evicted while in care.
Complaint Details
The complaint was substantiated. The allegation was that a resident was unlawfully evicted while in care. The investigation confirmed that the eviction notice was unlawful and invalid due to procedural deficiencies.
Findings
The investigation substantiated the allegation that the facility issued an unlawful 30-Day Notice of Termination of Residence Agreement. The eviction notice was found invalid due to incorrect 30th day calculation and missing required information such as the address of the State Local Long Term Care Ombudsman and resources for alternative housing and care options.
Deficiencies (1)
Failure to include required information in the eviction notice, including reasons for eviction, correct 30-day notice period, address of the State Local Long Term Care Ombudsman, and resources for alternative housing and care options.
Report Facts
Capacity: 92
Census: 62
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Jackie Jin | Licensing Program Manager | Reviewed the eviction letter and managed the licensing program |
| Kippie Castronovo | Executive Director | Met with LPAs during the investigation |
| Flavio Silva | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 92
Deficiencies: 0
Date: Jul 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-06 concerning staff response times, incident reporting, visitor treatment, and financial retaliation at Oakmont of San Jose.
Complaint Details
The complaint included allegations that staff did not attend to a resident in a timely manner, failed to report a resident's fall to the responsible party, did not treat a resident's visitor with dignity, and financially retaliated against the resident by increasing care fees. The investigation concluded all allegations were unsubstantiated.
Findings
The investigation found the allegations unsubstantiated based on staff interviews, record reviews, and observations. No deficiencies were cited. Staff generally responded to resident calls, incident reporting was not documented but the facility treated the incident as if it did not occur, visitor monitoring allegations were denied by staff, and the financial retaliation claim was linked to increased care needs but was not substantiated as retaliatory.
Report Facts
Capacity: 92
Census: 62
Staff interviewed: 10
Staff interviewed: 5
Staff interviewed: 9
Staff interviewed: 10
Resident assessments compared: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation |
| Kippie Castronovo | Executive Director | Facility representative met during investigation and report review |
Inspection Report
Follow-Up
Census: 57
Capacity: 92
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
The visit was a case management incident follow-up conducted unannounced to review a complaint regarding a refund issued to a resident who vacated the facility on 12/28/2023.
Complaint Details
The complaint involved allegations that the facility did not issue a refund within 15 days and did not provide the full refund based on the final account statement. The complaint was amended during the visit and found to be resolved with no deficiencies cited.
Findings
The review found that the facility initially delayed the refund beyond 15 days and incorrectly calculated the refund amount using the original community fee rate instead of the discounted rate. After correction, the refund amount was accurate and compliant with regulations. No deficiencies were cited during this visit.
Report Facts
Refund percentage: 40
Census: 57
Total capacity: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francisco Sudiacal | Business Office Director | Met during the inspection and involved in the refund discussion. |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Sarah Yip | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 56
Capacity: 92
Deficiencies: 0
Date: May 10, 2024
Visit Reason
Unannounced case management visit conducted due to information obtained during a complaint investigation.
Complaint Details
Visit was related to a complaint investigation with control number 26-AS-20231227155220; case management visit pending further investigation.
Findings
No deficiencies were cited per California Code of Regulations, Title 22. The visit was pending additional investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schuster | Interim Executive Director | Met with Licensing Program Analysts during the visit. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 92
Deficiencies: 1
Date: May 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple complaints received on 12/27/2023 regarding failure to seek timely medical attention resulting in hospitalization, medication dispensing errors, unauthorized recording of residents, retaliation against a resident, and unmet showering needs.
Complaint Details
The complaint investigation was substantiated for failure to seek timely medical attention for resident (R1), resulting in hospitalization with a life-threatening infection and virus. Other complaints regarding medication dispensing, unauthorized recording, retaliation, and showering needs were unsubstantiated or unfounded.
Findings
The investigation substantiated the allegation that the facility failed to seek timely medical attention for a resident (R1), resulting in hospitalization and an immediate civil penalty. Other allegations including medication dispensing errors, unauthorized recording, retaliation, and unmet showering needs were found to be unsubstantiated or unfounded. One deficiency was cited related to failure to ensure timely medical attention.
Deficiencies (1)
Failure to ensure timely medication attention for resident (R1) resulting in hospitalization, posing an immediate health, safety, and personal rights risk.
