Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally adequate care and compliance. However, some substantiated deficiencies involved resident care issues such as failure to assist with medications properly, neglect related to falls, and failure to update care plans, with one incident resulting in a $250 fine issued in May 2025. Other notable issues included failure to safeguard resident funds, delayed refunds, and violations of residents’ personal rights, such as locking a resident outside, though these were isolated. The facility showed improvement over time, with the most recent report on August 28, 2025, finding no deficiencies and deeming infection control and resident care allegations unsubstantiated. While there were some serious concerns in earlier reports, recent findings suggest better compliance and oversight.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
74% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 94
Capacity: 127
Deficiencies: 0
Date: Aug 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not ensure infection control guidelines were followed and that residents' care needs were not being met.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to follow infection control guidelines during a COVID-19 outbreak and failure to meet resident care needs, specifically regarding food delivery and adult diaper restocking. Evidence did not support these claims.
Findings
The investigation found insufficient evidence to corroborate the allegations regarding infection control and resident care needs. The facility had adequate PPE supplies and staff training, and resident care concerns were denied by staff and not supported by interviews or observations. Therefore, the allegations were deemed unsubstantiated.
Report Facts
COVID-19 positive cases: 2
PPE storage tiers: 3
Interview counts: 6
Interview counts: 2
Interview counts: 2
Interview counts: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Executive Director | Named in relation to infection control and complaint investigation. |
| Gloria Morales | Wellness Director | Named in relation to infection control, PPE supplies, and complaint investigation. |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 127
Deficiencies: 2
Date: Aug 14, 2025
Visit Reason
The visit was conducted as a Case Management - Deficiencies inspection in conjunction with a complaint investigation (Complaint Control # 29-AS-20241113085831) to issue citations for deficiencies observed during the complaint investigation.
Complaint Details
The visit was triggered by complaint # 29-AS-20241113085831. The complaint was substantiated as deficiencies were found related to neglect and failure to update care plans after falls resulting in injury.
Findings
The investigation found that Resident #1 (R1) had multiple falls and hospitalizations between October 2024 and January 2025, including a fall on 11/06/2024 that resulted in a subdural hematoma. The facility failed to update R1's care plan after the fall and did not provide proper assistance, leading to neglect and injury.
Deficiencies (2)
Staff did not properly assist Resident #1 while dressing which resulted in a fall and injury posing an immediate health and safety risk.
Resident #1’s care plan was not updated as necessary after a significant change in condition, posing a potential health and safety risk.
Report Facts
Deficiencies cited: 2
Capacity: 127
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Executive Director | Met with Licensing Program Analyst during inspection; named in findings related to resident care. |
| Emily Peraldi | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 127
Deficiencies: 1
Date: May 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following allegations that staff did not safeguard a resident's personal belongings and did not report incidents to appropriate parties.
Complaint Details
The complaint was substantiated. It was alleged that in December 2024, $670 was stolen from Resident #1 and that the Executive Director and staff were aware but did not report it to police, the State Long-Term Care Ombudsman, or Licensing. The Executive Director later filed a police report on 05/16/2025. The resident was credited a total of $700 towards rent in January and February 2025. The preponderance of evidence supported the allegations.
Findings
The investigation substantiated that staff failed to safeguard Resident #1's money, which was allegedly stolen, and failed to report the incident to appropriate authorities. The Executive Director credited the missing amount towards the resident's rent but did not report the incident timely. A deficiency related to failure to implement a theft and loss program was cited.
Deficiencies (1)
Failure to implement a theft and loss program as required by Health and Safety Code 1569.153, including failure to safeguard Resident #1's cash resources and follow the facility's Theft and Loss Policy.
Report Facts
Amount stolen: 670
Credit amount: 700
Facility capacity: 127
Facility census: 89
Plan of Correction due date: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Executive Director | Named in findings related to failure to report missing resident funds and safeguarding resident belongings |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation |
| Ty Hanson | Staff member met during inspection and authorized to sign report | |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 127
Deficiencies: 0
Date: May 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that the facility did not ensure that staff are trained, specifically that medication technicians were never trained to administer medications.
