Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. However, some deficiencies were identified over time, primarily related to resident care, medication management, food safety, and facility maintenance. Notably, the facility received immediate civil penalties in early 2024 for leaving a resident unattended and for vermin issues in locked apartments, and there were substantiated findings of medication errors and delayed medical care for a resident’s wounds. The most recent report on October 16, 2025, was clean with no deficiencies cited, showing improvement from earlier issues. While some concerns have arisen, recent inspections suggest the facility has addressed many prior problems.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
62% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 89
Capacity: 143
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements at the facility.
Findings
No deficiencies were cited during the inspection. The facility was found to be in compliance with all applicable regulations including food safety, medication administration, resident safety, and staff background clearances.
Report Facts
Employees with background clearances: 84
Residents observed eating breakfast: 9
Residents in assisted living fitness class: 6
Residents in memory care exercise class: 7
Staff response time to call alert: 133
Hot water temperature: 109.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marianne Richardson | Administrator/Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection visit. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 143
Deficiencies: 3
Date: Apr 3, 2025
Visit Reason
An unannounced case management deficiencies inspection was conducted to address deficiencies observed during a complaint investigation regarding resident R1.
Complaint Details
The inspection was triggered by a complaint investigation concerning resident R1's bilateral thigh wounds that were worsening and not properly addressed by the facility.
Findings
The facility failed to provide timely medical assistance for R1's worsening bilateral thigh wounds and did not implement interventions to prevent further deterioration. Additionally, the facility did not meet requirements for basic services, including proper toileting assistance and re-evaluation of R1's condition, resulting in serious bodily injuries and immediate health and safety risks.
Deficiencies (3)
Failure to arrange or assist in arranging timely medical care for resident's deteriorating wounds, posing immediate health and safety risks.
Failure to communicate significant changes in resident's condition and recommendations of licensed medical professionals, with documentation missing in resident's record.
Failure to ensure corresponding changes in care and supervision for resident despite changes in condition and worsening wounds.
Report Facts
Capacity: 143
Census: 81
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the unannounced inspection and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
| Marianne R Richardson | Administrator/Director | Facility Administrator met during inspection and referenced in findings |
Inspection Report
Census: 78
Capacity: 143
Deficiencies: 0
Date: Dec 10, 2024
Visit Reason
An unannounced case management inspection was conducted to observe and photograph a resident bedroom.
Findings
No deficiencies were cited during the inspection per California Code of Regulations, Title 22.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marianne Richardson | Administrator | Met with Licensing Program Analyst during the inspection and toured the facility. |
| Kevin Gould | Licensing Program Analyst | Conducted the unannounced case management inspection. |
Inspection Report
Annual Inspection
Census: 78
Capacity: 143
Deficiencies: 1
Date: Nov 6, 2024
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst Kimberly Viarella to evaluate compliance with regulatory requirements at the facility.
Findings
The inspection found the facility generally in compliance with medication administration, resident room safety, and fire extinguisher maintenance. However, deficiencies were cited related to expired pantry food items and improper storage of a refrigerated item, posing potential health and safety risks.
Deficiencies (1)
Expired pantry items including 3 cans of Crisco and 5 containers of grits, plus a half-full bottle of teriyaki sauce that was supposed to be refrigerated after opening.
Report Facts
Expired pantry items: 8
Pantry items with improper storage: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marianne Richardson | Designated Facility Administrator/Executive Director | Met with Licensing Program Analyst during inspection and named in plan of correction |
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephen Richardson | Licensing Program Manager | Named as supervisor and licensing program manager in the report |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 143
Deficiencies: 2
Date: Oct 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2024-07-25 regarding food storage temperatures and kitchen equipment repair.
Complaint Details
The complaint investigation was substantiated for two allegations: improper food storage temperatures and kitchen equipment not in good repair. The refrigerator was not maintaining required temperatures and was replaced after 61 days. The deli slicer was also broken and repaired. Other allegations regarding contaminated food disposal, resident communication, personal hygiene, and infection control were unsubstantiated.
Findings
Two allegations were substantiated: staff did not ensure perishable food was stored at proper temperatures due to a malfunctioning refrigerator replaced on 2024-09-30, and staff did not ensure kitchen equipment was in good repair, including a broken deli slicer. Other allegations related to contaminated food disposal, resident communication, personal hygiene, and infection control were found to be unsubstantiated.
Deficiencies (2)
Staff does not ensure that food is stored at proper temperatures due to a malfunctioning refrigerator.
Staff does not ensure kitchen equipment is in good repair; deli slicer was broken and refrigerator malfunctioned.