Report Facts
Capacity: 92
Census: 56
Civil penalty: 500
Acuity points: 65
Billable points: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schuster | Interim Executive Director | Met with Licensing Program Analysts during investigation |
| Christine Dolores | Licensing Program Analyst | Conducted complaint investigation |
| Grace Donato | Licensing Program Analyst | Assisted in complaint investigation |
| Paula Spanek | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 92
Deficiencies: 0
Date: May 10, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that facility staff disclosed confidential information about other residents to a visitor.
Complaint Details
The complaint alleged that in the first week of December 2023, a staff member randomly shared confidential information about residents R1, R2, and R3 to a visitor. Interviews with 7 staff members and 3 witnesses all denied the disclosure. No disciplinary actions were taken against the staff member involved. The allegation was found unsubstantiated.
Findings
The investigation included interviews with staff and witnesses and a review of records. The allegation was determined to be unsubstantiated as there was no preponderance of evidence to prove the alleged violation occurred. No deficiencies were cited.
Report Facts
Capacity: 92
Census: 56
Staff interviewed: 7
Witnesses interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francisco Sudiacal | Business Office Director | Met with Licensing Program Analysts during investigation and report review |
| Christine Dolores | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 92
Deficiencies: 2
Date: May 10, 2024
Visit Reason
The visit was an unannounced case management deficiencies inspection conducted due to violations observed during a prior complaint investigation related to resident care.
Complaint Details
The visit was triggered by a complaint investigation (control number: 26-AS-20231227155220) regarding delayed medication administration and failure to notify the physician of a resident's change in condition. The complaint was substantiated with deficiencies cited.
Findings
The facility failed to provide a resident (R1) with a PRN medication in a timely manner, delaying administration by about 2 hours, and did not immediately notify the resident's physician of a change in condition, posing immediate health, safety, and personal rights risks.
Deficiencies (2)
Resident (R1) was not provided a PRN medication within a timely manner, with about a 2-hour delay before administration.
The licensee did not immediately inform resident (R1)'s physician of R1's change of condition on 12/26/2023.
Report Facts
Civil penalty amount: 250
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schuster | Interim Executive Director | Met with Licensing Program Analysts during the inspection and was reviewed the report. |
| Christine Dolores | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Sarah Yip | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 92
Deficiencies: 5
Date: May 10, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2023-10-27 regarding resident care issues including pressure injuries, medication administration, soiled diapers, staffing adequacy, and food service.
Complaint Details
The complaint investigation was substantiated for allegations including resident pressure injury due to staff neglect, failure to administer medication, leaving resident in soiled diapers, unmet resident needs, and inadequate staffing in memory care. Allegations of inadequate food service and unqualified staff were unsubstantiated or unfounded.
Findings
The investigation substantiated several allegations including resident pressure injury due to staff neglect, failure to administer medication as prescribed, leaving resident in soiled diapers, unmet resident needs, and inadequate staffing in memory care. Some allegations such as inadequate food service and unqualified staff were unsubstantiated or unfounded. Deficiencies were cited with plans of correction required.
Deficiencies (5)
Failure to conduct skin check prior to admission to identify pressure injury on resident R1.
Failure to administer PRN medication as prescribed, applied only on random days instead of after each bowel movement/diaper change.
Failure to regularly observe and document changes in resident condition, including pressure injury blister.
Failure to update pre-admission appraisal based on significant changes in resident's health care needs.
Insufficient staffing to meet resident R1's needs, particularly related to incontinence care.
Report Facts
Capacity: 92
Census: 56
Civil penalty amount: 250
Diaper changes: 4
Caregivers per shift: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Christopher Schuster | Interim Executive Director | Met with LPAs during investigation |
| Paula Spanek | Administrator | Facility administrator named in report |
Inspection Report
Annual Inspection
Census: 60
Capacity: 92
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
An unannounced annual visit was conducted to evaluate the facility's compliance with regulatory requirements and overall conditions.
Findings
The facility was found to be in good condition with no deficiencies cited. Resident and staff records were complete and up to date, medications were properly stored and accounted for, and residents reported satisfaction with care and food.
Report Facts
Temperature: 78
Hot water temperature: 110
Food supply duration: 2
Food supply duration: 7
Resident records reviewed: 5
Staff records reviewed: 5
Residents interviewed: 5
Staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schuster | Interim Executive Director | Met with Licensing Program Analyst during inspection |
| Grace Donato | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 92
Deficiencies: 2
Date: Feb 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff did not administer a resident's medication as prescribed and failed to notice a resident's change of condition.
Complaint Details
The complaint was substantiated based on evidence that staff did not administer PRN medication as prescribed and failed to notice and report a resident's change of condition related to constipation. The investigation included interviews with 9 staff members and review of medical and facility records.