Complaint Details
The allegation was that medication technicians were never trained to administer medications. The investigation reviewed personnel files and training records and found most med techs compliant with training requirements. The allegation was deemed unsubstantiated due to insufficient evidence.
Findings
The investigation found that five out of six medication technicians had completed their annual eight hours of medication-related training, and one had completed four hours with the remaining four hours scheduled. There was insufficient evidence to substantiate the allegation, and it was deemed unsubstantiated.
Report Facts
Medication related training hours completed: 8
Medication related training hours completed: 4
Personnel files reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Executive Director | Named in investigation findings and exit interview authorization |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ty Hanson | Staff member met during visit and authorized to sign report | |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 127
Deficiencies: 1
Date: May 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-04-17 regarding resident care issues including failure to shower a resident per admission agreement, incontinence care needs, cleanliness, and meal quality.
Complaint Details
The complaint investigation was substantiated for the allegation that facility staff did not shower Resident #1 per the admission agreement. Other allegations about incontinence care, cleaning of feces, and meal quality were unsubstantiated. The investigation included multiple interviews with staff, residents, family members, observations, and document reviews. The facility was cited for noncompliance with CCR 87507(f) related to admission agreements.
Findings
The investigation substantiated the allegation that facility staff did not shower a resident per the admission agreement due to hospice providing showers instead. Other allegations regarding incontinence care, cleanliness, and meal quality were found unsubstantiated based on interviews, observations, and documentation review.
Deficiencies (1)
Licensee did not comply with admission agreement terms when staff did not provide stand-by assist showers to Resident #1, posing a potential health and safety risk.
Report Facts
Capacity: 127
Census: 89
Deficiency count: 1
Plan of Correction Due Date: May 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Administrator | Confirmed hospice shower services and was unavailable during some visits |
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation |
| Ty Henson | Sales Director | Met with Licensing Program Analyst during visits and agreed to develop plan of correction |
| Sandra Urena | Licensing Program Analyst | Collected pertinent documents relevant to the investigation |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 127
Deficiencies: 2
Date: May 21, 2025
Visit Reason
The visit was conducted as a Case Management - Deficiencies inspection in conjunction with a complaint investigation (Complaint Control # 29-AS-20250509102647) to issue citations for deficiencies observed during the complaint investigation.
Complaint Details
The visit was triggered by complaint # 29-AS-20250509102647. Deficiencies were substantiated as the facility lacked a surety bond and the Executive Director failed to comply with regulations.
Findings
Two Type B deficiencies were cited: the facility did not have a surety bond on file to safeguard resident R1's cash resources, and the Executive Director did not demonstrate knowledge or compliance with applicable regulations, posing potential health and safety risks to residents.
Deficiencies (2)
Facility did not have a surety bond on file to safeguard resident R1's cash resources.
Executive Director did not demonstrate knowledge or comply with Title 22 regulations.
Report Facts
Deficiencies cited: 2
Plan of Correction Due Date: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Executive Director | Named in findings related to lack of surety bond and regulatory noncompliance. |
| Emily Peraldi | Licensing Program Analyst | Conducted the inspection and complaint investigation. |
| Ty Hanson | Met with Licensing Program Analyst during inspection and authorized to sign report. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 127
Deficiencies: 2
Date: May 21, 2025
Visit Reason
The visit was an unannounced Case Management Deficiency inspection conducted in conjunction with a subsequent complaint visit to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint allegations.
Complaint Details
The visit was conducted in conjunction with a complaint investigation (CC #29-AS-20240417093431). The deficiencies cited were not related to the complaint allegations but were observed during the complaint investigation.
Findings
Two Type B deficiencies were cited: one for locking a resident outside in the memory care courtyard, violating residents' personal rights, and another for failure to check and change an incontinent resident (R1) for over two hours, posing a potential health risk.
Deficiencies (2)
Resident was locked outside in the memory care courtyard, violating personal rights by restricting the ability to leave or depart the facility at any time.
Incontinent resident (R1) was not checked or changed for over two hours, posing a potential health risk.