Report Facts
Complaint received date: Jul 25, 2024
Refrigerator replacement date: Sep 30, 2024
Refrigerator malfunction duration (days): 61
Refrigerator replacement cost: 4380
Deli slicer repair cost: 945
Number of substantiated allegations: 2
Number of unsubstantiated allegations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Marianne Richardson | Executive Director | Facility administrator met during the investigation and involved in findings |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 143
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the licensee does not ensure the facility is in good repair and that staff do not respond to resident requests for assistance in a timely manner.
Complaint Details
The complaint was unsubstantiated. Allegations included facility disrepair, elevator breakdowns, delayed staff response to resident calls, and safety concerns. Investigations included interviews with residents and staff, review of maintenance logs, and observations. The elevator broke down 12 times with some prolonged outages. Staff and external services assisted residents during outages. Response times ranged from immediate to up to 45 minutes depending on staffing and time period. No fire drills had been conducted according to residents. The roof leak allegation was found unfounded.
Findings
The investigation found that although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur. The elevator had multiple breakdowns, causing delays in resident assistance, but the facility implemented measures such as staff assistance and alternative dining arrangements. Staff response times varied but were generally timely. No deficiencies were cited.
Report Facts
Elevator breakdowns: 12
Elevator trouble calls: 14
Elevator outage duration: 10
Staff on shift: 5
Staff response time: 45
Staff response time: 10
Staff response time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Marianne Richardson | Administrator | Facility administrator interviewed during the investigation and named in findings. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 143
Deficiencies: 0
Date: Jul 3, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address multiple allegations received on 2024-03-14 regarding inappropriate resident placement decisions, coercion of a dementia resident into signing documents, billing a resident for two rooms simultaneously, and denial of dining room choice.
Complaint Details
The complaint investigation addressed four main allegations: 1) Facility director made inappropriate decisions for a resident's placement at another facility where a staff member later became director; 2) Staff coerced a dementia resident into signing documents; 3) Staff billed a resident for two rooms at the same time; 4) Staff did not allow a resident to dine in the dining room of their choice. All allegations were found to be unfounded or unsubstantiated based on interviews, document reviews, and resident care assessments.
Findings
All allegations were investigated through staff interviews, document reviews, and resident file assessments. The Department concluded that all allegations were either unfounded or unsubstantiated, with no evidence supporting claims of inappropriate decision-making, coercion, improper billing, or denial of dining room choice.
Report Facts
Facility capacity: 143
Resident census: 76
Complaint received date: Mar 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arvin Villanueva | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Marianne Richardson | Executive Director/Administrator | Facility representative met during the investigation and exit interview |
| Pamela Munday | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 143
Deficiencies: 0
Date: Apr 15, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not prevent the facility roof from leaking.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis. No deficiencies were cited.
Findings
The investigation found that roofing work was actively being conducted by Sonray and Paragon Construction crews with no resident rooms affected. The allegation was deemed unfounded as no deficiencies were observed or cited.
Report Facts
Estimated Days of Completion: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
| Marianne Richardson | Executive Director | Met with Licensing Program Analyst during investigation |
| Pamela Munday | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Capacity: 143
Deficiencies: 1
Date: Mar 5, 2024
Visit Reason
The visit was an unannounced case management inspection conducted as part of an investigation into complaint control number 27-AS-20231121160532 regarding deficiencies identified during the complaint investigation.
Complaint Details
The visit was conducted in response to complaint control number 27-AS-20231121160532. Deficiencies were substantiated related to failure to provide meals to resident R1 as alleged.
Findings
The investigation revealed that resident R1 was not served meals from 11/19/23 to 11/21/23 at breakfast, lunch, and dinner, as confirmed by interviews and review of meal logs. A deficiency was cited for failure to ensure R1 received at least three meals per day during that period.
Deficiencies (1)
Failure to ensure resident R1 received at least three meals per day from 11/19/23 to 11/21/23 at breakfast.
Report Facts
Deficiency Type: 1
Total Capacity: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marianne Richardson | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Arvin Villanueva | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager overseeing the case. |
Inspection Report
Complaint Investigation
Capacity: 143
Deficiencies: 0
Date: Jan 25, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were not addressing vermin in the facility and not keeping the facility free from odors from incontinence.
Complaint Details
The complaint investigation was unsubstantiated based on facility observations, staff interviews, and record reviews. Allegations regarding vermin and odors from incontinence were both found to be unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Pest control services were documented as ongoing and effective, and no odors from incontinence were observed during multiple visits.
Report Facts
Facility capacity: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arvin Villanueva | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Pamela Munday | Administrator | Facility administrator mentioned in relation to pest control documentation |
| Marianne Richardson | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 143
Deficiencies: 4
Date: Jan 25, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff left a resident soiled for an extended period, did not meet the resident's care needs timely, did not clean the resident's room adequately, and did not maintain a comfortable room temperature.
