Inspection Report Summary
Most inspections found deficiencies related primarily to medication management, infection control, and staffing issues, with several complaint investigations substantiating these concerns. The facility faced substantiated findings including medication errors that posed immediate health risks, insufficient infection control during a scabies outbreak, and inadequate staff training documented in the most recent annual inspection on September 10, 2025. The latest report from October 30, 2025, however, showed no deficiencies, indicating some improvement in compliance. Several complaints about medication and care issues were substantiated, while others, such as allegations of falsified records and untimely medical attention, were unsubstantiated. Although some issues remain, the absence of deficiencies in the most recent inspection suggests progress in addressing prior concerns.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
61% 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
Census: 121
Capacity: 199
Deficiencies: 0
Date: Oct 30, 2025
Visit Reason
The inspection was a case management visit conducted due to incident reports regarding a resident's behavioral episodes requiring medical assessment.
Findings
No deficiencies were noted as a result of the inspection. The Licensing Program Analyst and Executive Director discussed the resident's behavioral expressions plan and ongoing strategies.
Report Facts
Incident dates: Behavioral episodes occurred on 2025-10-16 and 2025-10-18 requiring medical assessment
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit |
| Michael Clymo | Administrator/Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Annual Inspection
Census: 119
Capacity: 199
Deficiencies: 2
Date: Sep 10, 2025
Visit Reason
The inspection was a required annual unannounced inspection conducted by Licensing Program Analyst Kevin Mknelly to assess compliance with licensing requirements using the full CARE tool.
Complaint Details
The complaint was substantiated based on the preponderance of evidence, indicating valid allegations related to staff training deficiencies.
Findings
The facility was observed to be clean, safe, and in good repair. However, deficiencies were found related to staff training documentation, with some staff lacking required training, posing potential health, safety, or personal rights risks to residents.
Deficiencies (2)
Licensee did not comply with training requirements including additional 20 hours annually with dementia care and specific training for postural supports, restricted health conditions, and hospice care for 4 staff files.
Licensee did not ensure that employees assisting residents with self-administration of medications completed required 24 hours of initial training for 2 medication technician records reviewed.
Report Facts
Staff files reviewed: 4
Resident files reviewed: 6
Personnel files reviewed: 2
Medication technician records reviewed: 2
Plan of Correction Due Date: Oct 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Clymo | Executive Director | Met with Licensing Program Analyst during inspection and discussed findings |
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and authored the report |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 199
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including failure to ensure reporting requirements were followed, medication dispensing errors, and staffing qualifications.
Complaint Details
The complaint was substantiated regarding failure to notify family of an infectious illness due to an administrative error, leading to exposure risk. Other complaints about medication errors and staffing were unsubstantiated or unfounded.
Findings
The investigation substantiated that staff failed to notify a resident's family timely about an infectious illness due to an administrative error, posing a potential health risk. Other allegations regarding medication errors and staffing qualifications were found unsubstantiated or unfounded after review of records and interviews.
Deficiencies (2)
Observation of resident- The licensee shall ensure that residents are regularly observed for changes such as physical health condition and brought to the attention of the resident's physician and responsible person. This requirement was not met.
Based on statements that found responsible party was not notified timely of an infectious illness. This posed a potential risk to others.
Report Facts
Capacity: 199
Census: 124
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Michael Clymo | Executive Director/Administrator | Met with Licensing Program Analyst during investigation and received report |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 199
Deficiencies: 2
Date: Feb 11, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not ensure infectious disease protocols were followed to prevent the spread of scabies and that there were insufficient staff to meet residents' needs.
Complaint Details
The complaint was substantiated. The investigation found that infectious disease protocols were not fully followed to prevent scabies spread and that staffing was insufficient at times to meet resident needs, leading to delays in care.
Findings
The investigation substantiated the allegations, finding that infection control measures were not comprehensively implemented at the onset of the scabies outbreak and that staffing shortages occurred, leading to delays in resident care. Deficiencies were cited related to infection control and staffing.
Deficiencies (2)
Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained. This requirement was not met based on interviews and records review which found that the infection control for this outbreak was not consistently and effectively implemented, posing a risk to residents.
Additional Personal Rights of Residents in Privately Operated Facilities (a) residents shall have the right to care, supervision, and services that meet their individual needs and are delivered by staff sufficient in numbers to meet their needs. This requirement was not met based on records and interviews which found that for a period of time, there were insufficient staff to meet residents' needs, posing a potential risk.
Report Facts
Residents treated prophylactically for scabies: 12
Staff treated prophylactically for scabies: 7
Facility capacity: 199
Census: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carol Pickard | Administrator | Facility administrator met with during investigation and report review |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 199
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations of staff mismanaging resident's medication and falsifying medication administration records.
Complaint Details
The complaint investigation was substantiated for staff mismanaging resident's medication but unsubstantiated for falsifying medication administration records.
Findings
The investigation substantiated the allegation that staff mismanaged a resident's medication, specifically an inhaler with zero doses remaining was used and recorded as administered, posing an immediate health and safety risk. The allegation of falsifying medication administration records was found unsubstantiated due to lack of evidence.
Deficiencies (1)
Failure to develop and follow a plan for incidental medical and dental care, specifically medication administration compliance, resulting in an immediate risk to resident R1.
Report Facts
Facility capacity: 199
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carol Pickard | Administrator | Facility administrator met with during investigation and report delivery |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 199
Deficiencies: 1
Date: Nov 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-09-24 regarding inadequate monitoring of a resident's oxygen administration, failure to ensure resident's room was cleaned, and failure to seek timely medical attention for a resident.