Report Facts
Census: 89
Total Capacity: 127
Time resident not checked: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Administrator | Named in relation to fixing the locked courtyard door after incident |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Ty Henson | Sales Director | Met with Licensing Program Analyst during visit |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 127
Deficiencies: 1
Date: May 15, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that staff did not administer medication to a resident in care.
Complaint Details
The complaint alleged that staff did not administer Resident #1's morphine medication as prescribed. The allegation was substantiated based on record review and interviews, confirming missed doses and improper assistance with medication.
Findings
The investigation substantiated that staff failed to administer morphine medication to Resident #1 as prescribed, missing four scheduled doses and not properly assisting with self-administration. A deficiency was cited and a civil penalty of $250 was issued.
Deficiencies (1)
Failure to assist Resident #1 with self-administered medications as prescribed, posing an immediate health and safety risk.
Report Facts
Civil Penalty Amount: 250
Missed Medication Doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Executive Director | Met with Licensing Program Analyst during investigation and named in findings. |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 127
Deficiencies: 0
Date: May 12, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that facility staff were not providing activities for residents.
Complaint Details
The complaint alleged that facility staff were not providing activities for residents. The investigation included multiple interviews with staff, residents, and family members, as well as observations of activities. The allegation was found to be unsubstantiated.
Findings
The investigation found that the facility provides activities for all residents as per the activity calendar, with staff encouraging participation. Some residents did not participate due to personal choice or limitations, but all were allowed to participate. The allegation was deemed unsubstantiated based on interviews and observations.
Report Facts
Memory Care residents: 35
Residents observed exercising: 10
Residents playing bingo: 5
Residents in courtyard: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and multiple interviews |
| Kenneth Mahler | Administrator | Met with Licensing Program Analyst during investigation |
| Kasandra Lopez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 127
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2024-04-17, including failure to dispense medication resulting in hospitalization, lack of supervision leading to resident elopement, and inappropriate staff communication with a resident.
Complaint Details
The complaint included allegations that facility staff did not dispense medication to a resident resulting in hospitalization, did not supervise residents leading to elopement, and spoke inappropriately to a resident. After investigation including interviews, document reviews, and observations, all allegations were found unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate the allegations. The medication refill delay was due to a pharmacy documentation error, and staff made efforts to obtain the refill. There was no evidence supporting neglect or lack of supervision related to resident elopement, and no evidence that staff spoke inappropriately to residents. All allegations were deemed unsubstantiated.
Report Facts
Capacity: 127
Census: 88
Staff interviewed: 10
Residents interviewed: 7
Resident family members interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Administrator | Met with Licensing Program Analysts during investigation and named in findings |
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sandra Urena | Licensing Program Analyst | Conducted unannounced 10-day visit as part of investigation |
| Edward Hector | Investigator | Investigated medication-related allegation |
| Gloria Morales | Associate Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 127
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not adequately supervise a resident while in care.
Complaint Details
The complaint alleged that Resident #1 was locked out of their room and found on the floor sleeping with a possible fall or head injury. The resident was diagnosed with a urinary tract infection and dehydration after being sent to urgent care. Staff and family interviews denied the fall or injury, and communication about the resident's condition was ongoing. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegation that Resident #1 was inadequately supervised or suffered a fall or head injury. Interviews with staff and the resident's family denied the occurrence of a fall, and the allegation was deemed unsubstantiated.
Report Facts
Complaint Control Number: 29-AS-20250314160022
Number of residents interviewed: 5
Number of staff interviewed: 9
Number of staff interviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced subsequent complaint visit |
| Kenneth Mahler | Executive Director | Met with LPAs during visits and was involved in interviews |
| Gloria Morales | Wellness Director | Provided information regarding Resident #1's condition and supervision |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 90
Capacity: 127
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The inspection was an unannounced Case Management - Annual Continuation visit to evaluate the facility's compliance with health and safety regulations.
Findings
The Licensing Program Analyst observed the facility to be clean, well-maintained, and properly furnished with no health or safety hazards. Medication administration and documentation were properly conducted, and no deficiencies were cited during the inspection.