Complaint Details
The complaint investigation was substantiated. The allegations included staff leaving a resident soiled for an extended period, failure to meet care needs timely, inadequate room cleaning, and failure to maintain comfortable room temperature. The resident was left unattended for about 2-3 days. Immediate civil penalties of $500 and $250 (repeat violation) were assessed.
Findings
The investigation substantiated the allegations that a resident was left unattended for 2-3 days, resulting in inadequate care, supervision, and environmental conditions. Deficiencies were cited related to basic services, maintenance of comfortable temperature, cleanliness, and incontinent care, posing immediate or potential health and safety risks.
Deficiencies (4)
Licensee did not ensure care and supervision needs were provided in a timely manner to resident, resulting in absence of care and supervision longer than one day.
Licensee did not ensure resident’s apartment unit was maintained at a comfortable room temperature of at least 68 degrees F.
Licensee did not ensure resident’s apartment unit was cleaned adequately.
Licensee did not ensure incontinent care was provided, leaving resident soiled for an extended time.
Report Facts
Capacity: 143
Census: 76
Civil penalty: 500
Civil penalty: 250
Plan of Correction Due Date: Jan 26, 2024
Plan of Correction Due Date: Feb 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arvin Villanueva | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Marianne Richardson | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Pamela Munday | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 143
Deficiencies: 1
Date: Jan 25, 2024
Visit Reason
The visit was an unannounced case management inspection conducted as part of an investigation into complaint control number 27-AS-20231206120154, addressing identified deficiencies related to vermin issues in the facility.
Complaint Details
Investigation was triggered by complaint control number 27-AS-20231206120154. The deficiency was substantiated as vermin droppings were observed, and an immediate civil penalty of $250 was assessed due to repeat violation.
Findings
The inspection found vermin droppings in two locked apartments (#312 and #316) that were not accessible to residents but posed potential health and safety risks. Although ongoing pest control services were documented, the licensee failed to ensure these apartments were cleaned and free of vermin droppings.
Deficiencies (1)
Facility was not clean, safe, and sanitary as evidenced by vermin droppings in two apartments, posing potential health and safety risks to residents.
Report Facts
Civil penalty amount: 250
Plan of Correction due date: Feb 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marianne Richardson | Executive Director | Met during inspection and exit interview; involved in discussion of findings. |
| Arvin Villanueva | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 143
Deficiencies: 0
Date: Dec 14, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility elevator was in disrepair and that facility staff did not provide adequate food service to residents in care.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
Based on interviews, observation, and record review, the allegations were found to be unsubstantiated. The elevator was repaired promptly and was operational during the investigation, and food service was adequately provided to residents during the elevator outage.
Report Facts
Facility capacity: 143
Resident census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation |
| Pamela Munday | Administrator | Facility administrator interviewed regarding elevator issues |
| Xochitl Vuittonet | Memory Care Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 143
Deficiencies: 2
Date: Dec 13, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility is in disrepair.
Complaint Details
The complaint was substantiated based on observations and interviews confirming the facility is in disrepair, specifically a malfunctioning fire door that did not close properly during a fire alarm test.
Findings
The investigation substantiated the allegation that a fire door near the laundry room and memory care entrance was in disrepair, not functioning or closing properly, posing an immediate health, safety, and personal rights risk to residents.
Deficiencies (2)
Fire door near the memory care area was not functioning and not closing properly when released from its magnet, posing an immediate health, safety, and personal rights risk.
Facility was not clean, safe, sanitary, and in good repair; fire door near memory care area was in disrepair posing potential health, safety, and personal rights risk.
Report Facts
Facility capacity: 143
Census: 105
Plan of Correction Due Date: Dec 12, 2023
Plan of Correction Due Date: Dec 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Hartnett | Interim Administrator | Met with Licensing Program Analysts during investigation and confirmed details about the fire door |
| Michael Bilger | Licensing Program Analyst | Conducted facility observation and staff interviews during complaint investigation |
| Arvin Villanueva | Licensing Program Analyst | Conducted facility observation and staff interviews during complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 143
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-09-11 alleging the facility failed to repair a broken elevator and that staff failed to serve meals in a timely manner.
Complaint Details
The complaint was unsubstantiated. The elevator repair delay was due to waiting for replacement circuit boards. Staff and resident interviews confirmed timely meal service. The same elevator had a prior outage in May 2023, which was also unsubstantiated in a previous complaint.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The elevator was inoperable from September 7 to 15 due to a bad circuit board, but the facility acted promptly to remedy the issue. Staff and resident interviews indicated meals were provided in a timely manner despite elevator outages.