Complaint Details
The complaint investigation was substantiated for inadequate monitoring of oxygen administration, with evidence showing the resident was not always escorted or monitored as per care plan, leading to non-use of oxygen as prescribed. The allegations regarding room cleanliness and timely medical attention were unsubstantiated.
Findings
The investigation substantiated the allegation that staff did not adequately monitor the resident's oxygen administration, resulting in potential health and safety risks. The allegations that staff did not ensure the resident's room was cleaned and did not seek timely medical attention were found to be unsubstantiated.
Deficiencies (1)
Oxygen Administration - The licensee failed to monitor the resident's ongoing ability to operate oxygen equipment in accordance with physician's orders, posing a potential risk to the resident.
Report Facts
Capacity: 199
Census: 115
Plan of Correction Due Date: Dec 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carol Pickard | Executive Director / Administrator | Facility representative met during investigation and named in findings |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 199
Deficiencies: 2
Date: Oct 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff did not administer medications as prescribed and were mismanaging residents' medications.
Complaint Details
The complaint was substantiated based on evidence including resident and facility records and interviews. The findings confirmed medication errors and mismanagement, including a medication mix-up and missed doses due to pharmacy and storage issues.
Findings
The investigation substantiated the allegations, finding incidents where a resident was given another resident's medication and missed medication doses due to pharmacy and storage issues. These deficiencies posed immediate and potential health and safety risks to residents.
Deficiencies (2)
Incident of a resident being handed another's medication and an incident of a missed medication.
Medications were not stored in their originally received containers, posing a potential risk to residents.
Report Facts
Capacity: 199
Census: 115
Plan of Correction Due Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carol Pickard | Administrator | Facility administrator involved in the investigation and report review |
| Maribeth Senty | Licensing Program Manager | Oversaw the licensing program related to the investigation |
Inspection Report
Annual Inspection
Census: 114
Capacity: 199
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
The inspection was a required unannounced annual inspection conducted using the full CARE tool to evaluate compliance with licensing requirements.
Findings
The facility was found to be in substantial compliance with no deficiencies observed. The facility was clean, safe, and in good repair, with mostly complete resident and personnel files. Some discussion occurred regarding hospice care plan content and requests for staff first aid training certificates.
Report Facts
Personnel files reviewed: 6
Resident files reviewed: 10
Hospice waiver capacity: 15
Inspection duration hours: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Executive Director | Met with Licensing Program Analysts during inspection and discussed hospice care plan requirements |
| Graham Gunby | Licensing Program Analyst | Conducted the inspection |
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Census: 107
Capacity: 199
Deficiencies: 0
Date: Aug 30, 2024
Visit Reason
The inspection was a case management visit conducted regarding an unexpected resident death at the facility.
Findings
The resident who passed away had multiple chronic illnesses and appeared to have received the necessary level of care and supervision. No deficiencies were noted as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Senior Executive Director | Met with during case management visit regarding unexpected resident death. |
| Liza Spencer | Program Director, LVN | Met with during case management visit regarding unexpected resident death. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit. |
| Maribeth Senty | Licensing Program Manager | Named in report review and signature section. |
Inspection Report
Census: 45
Capacity: 199
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
The visit was a case management visit to discuss incident reports received by the department, including resident health changes, incidents of residents leaving the memory care unit, and a fall with fracture.
Findings
No violations or deficiencies were noted during the inspection. The facility was found to have proper measures in place for resident hydration, delayed egress system functioning, staff training, and fall prevention programs.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and discussed incidents with facility staff. |
| Eva Bowlin | Executive Director | Met with Licensing Program Analyst during the visit and discussed incidents. |
| Aaron Burgos | Memory Care Director | Met with Licensing Program Analyst during the visit and discussed incidents. |
Inspection Report
Census: 37
Capacity: 199
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct a collateral visit to interview a resident concerning an issue not related to this facility.
Findings
No deficiencies were observed in the areas evaluated at the time of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Galvez | Administrator | Met with Licensing Program Analyst during the visit. |
| Bethany Mirlohi | Licensing Program Analyst | Conducted the unannounced collateral visit. |
| Troy Ordonez | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 25
Capacity: 199
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
The inspection was a Post Licensing unannounced visit conducted to evaluate the facility's compliance and ensure health and safety of residents using the CARE inspection tool.
Findings
No immediate health, safety, or personal rights violations were observed during the tour of the facility. Resident and staff files were complete, though some recommendations were made for file organization and ensuring completeness of physician reports. No deficiencies were cited as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Galvez | Executive Director / Administrator | Met with Licensing Program Analyst during inspection and discussed file completeness and organization. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the Post Licensing Inspection and authored the report. |
| Maribeth Senty | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Original Licensing
Capacity: 199
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The visit was a pre-licensing inspection conducted to evaluate the facility prior to opening, referencing the CARE inspection tool.
Findings
The facility was toured with no immediate health or safety concerns observed. The facility is in significant compliance with licensing requirements, with license approval pending.
Report Facts
Stairwell evacuation chairs pending delivery: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Galvez | Administrator | Facility administrator named in report header |
| Kevin Mknelly | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Maribeth Senty | Licensing Program Manager | Named in report |
Inspection Report
Original Licensing
Capacity: 199
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
The visit was an initial licensing evaluation for the Residential Care Facility for the Elderly to assess pre-licensing readiness and compliance with California Code Title 22 Regulations.
Findings
The applicant and administrator participated in a telephone interview (COMP II) confirming their understanding of facility operation, admission policies, staffing requirements, restricted health conditions, emergency preparedness, complaints and reporting, and general provisions. Identification was verified and required documentation was obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Galvez | Administrator | Applicant/administrator participating in COMP II and confirming understanding of regulations. |
| Michael Hughes | Participant in COMP II interview with applicant/administrator. | |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
Report
October 30, 2025
Report
May 6, 2025
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