Report Facts
Residents interviewed: 12
Residents medication reviewed: 8
Resident rooms observed: 22
Restrooms observed: 22
Fire extinguisher last serviced: Apr 12, 2024
Fire alarm/sprinkler system last tested: Jan 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ken Mahler | Executive Director | Met with Licensing Program Analyst during inspection and involved in physical plant tour |
| Emily Peraldi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 127
Deficiencies: 1
Date: Feb 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility did not provide a refund to an authorized representative and did not release records to an authorized representative.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility did not provide a refund to the authorized representative related to overcharged rent payments for Resident #1. The allegation regarding failure to release records to the authorized representative was unsubstantiated.
Findings
The allegation that the facility did not provide a refund to the authorized representative was substantiated, with evidence showing the facility overcharged rent and delayed refunding approximately $3,743.50. The allegation that the facility did not release records to the authorized representative was unsubstantiated, as there was no evidence the facility withheld records or refused requests.
Deficiencies (1)
The licensee did not comply with the admission agreement by not ensuring Resident #1 and/or their authorized person received a refund, posing a potential health, safety, and personal rights risk for residents in care.
Report Facts
Capacity: 127
Census: 90
Refund amount: 3743.5
Late fees: 250
Monthly rent fee: 4845
Pro-rated rent for March 2024: 3230
Payments received in January 2024: 13440
Payments received in February 2024: 3500
Payments received in March 2024: 3230
Payments received in April 2024: 3500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation report |
| Kenneth Mahler | Administrator / Executive Director | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 127
Deficiencies: 0
Date: Jan 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that unqualified facility staff were providing wound care to residents and that facility staff were falsifying resident records.
Complaint Details
The complaint alleged that unqualified staff were providing wound care instead of calling hospice or home health agencies, and that staff were falsifying resident records. Interviews and document reviews did not provide sufficient evidence to corroborate these allegations, resulting in an unsubstantiated finding.
Findings
The investigation found insufficient evidence to substantiate either allegation. Staff and administrator interviews indicated that wound care was provided by outside agencies and that no falsification of resident records was witnessed. Both allegations were deemed unsubstantiated.
Report Facts
Complaint Control Number: 29-AS-20241211134457
Number of residents present (census): 92
Total licensed capacity: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Ken Mahler | Executive Director | Met with Licensing Program Analyst during the investigation and provided interviews |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 92
Capacity: 127
Deficiencies: 0
Date: Jan 28, 2025
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct a required annual visit to the facility.
Findings
The Licensing Program Analyst reviewed resident and personnel records, all of which were found to be in order. A disaster drill was last conducted on 2025-01-18, and the administrator's certificate was current. Interviews and a physical plant tour were conducted with no health or safety hazards noted. The annual inspection was not completed due to time constraints and will be resumed later.
Report Facts
Residents reviewed: 9
Staff reviewed: 8
Staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ken Mahler | Executive Director | Met with Licensing Program Analyst during inspection and participated in interviews and physical plant tour |
| Emily Peraldi | Licensing Program Analyst | Conducted the inspection visit and interviews |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 127
Deficiencies: 1
Date: Dec 18, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff do not dispense medications as prescribed.
Complaint Details
The complaint alleging that facility staff do not dispense medications as prescribed was substantiated based on medication review and observations during the visit.
Findings
The investigation found discrepancies in medication quantities for multiple residents, confirming that staff did not properly assist with self-administered medications as prescribed, posing an immediate health and safety risk. The allegation was substantiated.
Deficiencies (1)
Facility staff did not properly assist with residents' self-administered medications per physician’s order, violating CCR 87465(a)(4).
Report Facts
Residents reviewed for medication: 10
Census: 93
Total Capacity: 127
Plan of Correction Due Date: Dec 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation and medication review. |
| Ken Mahler | Executive Director | Met with Licensing Program Analyst during the investigation. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 127
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/08/2023 regarding lack of care and supervision resulting in resident falls and violation of residents' personal rights.
Complaint Details
The complaint was unsubstantiated. Allegations included lack of care and supervision resulting in two unwitnessed falls of Resident #1 during a short respite stay, and violation of residents' personal rights. Investigations included interviews with staff, residents, and review of incident reports. No evidence supported the allegations.