Report Facts
Complaint received date: Sep 11, 2023
Elevator inoperable duration: 9
Resident interviews: 7
Staff interviews: 4
Residents confirming timely meals: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Elena Cuevas | Interim Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 86
Capacity: 143
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
An unannounced annual continuation inspection was conducted to ensure compliance with Title 22 regulations and to review the physical plant of the facility.
Findings
The inspection found no deficiencies. The Licensing Program Analyst toured the facility, reviewed fire inspection reports, medication administration records, staff and resident files, and inspected the kitchen and fire extinguisher tags.
Report Facts
Memory care unit census: 9
Licensed capacity: 143
Hospice waiver capacity: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the inspection and toured the facility |
| Elena Cuevas | Facility representative who met with the Licensing Program Analyst and toured the facility | |
| Pamela Munday | Administrator | Facility administrator mentioned in the report |
Inspection Report
Annual Inspection
Census: 86
Capacity: 143
Deficiencies: 4
Date: Sep 28, 2023
Visit Reason
An unannounced annual inspection was conducted to ensure compliance with Title 22 regulations, including inspection of the physical plant and review of facility operations.
Findings
The inspection identified several deficiencies including missing first aid certificates for nine out of ten employees, improper kitchen freezer and refrigerator temperatures, and lack of implementation of gluten-free diet plans for residents. The inspection was not completed due to time constraints and will continue at a later date.
Deficiencies (4)
Nine out of ten employees were missing first aid certificates.
Kitchen freezer measured at 10 degrees, exceeding the required 0 degrees.
Kitchen refrigerator measured at 47 degrees, exceeding the maximum allowed 40 degrees.
Facility kitchen staff unaware of gluten-free diets for residents R1 and R2; no gluten-free plan implemented.
Report Facts
Capacity: 143
Census: 86
Freezer temperature: 10
Refrigerator temperature: 47
Employees missing first aid certificates: 9
Plan of Correction Due Date: Oct 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the annual inspection and identified deficiencies |
| Chelsea Xiong | Met with Licensing Program Analyst during inspection | |
| Pamela Munday | Administrator | Facility administrator holding current certificate |
| Karla Rocha | Accompanied Licensing Program Analyst during facility tour | |
| Czarrina A Camilon-Lee | Licensing Program Manager / Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 143
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations regarding elevator disrepair, accessibility of doctor appointments and planned activities, staff response to call buttons, and accuracy of food menu.
Complaint Details
The complaint included allegations of elevator disrepair, inaccessible doctor appointments and planned activities, delayed staff response to call buttons, and inaccurate food menus. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found conflicting statements and insufficient evidence to substantiate the allegations. Elevator issues were confirmed but promptly addressed, residents had access to appointments and activities with staff assistance, call response times averaged 8 minutes within training objectives, and food service provided multiple meal options meeting nutritional needs. No deficiencies were cited.
Report Facts
Resident interviews: 5
Staff interviews: 6
Call response time (minutes): 8
Call response training objective (minutes): 7
Call response training objective (minutes): 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Michael Talani | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 143
Deficiencies: 0
Date: Jul 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-02-01 regarding staff neglect, hygiene needs, assistance with ADLs, room cleanliness, feeding, and medication administration.
Complaint Details
The complaint investigation was unsubstantiated. The allegations included staff neglect causing a pressure injury, failure to meet hygiene needs, failure to assist with ADLs, failure to maintain clean rooms, failure to feed residents, and improper medication administration. The investigation concluded there was insufficient evidence to support these allegations and found them unsubstantiated or unfounded.
Findings
The investigation found the allegation of staff neglect causing an unstageable pressure injury to be unsubstantiated, with evidence showing the injury existed prior to the resident's return. Allegations regarding unmet hygiene needs, lack of assistance with ADLs, unclean rooms, feeding, and medication administration were found to be unsubstantiated or unfounded based on interviews and record reviews.
Report Facts
Capacity: 143
Census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Elena Cuevas | Interim Administrator | Met with Licensing Program Analyst during the investigation |
| Michael Talani | Administrator | Named as facility administrator |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 143
Deficiencies: 1
Date: Jul 19, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff do not answer resident's call button in a timely manner and that there was insufficient staffing to meet residents' needs.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not answer resident's call button in a timely manner. The allegation of insufficient staffing was unsubstantiated. The investigation was conducted by Licensing Program Analyst Tung Truong, with findings delivered on 07/19/2023.
Findings
The allegation regarding delayed response to resident call buttons was substantiated, with records showing approximately 16 instances in June 2023 where staff responded after 25 minutes. The allegation of insufficient staffing was found to be unsubstantiated based on resident interviews and evidence reviewed.
Deficiencies (1)
Failure to ensure residents were seen in a timely manner based on pendant time logs, with approximately 16 times staff responded after 25 minutes, posing a potential health and safety risk.