Findings
The investigation substantiated that staff failed to assist resident R1 with prescribed PRN medication for constipation after noting no bowel movement for over 3 days, and failed to notify the resident's physician and family member, posing immediate health and safety risks.
Deficiencies (2)
Licensee did not ensure to assist R1 with prescribed PRN medication for constipation after noting no bowel movement for more than 3 days.
Licensee did not ensure residents were regularly observed for changes in condition and failed to document and notify physician and responsible party of R1's condition.
Report Facts
Staff interviewed: 9
Days without bowel movement: 3
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Spanek | Executive Director | Met with Licensing Program Analyst during investigation and named in report |
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 58
Capacity: 92
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
The visit was an unannounced case management follow-up regarding a concern about a pending refund for a resident who vacated the premises on 12/28/2023.
Findings
During the visit, the Licensing Program Analyst interviewed one staff member and obtained the resident's final account statement and Residence and Services Agreement. The case management visit remains open and pending further investigation.
Report Facts
Resident vacated date: Dec 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Spanek | Executive Director | Met with Licensing Program Analyst during visit and reviewed report |
| Christine Dolores | Licensing Program Analyst | Conducted the case management visit |
| Sarah Yip | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 92
Deficiencies: 1
Date: Jan 17, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that the facility did not report suspected abuse within the required 24-hour timeframe to appropriate agencies.
Complaint Details
The complaint alleged that the facility did not report suspected abuse within 24 hours to the Department and appropriate agencies. The allegation was substantiated based on interviews, record review, and observation.
Findings
The investigation substantiated that the facility failed to report suspected physical abuse of a resident by staff within 24 hours to local law enforcement and the licensing department, posing an immediate health and safety risk. A deficiency was cited under California Code of Regulations, Title 22, Section 87211(c).
Deficiencies (1)
Failure to report suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult to the local ombudsman, licensing agency, and local law enforcement within 24 hours as required by Welfare and Institutions Code Section 15630(b)(1).
Report Facts
Capacity: 92
Census: 58
Deficiency count: 1
Plan of Correction Due Date: Jan 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Dolores | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Paula Spanek | Executive Director | Facility representative involved in the investigation and report review |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 92
Deficiencies: 2
Date: Nov 1, 2023
Visit Reason
The visit was an unannounced case management - incident inspection conducted as a continuation of a prior investigation triggered by an incident and death report involving resident R1.
Complaint Details
The visit was based on an incident report and death report for resident R1. The complaint investigation substantiated that the facility failed to conduct required re-assessment and notification after multiple falls, contributing to resident harm.
Findings
The investigation found that the facility failed to re-assess resident R1 after a fall in memory care and did not notify the resident's family or physician after a second fall on the same day, posing immediate health, safety, and personal rights risks.
Deficiencies (2)
The licensee did not ensure to re-assess resident (R1) after sustaining a fall in memory care which poses/posed an immediate health, safety, and personal rights risk to persons in care.
The licensee did not ensure to inform the resident's responsible party and physician after resident (R1) sustained a second fall on the same day which poses/posed an immediate health safety and personal rights risk to persons in care.
Report Facts
Capacity: 92
Census: 92
Deficiencies cited: 2
Plan of Correction Due Date: Nov 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Spanek | Executive Director | Met with Licensing Program Analyst during inspection and discussed findings |
| Christine Dolores | Licensing Program Analyst | Conducted the case management - incident visit and authored the report |
| Sarah Yip | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 61
Capacity: 92
Deficiencies: 0
Date: Aug 4, 2023
Visit Reason
The visit was an unannounced case management - incident visit triggered by an incident and death report received on 08/03/2023 for a resident.
Findings
No deficiencies were cited during the visit. The case management remains open pending additional information.
Report Facts
Capacity: 92
Census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Spanek | Assistant Executive Director | Met with Licensing Program Analyst during the visit |
| Christine Dolores | Licensing Program Analyst | Conducted the case management - incident visit |
| Sarah Yip | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 92
Deficiencies: 1
Date: Jun 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff did not respond to residents' call buttons and did not immediately provide residents' authorized representatives with facility policies and procedures.
Complaint Details
The complaint investigation was substantiated for failure to respond to resident call buttons but unfounded for failure to provide documents to authorized representatives.
Findings
The investigation substantiated that staff failed to respond to resident call alarms, with 116 instances recorded where calls were not answered. However, the allegation regarding withholding documents from authorized representatives was found to be unfounded after review of records and interviews.