Findings
The investigation found insufficient evidence to substantiate the allegations of lack of care and supervision resulting in resident falls and violation of residents' personal rights. Interviews with staff and residents indicated timely response to resident needs and no reported concerns about personal rights violations.
Report Facts
Resident falls: 2
Staff interviewed: 6
Residents interviewed: 7
Response time goal (minutes): 3
Response time goal (minutes): 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kenneth Mahler | Executive Director | Facility administrator met during investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 127
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 07/14/2023 that staff were smoking marijuana while on duty in the facility common restroom.
Complaint Details
The complaint alleged that staff were smoking marijuana while on duty in the facility common restroom. The investigation included interviews with staff and residents and a physical plant tour. The allegation was found unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to support the allegation that staff were smoking marijuana or acting inappropriately while on duty. Interviews with staff and residents denied the allegation, and the complaint was deemed unsubstantiated.
Report Facts
Capacity: 127
Census: 80
Staff interviewed: 8
Residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Kenneth Mahler | Executive Director | Facility administrator met during the inspection |
| Meshyll Filipinas | Wellness Director | Former Wellness Director interviewed during initial visit |
Inspection Report
Annual Inspection
Census: 79
Capacity: 127
Deficiencies: 4
Date: Jan 22, 2024
Visit Reason
An unannounced Annual Continuation Visit was conducted to continue the annual inspection visit initiated on 01/04/2024, including medication audit and record review.
Findings
The inspection found deficiencies related to medication administration where one resident did not receive medication as prescribed, incomplete staff first aid certifications, missing annual medication training for some staff, and incomplete documentation of centrally stored medications.
Deficiencies (4)
One out of five residents did not get their medication as prescribed, posing an immediate health and safety risk.
Three out of five staff lacked appropriate first aid certification.
Two out of five staff lacked annual medication training and training for restricted health conditions.
Four medications were not documented on the Centrally Stored Medication and Destruction Record.
Report Facts
Residents reviewed: 1
Staff files reviewed: 5
Medications not documented: 4
Staff lacking first aid certification: 3
Staff lacking annual medication training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Administrator | Named in medication error finding and participated in exit interview |
| Esther Cortez | Licensing Program Analyst | Conducted inspection and medication audit |
| Kasandra Lopez | Licensing Program Manager | Supervisor and named in report |
Inspection Report
Annual Inspection
Census: 79
Capacity: 127
Deficiencies: 2
Date: Jan 4, 2024
Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 regulations and ensure health and safety standards were met.
Findings
The facility was generally found to be in compliance with health and safety regulations, with clean and functional areas including kitchen, bedrooms, bathrooms, and common areas. However, deficiencies were cited related to unsecured laundry rooms with accessible chemicals and medications stored in residents' rooms in memory care, posing immediate health and safety risks.
Deficiencies (2)
Laundry rooms in both memory care and assisted living were left unlocked with chemicals accessible to residents, posing an immediate health, safety, or personal rights risk.
Prescribed and over-the-counter medication was observed in residents' rooms in memory care, posing an immediate health, safety, or personal rights risk.
Report Facts
Resident files reviewed: 4
Residents requiring updated appraisal and service plan: 1
Residents missing personal rights or medical consent forms: 1
Temperature range: 113
Temperature range: 118
Facility temperature: 69
Number of resident bedrooms inspected: 10
Number of bathrooms inspected: 10
Number of resident interviews: 5
Number of staff interviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Administrator | Met with Licensing Program Analyst during inspection and involved in observations and discussions. |
| Gloria Morales | Associate Administrator | Accompanied Licensing Program Analyst during facility tour and provided information about room furnishings. |
| Esther Cortez | Licensing Program Analyst | Conducted the inspection, observations, interviews, and file reviews. |
| Kasandra Lopez | Licensing Program Manager | Supervisor of the Licensing Program Analyst and named on the report. |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 127
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident leaving the facility unsupervised due to an unlocked door, staff locking a resident in their room, and inadequate feeding of a resident.
Complaint Details
The complaint investigation was substantiated regarding the allegation that staff did not ensure a facility door was locked, resulting in a resident with dementia leaving the facility unsupervised and being taken to the hospital. The allegations that staff locked the resident in their room and did not ensure adequate feeding were unsubstantiated.