Report Facts
Instances of delayed response: 16
Census: 87
Total Capacity: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Elena Cuevas | Interim Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Michael Talani | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 143
Deficiencies: 1
Date: Jun 21, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff administered the wrong medication to a resident.
Complaint Details
The complaint was substantiated based on interviews and records reviewed. The allegation involved medication error where staff administered the wrong medication to a resident.
Findings
The investigation substantiated that the facility did not administer the correct medication to resident R1, as another resident's medications were given to R1 by staff. This posed an immediate health and safety risk to residents in care.
Deficiencies (1)
The licensee did not ensure resident R1 was administered medication as prescribed; another resident's medications were given to R1 by staff, posing an immediate health and safety risk.
Report Facts
Capacity: 143
Census: 74
Deficiency Type A: 1
Plan of Correction Due Date: Jun 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in relation to the investigation and report |
| Elena Cuevas | Interim Administrator | Met with the Licensing Program Analyst during the investigation and corroborated findings |
| Michael Talani | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 143
Deficiencies: 2
Date: May 23, 2023
Visit Reason
The inspection was an unannounced visit to investigate complaints received on 01/27/2023 regarding the facility's adherence to the Admission Agreement and proper notification of resident rate increases.
Complaint Details
The complaint investigation was substantiated for failure to adhere to the Admission Agreement and failure to provide proper notification of rate increases. The allegation regarding unclean resident room was found to be unfounded.
Findings
The investigation substantiated that the facility failed to properly monitor resident R1 as required by the Admission Agreement, resulting in elopement, and did not provide proper written notice of rate increases to the resident and representative. Another allegation regarding cleanliness of a resident's room was found to be unfounded.
Deficiencies (2)
The licensee did not comply with the admission agreement to ensure resident R1 is properly monitored; resident eloped due to malfunctioning wander guard.
The licensee did not provide resident R1 and representative written notice of rate increases due to change in level of care within two business days as required.
Report Facts
Facility capacity: 143
Census: 84
Plan of Correction due date: May 24, 2023
Plan of Correction due date: May 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Pam Munday | Interim Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 86
Capacity: 143
Deficiencies: 0
Date: May 3, 2023
Visit Reason
An unannounced Case Management Inspection was conducted to address the current administrator status at the facility, following the departure of the former administrator and pending appointment of a new administrator.
Findings
The facility is currently conducting interviews for a permanent new administrator, with the Regional Director temporarily assuming administrator responsibilities. No deficiencies were cited during the inspection.
Report Facts
Capacity: 143
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the inspection and authored the report |
| Pam Munday | Regional Director | Met with LPA and temporarily assumed administrator responsibilities |
| Michael Talani | Administrator | Former facility administrator whose last day was 4/19/23 |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 143
Deficiencies: 0
Date: May 3, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were not administering medication to a resident.
Complaint Details
The complaint alleging staff not administering medication to a resident was investigated and determined to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found the allegation to be unfounded after reviewing medication records and interviews, confirming that the facility followed regulations and medication was administered as prescribed. No deficiencies were cited.
Report Facts
Capacity: 143
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Gould | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Michael Talani | Administrator | Facility administrator involved in investigation discussion |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 143
Deficiencies: 1
Date: Feb 2, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation that a resident wandered from the facility due to lack of supervision by staff.
Complaint Details
The complaint was substantiated based on interviews and record reviews. Civil penalties of $500 were assessed for immediate violations related to the resident wandering due to lack of supervision.
Findings
The investigation found that a resident (R1) eloped from the facility on 2023-01-24 and the facility was unaware of the resident's whereabouts at that time. The resident was determined by a physician to be unable to leave the facility unassisted. The allegation was substantiated and deficiencies were cited.
Deficiencies (1)
Personnel Requirements - Facility personnel were not sufficient in numbers and competent to meet resident needs, resulting in a resident AWOL incident.
Report Facts
Civil penalty amount: 500
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Talani | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 143
Deficiencies: 2
Date: Dec 15, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were mismanaging residents' medications.
Complaint Details
The complaint alleging staff mismanagement of resident medications was substantiated based on interview and record review. Resident 1 missed two days of medication due to staff oversight.
Findings
The investigation substantiated that Resident 1 missed two days of a daily prescribed medication due to staff oversight, posing an immediate health and safety risk. Deficiencies were cited related to failure to assist residents with self-administered medications.
Deficiencies (2)
Failure to develop and implement a plan for incidental medical and dental care, including assisting residents with self-administered medications as needed.
Licensee did not ensure that Resident 1 took the daily prescribed medication, posing an immediate health and safety risk.
Report Facts
Deficiencies cited: 2
Census: 77
Total Capacity: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Talani | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 143
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding multiple allegations including facility infestation, resident hygiene, missed meals, and timely staff response to resident needs.