Deficiencies (1)
Facility personnel did not respond to calls for assistance from resident call pendants and alarms, posing a potential threat to resident health and safety.
Report Facts
Instances of unanswered calls: 116
Number of caregivers in memory care wing: 3
Facility capacity: 92
Resident census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted the complaint investigation |
| San Sor | Administrator | Facility administrator involved in investigation and exit interview |
| Sherry Tham | Memory Care Director | Informed investigator about alarm notifications |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 92
Deficiencies: 0
Date: Jun 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-06-01 regarding staff not safeguarding a resident's personal property.
Complaint Details
The complaint alleged staff were not safeguarding a resident's personal property. The investigation included interviews with the resident, two witnesses, and the administrator. The resident opted out of a personal property inventory. The allegation was unsubstantiated.
Findings
The investigation found that one resident expressed concerns about missing clothing items, but was unable to identify specific articles. Witnesses observed missing items but noted the facility promptly corrected issues and reimbursed missing clothing upon proof of purchase. No proof of purchase was provided. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the visit.
Report Facts
Complaint Control Number: 26
Capacity: 92
Census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| San Sor | Administrator | Facility administrator interviewed during investigation |
| Sarah Yip | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Follow-Up
Census: 64
Capacity: 92
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
The visit was an unannounced case management incident follow-up to review an elopement incident involving a resident on 02/18/2023.
Findings
The inspection found no deficiencies; the facility had conducted staff in-service training and care planning following the elopement incident, and the resident was safe with no injuries noted.
Report Facts
Incident date: Feb 18, 2023
Staff in-service training date: Feb 20, 2023
Care meeting date: Feb 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| San Sor | Executive Director | Met with Licensing Program Analysts during the visit and involved in incident follow-up |
| Sherry Theam | Memory Care Director | Met with Licensing Program Analysts during the visit and involved in incident follow-up |
| Paula Spanek | Health Service Director | Met with Licensing Program Analysts during the visit and involved in incident follow-up |
Inspection Report
Follow-Up
Capacity: 92
Deficiencies: 3
Date: Apr 8, 2022
Visit Reason
The visit was an unannounced follow-up pre-licensing inspection to verify correction of deficiencies and technical violations cited during a previous visit on 03/24/2022.
Findings
The Licensing Program Analyst observed that the previously cited deficiency and technical violations were corrected, including medication logs, personnel records, and emergency supplies. No issues were noted during this pre-licensing inspection, and the facility was deemed ready to be licensed pending final approval.
Deficiencies (3)
Deficiency related to centrally stored medication logs
Technical violations related to personnel records including 1st Aid certification and health screening reports
Technical violation related to emergency non-perishable supplies
Report Facts
Personnel records reviewed: 4
Resident medication logs reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Flavio Silva | Executive Director | Met with Licensing Program Analyst during the inspection |
| Christine Dolores | Licensing Program Analyst | Conducted the follow-up pre-licensing visit |
| Jackie Jin | Licensing Program Manager | Named in report header |
Inspection Report
Original Licensing
Census: 56
Capacity: 92
Deficiencies: 1
Date: Mar 24, 2022
Visit Reason
The visit was an unannounced pre-licensing inspection conducted to evaluate the facility's readiness for licensing.
Findings
The facility was found to have one deficiency and a technical violation during the pre-licensing inspection. The facility was not ready to be licensed and a follow-up visit will be conducted once corrections are made.
Deficiencies (1)
Staff files did not include 1st Aid Certification, Health Screening, TB Information, and Criminal Record Statement.
Report Facts
Resident records reviewed: 6
Staff records reviewed: 2
Facility capacity: 92
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Flavio Silva | Executive Director | Met with Licensing Program Analyst during inspection |
| Christine Dolores | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Jackie Jin | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 92
Deficiencies: 0
Date: Dec 1, 2021
Visit Reason
The visit was an office type evaluation related to a Change of Ownership (CHOW) application process, including a telephone call to complete Component II (COMP II) with the applicant/administrator.
Findings
The applicant/administrator successfully completed COMP II via telephone, demonstrating understanding of facility operation, staff qualifications, program policies, and application document requirements. Identification was verified and technical assistance was provided.
Report Facts
Capacity: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Flavio Silva | Administrator | Applicant/administrator who participated in COMP II and was met during the visit |
| Mirella Quaranta | Licensing Program Manager | Named in report as Licensing Program Manager |
| Stefania Fonteno | Licensing Program Analyst | Named in report as Licensing Program Analyst who conducted COMP II |
Report
January 28, 2026
Report
January 8, 2026
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