Findings
The investigation substantiated that a resident with dementia left the facility unsupervised through an unlocked exit door during a power outage, posing an immediate health and safety risk. Two other allegations regarding staff locking a resident in their room and inadequate feeding were unsubstantiated due to insufficient evidence.
Deficiencies (1)
Failure to provide adequate care and supervision as evidenced by a resident with dementia leaving through an unlocked exit door, posing an immediate health and safety risk.
Report Facts
Capacity: 127
Census: 72
Deficiencies cited: 1
Plan of Correction Due Date: Dec 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Mahler | Administrator | Met with Licensing Program Analyst during the complaint investigation and named in findings |
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation |
| Kasandra Lopez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 127
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that the licensee was refusing to give a refund without a signed release.
Complaint Details
The complaint alleged that the licensee was refusing to give a refund without a signed release. The complaint was investigated and found to be unsubstantiated.
Findings
The investigation found that Resident 1, who stayed for two days and had two falls, was refunded the total amount of $1,900 electronically on the day of the visit. The allegation was deemed unsubstantiated.
Report Facts
Refund amount: 1900
Capacity: 127
Census: 72
Refund breakdown: 500
Refund breakdown: 1400
Resident stay duration: 2
Resident falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kenneth Mahler | Executive Director | Met with Licensing Program Analyst during investigation and provided evidence of refund |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 127
Deficiencies: 1
Date: Jul 21, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/14/2023 regarding a resident's apartment being a safety hazard.
Complaint Details
The complaint was substantiated based on observations during the visit. The allegation was that Resident #1's apartment was a safety hazard, which was confirmed by the Licensing Program Analyst.
Findings
The investigation substantiated the allegation that Resident #1's apartment was a safety hazard due to clutter and lack of clear paths to ambulate in the room and bathroom, posing a potential safety risk.
Deficiencies (1)
Maintenance and Operation: The facility failed to maintain Resident #1's room in a clean, safe, sanitary, and good repair condition as it was cluttered with very limited to no path to ambulate, posing a safety risk.
Report Facts
Capacity: 127
Census: 63
Deficiencies cited: 1
Plan of Correction Due Date: Jul 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and cited the deficiency |
| Meshyll Filipinas | Wellness Director | Met with Licensing Program Analyst during the investigation and communicated plan of correction |
| Kenneth Mahler | Administrator | Named as facility administrator |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 127
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 03/10/2023 regarding incontinent residents not being changed timely and residents not being bathed.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included incontinent residents not being changed timely and residents not being bathed. Interviews and record reviews did not support these allegations.
Findings
The investigation found insufficient evidence to support the allegations. Staff and resident interviews indicated that incontinent residents were changed every two hours or as needed and residents were bathed at least twice a week or when soiled. The allegations were deemed unsubstantiated.
Report Facts
Capacity: 127
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Ken Mahler | Administrator | Facility administrator met during the inspection |
| Desaree Perera | Licensing Program Manager | Named in report signature and oversight |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 127
Deficiencies: 2
Date: Jul 12, 2023
Visit Reason
The inspection visit was conducted in response to a complaint alleging that the facility is in financial distress, including concerns about bankruptcy and its impact on residents.
Complaint Details
The complaint was received on 09/21/2022 alleging the facility is in financial distress due to bankruptcy. The complaint was substantiated based on evidence including bankruptcy filing, financial losses, insufficient cash reserves, unpaid taxes, and inadequate food expenses.
Findings
The investigation substantiated the allegation of financial distress, finding that the licensee filed Chapter 11 bankruptcy, did not maintain sufficient cash reserves, had an operating loss, failed to pay property taxes, and did not file State or Federal tax forms. The licensee's monthly food expenses were below USDA guidelines, posing potential health and safety risks to residents.
Deficiencies (2)
87213 Finances - The licensee did not maintain sufficient cash reserves, had an operating loss, did not pay taxes, and filed bankruptcy, posing a potential health and safety risk to residents.