Complaint Details
The complaint investigation was triggered by allegations of bed bugs, residents not showered, residents left in soiled diapers and dirty clothes, rats in the facility, missed meals, and untimely staff response. The allegations were found to be unsubstantiated or unfounded after interviews, observations, and record reviews.
Findings
The investigation found no evidence of bed bugs or neglect related to resident hygiene, missed meals, or timely care. The facility has a rat problem due to location but is actively managing it. Allegations were determined to be unsubstantiated or unfounded.
Report Facts
Facility capacity: 143
Resident census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 143
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding the allegation that facility staff is not providing the necessary documents to the insurance company.
Complaint Details
The complaint alleged that facility staff were not providing necessary documents to the insurance company. The allegation was investigated and determined to be unfounded.
Findings
The investigation found that the facility is providing the insurance documents to Long Term Care. A staff member made a mistake filling out the documents, but it was corrected promptly. The allegation was determined to be without a reasonable basis and was found to be unfounded.
Report Facts
Facility capacity: 143
Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 143
Deficiencies: 3
Date: Oct 13, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff did not seek medical attention in a timely manner, did not provide adequate food service, did not administer medications timely, did not respond to call buttons timely, and resident's laundry needs were not being met.
Complaint Details
The complaint investigation was unannounced and initiated based on a complaint received on 08/08/2022. The investigation was conducted by Licensing Program Analyst Christopher Hopkins-Clarke. Some allegations were found unsubstantiated due to lack of preponderance of evidence, while others were substantiated based on interviews and record reviews.
Findings
The investigation found some allegations unsubstantiated, including delayed medical attention and inadequate food service due to multiple outbreaks. However, allegations that staff delayed medication administration, delayed response to call buttons, and failed to meet laundry needs were substantiated, posing potential or immediate health and safety risks to residents.
Deficiencies (3)
Licensee did not ensure that Resident 1, who was on hospice, received pain medication in a timely manner.
Licensee did not ensure that Resident 1's call button was answered in a timely manner.
Licensee did not ensure Resident 1's laundry was done on the scheduled day.
Report Facts
Capacity: 143
Census: 70
Deficiency count: 3
Plan of Correction Due Date: Oct 14, 2022
Plan of Correction Due Date: Oct 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Administrator | Met with Licensing Program Analyst during investigation and involved in findings |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw the complaint investigation and signed report |
Inspection Report
Annual Inspection
Census: 81
Capacity: 143
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
The inspection was an unannounced required 1 year annual inspection conducted to evaluate the facility's compliance with health and safety regulations.
Findings
The facility was observed to be clean, odor-free, and in good repair with compliant water temperatures, food supplies, fire safety equipment, and medication storage. However, deficiencies were cited related to personnel training, specifically expired First Aid certifications in 4 out of 5 staff files reviewed.
Deficiencies (1)
Staff providing care had expired First Aid certifications in 4 out of 5 files, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Staff files with expired First Aid: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Administrator | Met with Licensing Program Analyst during inspection and agreed to plan of correction |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the inspection and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 143
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that residents were not receiving medications on time during the night, the facility was not addressing a rat and mice problem, residents were leaving the building unsupervised, and there was insufficient staff to meet resident needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included medication timing, rodent problems, resident supervision, and staffing levels. Interviews, record reviews, and observations did not support the allegations.
Findings
The investigation found that residents were receiving their medications on time, the rodent issue was confined to the garbage area outside the facility and was being addressed with a contract, residents were not leaving unsupervised due to security measures, and staff responded to call buttons within a reasonable time. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 143
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report signature section |
| Michael Talani | Administrator | Facility administrator mentioned as out on day of visit |
| Scott Bissey | Regional Director of Operations | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 143
Deficiencies: 1
Date: Aug 30, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding allegations including that the facility elevator was in disrepair.
Complaint Details
The complaint investigation was substantiated based on preponderance of evidence standards regarding the elevator being in disrepair.
Findings
The investigation found that the elevator was in and out of service, which was substantiated. The elevator was repaired and observed to be functioning properly, but the failure to ensure proper elevator function posed a potential health and safety risk to residents.
Deficiencies (1)
87303 Maintenance and Operation (a): The facility shall be clean, safe, sanitary and in good repair at all times. Licensee did not ensure that the elevator was functioning properly, posing a potential health and safety risk to residents.
Report Facts
Facility capacity: 143
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Michael Talani | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 143
Deficiencies: 1
Date: May 19, 2022
Visit Reason
The visit was an unannounced case management inspection conducted on May 19, 2022, regarding a deficiency from a complaint investigation originally investigated on January 21, 2022.
Complaint Details
The visit was related to a deficiency from a complaint investigation conducted on 01/21/2022. The deficiency was substantiated based on video evidence showing the resident fell due to inability to lower the recliner footrest.
Findings
The facility was found deficient for not ensuring Resident 1 was able to get out of a recliner after a caregiver raised the footrest, which led to the resident falling out of the recliner. This posed an immediate health and safety risk to residents in care.
Deficiencies (1)
Based on video footage, the licensee did not ensure Resident 1 was able to get out of the recliner after the caregiver put the footrest up, posing an immediate health and safety risk.
Report Facts
Capacity: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Administrator / Executive Director | Met with Licensing Program Analyst during the visit |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the inspection and signed the report |
| Czarrina A Camilon-Lee | Licensing Program Manager / Supervisor | Named as Licensing Program Manager and Supervisor on the report |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 143
Deficiencies: 1
Date: Jan 21, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including failure to follow resident's care plan, inadequate staff training, resident injuries, and insufficient staffing.
Complaint Details
The complaint investigation was triggered by multiple allegations including failure to follow care plan, inadequate staff training, resident fractures, refusal to accept resident back after hospital visit, failure to notify representative timely, unclean room, resident unkempt, pressure injury, insufficient staffing, and failure to request exception for recliner use. Most allegations were unsubstantiated except for the resident left unattended on the floor overnight, which was substantiated.
Findings
The investigation found most allegations unsubstantiated due to lack of preponderance of evidence, except for the allegation that a resident was left unattended on the floor overnight, which was substantiated based on video footage and interviews. The facility was cited for failure to provide adequate care and supervision.
Deficiencies (1)
Failure to ensure care and supervision was provided to Resident 1, who was left on the ground overnight.
Report Facts
Capacity: 143
Census: 68
Deficiency count: 1
Plan of Correction Due Date: Jan 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Administrator | Met with during investigation and named in findings |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 143
Deficiencies: 0
Date: Dec 6, 2021
Visit Reason
The visit was an unannounced case management inspection regarding three incident reports submitted to the Department on 10/05/2021 and 10/07/2021.
Complaint Details
The visit was triggered by three incident reports related to theft. The internal investigation identified a staff member as the culprit, and the Sheriff's Department is handling the case. The complaint investigation is ongoing with no deficiencies cited.
Findings
The Executive Director reported that an internal investigation concluded with video evidence identifying a staff member from a staffing agency as responsible. The Sheriff's Department has taken over the investigation. Staff training on theft prevention was conducted, and residents are offered to list valuables upon admission. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Executive Director | Named in relation to the internal investigation and staff training regarding theft prevention. |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the case management visit. |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 143
Deficiencies: 1
Date: Oct 22, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 09/03/2021 alleging that staff did not assist residents with their toileting and shower needs in a timely manner.
Complaint Details
The complaint was substantiated for the allegation that staff did not assist a resident with toileting needs in a timely manner. The allegation regarding assistance with showers was unsubstantiated.
Findings
The investigation substantiated the allegation that staff did not assist a resident with their toileting needs in a timely manner, with the resident waiting approximately forty-five minutes for assistance. The allegation regarding staff not assisting residents with showers was found to be unsubstantiated based on interviews and facility logs.
Deficiencies (1)
The resident in question did not receive timely assistance in their daily necessities as stated in their Needs and Appraisal plan and Admission Agreement.
Report Facts
Capacity: 143
Plan of Correction Due Date: Oct 29, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Mohamed Filouane | Licensing Program Analyst | Conducted the complaint investigation |
| Liza King | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 74
Capacity: 143
Deficiencies: 0
Date: Oct 7, 2021
Visit Reason
The visit was an unannounced case management visit regarding three incident reports submitted to the Department involving missing money and stolen property reported by residents.
Findings
The Executive Director had taken proper steps including reporting to Licensing and Ombudsman, filing police reports, conducting interviews, internal investigations, staff retraining, and resident council meetings. No deficiencies were cited as a result of the visit.
Report Facts
Incident monetary values: 600
Incident monetary values: 720
Incident monetary values: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Executive Director | Met with Licensing Program Analyst and involved in incident reporting and investigation |
| Tung Truong | Licensing Program Analyst | Conducted the case management visit and interviews |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 143
Deficiencies: 0
Date: Sep 20, 2021
Visit Reason
The visit was an unannounced case management inspection conducted due to an incident reported on 09/07/2021 involving a missing coin purse from a resident's apartment.
Complaint Details
The incident involved a missing coin purse from resident R1's apartment on 09/07/2021. The complaint was investigated with interviews and review of reports, and no deficiencies were found.