87555(a) General Food Service Requirements - The licensee's monthly food expenses were below USDA guidelines, posing a potential health and safety risk to residents.
Report Facts
Operating loss: 54336
Negative cash balance: -2986.14
Food costs: 13839
Capacity: 127
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Ken Mahler | Administrator | Met with Licensing Program Analyst during inspection and interviewee |
| Christine Hanna | Managing Member of Global Premier Regency Palms Oxnard LP | Interviewed during investigation and participated in audit meeting |
| Jorge Mojica | CCLD General Auditor III | Conducted audit and participated in meeting to discuss findings |
| Sarang Tatimatla | Chief Restructuring Officer | Participated in audit meeting via video call |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 127
Deficiencies: 1
Date: Jul 12, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff did not attend to a resident in a timely manner, gave wrong medication dose, spoke inappropriately to a resident, and did not safeguard resident's personal belongings.
Complaint Details
The complaint investigation was triggered by an allegation that staff did not attend to Resident #1 in a timely manner after a fall on 01/16/2022. The allegation was substantiated based on interviews, record reviews, and the Oxnard Fire Department Incident Detail Report. Other allegations about medication errors, staff behavior, and missing belongings were unsubstantiated.
Findings
The investigation substantiated the allegation that staff did not attend to a resident's call for assistance in a timely manner, resulting in the resident calling 911 for help. The other allegations regarding wrong medication dose, inappropriate staff behavior, and missing personal belongings were found to be unsubstantiated.
Deficiencies (1)
Failed to comply with care, supervision, and services requirements as staff did not respond to Resident #1's call for assistance and the resident had to call 911 for help, posing a potential health and safety risk.
Report Facts
Facility Capacity: 127
Census: 64
Deficiency Count: 1
Plan of Correction Due Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kenneth Mahler | Administrator | Facility administrator involved in interviews and exit review |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 127
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations received on 03/08/2023 regarding medication assistance, timely medication administration, staff treatment of residents, and assistance with paying bills.
Complaint Details
The complaint investigation was initiated due to allegations that staff were not assisting the resident with medications correctly, the resident did not receive medication timely, staff did not treat the resident with dignity and respect, and staff were not assisting the resident with paying their bills. All allegations were found unsubstantiated based on interviews, record reviews, and observations.
Findings
The investigation found insufficient evidence to support any of the allegations. No medication errors, delays, or disrespectful staff behavior were substantiated, and the resident was reported to be independent in managing bills. Therefore, all allegations were deemed unsubstantiated.
Report Facts
Facility capacity: 127
Resident census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Meshyll Filipinas | Wellness Director | Met with the Licensing Program Analyst during the inspection |
| Kenneth Mahler | Administrator | Interviewed during the investigation regarding allegations |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 127
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that residents were not being provided with activities.
Complaint Details
The complaint alleged that residents were not being provided with activities. The allegation was investigated and found to be unsubstantiated based on observations, interviews, and document review.
Findings
The investigation found that activities were provided to residents, including an activities board, sign-up sheets, and a monthly activities calendar. Staff assisted residents to participate in activities, and observations and interviews did not support the allegation. Therefore, the complaint was deemed unsubstantiated.
Report Facts
Capacity: 127
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ken Mahler | Executive Director | Met with during the complaint investigation visit |
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation |
| Esther Cortez | Licensing Program Analyst | Conducted the complaint investigation |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 127
Deficiencies: 0
Date: Nov 29, 2022
Visit Reason
An unannounced complaint investigation was conducted following allegations that facility staff did not safeguard a resident's personal belongings and had inappropriate interaction with a resident.
Complaint Details
The complaint involved allegations that staff did not safeguard Resident #1's personal belongings, specifically approximately $200 missing, and that Staff #1 was disrespectful to Resident #1. Both allegations were found unsubstantiated based on interviews and record reviews.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews and record reviews revealed no reports of missing items or inappropriate staff behavior, and the allegations were deemed unsubstantiated.