Findings
The administrator had taken all proper steps with reporting, investigating, and retraining staff. No deficiencies were cited as a result of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Administrator | Met with Licensing Program Analyst during the case management visit and involved in incident investigation. |
| Tung Truong | Licensing Program Analyst | Conducted the case management visit and investigation. |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 69
Capacity: 143
Deficiencies: 0
Date: Sep 20, 2021
Visit Reason
The visit was an unannounced annual inspection conducted by Licensing Program Analyst Tung Truong to evaluate compliance with Title 22 regulations at the facility.
Findings
The facility was found to be clean, odor-free, and in good repair with proper furnishings, sanitary bathrooms, adequate food supply, and secure medication storage. No deficiencies were observed during this visit, and the facility had implemented a Covid-19 mitigation plan with routine symptom screening and hygiene procedures.
Report Facts
Residents in Assisted Living: 62
Residents in Memory Care: 7
Ambulatory residents: 26
Non-ambulatory residents: 117
Bedridden residents: 10
Hot water temperature: 107.1
Fire drill date: Jul 22, 2021
Certification expiration date: May 4, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mike Talani | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Tung Truong | Licensing Program Analyst | Conducted the annual inspection visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 143
Deficiencies: 1
Date: May 20, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2021-04-12 regarding the facility elevator being in disrepair.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The elevator was confirmed to be in disrepair for an hour, posing a potential risk to residents.
Findings
The investigation found that the elevator was in disrepair for an hour, which posed a potential risk to the health, safety, and personal rights of residents. The complaint was substantiated based on interviews and document review.
Deficiencies (1)
Facility elevator was in disrepair for an hour, failing to ensure the facility was clean, safe, sanitary, and in good repair at all times.
Report Facts
Estimated Days of Completion: 30
Capacity: 143
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Executive Director | Interviewed regarding elevator disrepair and acknowledged the issue. |
| Tirzah Hubbard | Licensing Program Analyst | Conducted the complaint investigation. |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation and signed the report. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 143
Deficiencies: 0
Date: Feb 17, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-12-21 regarding insufficient staffing to meet residents' needs and inadequate food services.
Complaint Details
The complaint investigation was unannounced and involved allegations of insufficient staffing and inadequate food services. The staffing allegation was unsubstantiated, meaning there was insufficient evidence to prove the violation occurred. The food services allegation was unfounded, meaning it was false or without reasonable basis.
Findings
The allegation of insufficient staffing was found to be unsubstantiated due to lack of preponderance of evidence, although some residents reported waiting up to 30 minutes for care. The allegation of inadequate food services was found to be unfounded after review of menus, facility documents, and tele-visit inspection showing adequate food variety and options.
Report Facts
Capacity: 143
Census: 75
Caregivers on shift: 5
Inspection start time: 1000
Inspection end time: 1030
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Administrator | Interviewed regarding staffing and food service allegations |
| Bethany Huusfeldt | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 143
Deficiencies: 1
Date: Feb 17, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 12/28/2020 regarding failure to meet residents' needs, pest issues, inadequate food services, trash disposal, and staff training.
Complaint Details
The complaint investigation was substantiated for failure to meet residents' needs related to continence care. The allegation regarding pests was unsubstantiated. Allegations about inadequate food services, trash disposal, and staff training were unfounded.
Findings
The investigation substantiated that an incontinent resident was left unattended on the toilet for approximately 40 minutes during a shift change, posing an immediate health risk. Other allegations including pest presence, inadequate food services, trash disposal, and staff training were found to be unsubstantiated or unfounded.
Deficiencies (1)
Licensee failed to check on incontinent resident during the time period when resident was known to be incontinent, posing an immediate health risk.
Report Facts
Capacity: 143
Census: 75
Deficiencies cited: 1
Plan of Correction Due Date: Feb 22, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Administrator | Met with Licensing Program Analyst during investigation |
| Bethany Huusfeldt | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Troy Ordonez | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 143
Deficiencies: 0
Date: Jan 29, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-07-30 regarding staff not providing timely assistance to residents.
Complaint Details
The complaint alleged staff not providing assistance to residents in a timely manner, staff not responding to residents' call buttons, residents' room carpets being dirty, and a resident sustaining a pressure sore while in care. The findings were unsubstantiated or unfounded based on interviews, documentation, and virtual tour evidence.
Findings
The investigation included interviews, document reviews, and a virtual tour. The department found the allegation of staff not providing timely assistance unsubstantiated, meaning there was insufficient evidence to prove the violation. Other allegations regarding call button response, room cleanliness, and pressure sores were found to be unfounded.
Report Facts
Capacity: 143
Census: 78
Complaint received date: Jul 30, 2020
Inspection start time: 1315
Inspection end time: 1345
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Talani | Executive Director | Met with during inspection and involved in findings discussion |
| Danyle Wolter | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation |
Report
February 25, 2026
Report
April 3, 2025
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