Report Facts
Capacity: 127
Census: 56
Missing money amount: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Ken Mahler | Administrator | Facility Administrator interviewed during investigation |
| Mike Day | Maintenance Director | Interviewed regarding safeguarding of resident belongings |
Inspection Report
Annual Inspection
Census: 56
Capacity: 127
Deficiencies: 1
Date: Nov 29, 2022
Visit Reason
An unannounced Required 1 Year annual inspection was conducted with a specific emphasis on infection control practices and procedures.
Findings
The facility was found to be generally compliant with Title 22 Regulations, with functional safety equipment and adequate infection control measures. However, expired food items were observed in the emergency food supply and were removed during the inspection.
Deficiencies (1)
Facility had food with past best by dates which poses an immediate health, safety or personal rights risk to persons in care.
Report Facts
Deficiency Plan of Correction Due Date: Nov 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ken Mahler | Administrator | Met with Licensing Program Analyst during inspection and discussed findings |
| Kasandra Lopez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor of the Licensing Program Analyst and named in the report |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 127
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding the allegation that the administrator was not providing a former resident prompt access to receive a copy of their facility records.
Complaint Details
The complaint alleged that the administrator was not providing a former resident prompt access to their facility records. The allegation was substantiated based on evidence that the resident's request on 09/09/2022 was not fulfilled promptly and the facility policy requiring an authorization form was not supported by regulations.
Findings
The investigation found sufficient evidence that the licensee did not provide the former resident prompt access to their medical records as required by regulations, which do not support the need for an authorization form to be completed. The allegation was substantiated and a deficiency was cited for failure to comply with prompt access requirements.
Deficiencies (1)
Failure to provide prompt access to review all records and to purchase photocopies within two business days at a cost not exceeding community standard.
Report Facts
Capacity: 127
Census: 54
Deficiency Type B count: 1
Plan of Correction Due Date: Oct 3, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kenneth Mahler | Administrator | Facility administrator involved in the investigation and cited in findings |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 127
Deficiencies: 0
Date: Apr 19, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding the allegation that the facility signal system is in disrepair.
Complaint Details
The complaint alleged that the pendant or pull cords do not function when pulled or pressed. After testing and interviews, the allegation was found unsubstantiated.
Findings
The investigation found insufficient evidence to support the allegation that the facility signal system was in disrepair. Testing of pendants and pull cords in multiple apartments and staff interviews revealed no issues with the signal system functioning properly. The allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 127
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Ken Mahler | Administrator | Facility administrator met with the Licensing Program Analyst during the inspection |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 40
Capacity: 127
Deficiencies: 0
Date: Jan 31, 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 found to be in compliance with Title 22 Regulations, with no deficiencies cited. Infection control practices were adequate, physical plant areas were safe, and safety equipment such as smoke detectors, carbon monoxide detectors, and fire extinguishers were functional and properly maintained.
Report Facts
Residents in memory care: 21
Resident apartments observed: 4
Hot water temperature range: 109.4
Hot water temperature range: 111.2
Fire extinguisher last serviced: 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ken Mahler | Administrator | Met with Licensing Program Analyst during inspection and discussed infection control practices |
| Kasandra Lopez | Licensing Program Analyst | Conducted the unannounced Required 1 Year inspection |
| Desaree Perera | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Original Licensing
Capacity: 127
Deficiencies: 0
Date: Jan 15, 2021
Visit Reason
The visit was a pre-licensing inspection conducted virtually due to COVID-19 to evaluate the facility's readiness to operate as a Residential Care Facility for the Elderly (RCFE).
Findings
The inspection found the facility clean, sanitary, and well-equipped with operational safety systems including smoke alarms, carbon monoxide detectors, and locked medication storage. No corrections were needed at the time of the inspection.
Report Facts
Maximum capacity: 127
Hot water temperature: 113.9
Hot water temperature: 116.4
Hot water temperature: 116.9
Hot water temperature: 116.9
Freezer temperature: 0
Refrigerator temperature: 39
Hot water temperature: 114.6
Hot water temperature: 114.4
Hot water temperature: 113.7
Fire extinguisher last serviced: Mar 13, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ken Mahler | Administrator | Met with Licensing Program Analyst during pre-licensing inspection |
| Kasandra Lopez | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Kelly Burley | Licensing Program Manager | Named in report header and signature section |
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