Inspection Report Summary
Most inspections found deficiencies related primarily to medication management, staffing shortages, and resident care issues such as privacy and supervision. Several complaint investigations were substantiated, including incidents of medication errors, delayed medical attention, inadequate supervision leading to resident elopement, and failure to process insurance invoices timely. The facility also faced pest control issues in August 2024, which were addressed promptly. The most recent report from August 20, 2025, cited a deficiency for not processing residents’ insurance invoices timely, but no fines or enforcement actions were listed in the available reports. While some older reports showed multiple deficiencies, recent inspections show a mix of substantiated and unsubstantiated complaints without a clear trend of improvement or decline.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
83% 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: 102
Capacity: 123
Deficiencies: 1
Date: Aug 20, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not process residents' insurance invoices in a timely manner for reimbursement.
Complaint Details
The complaint was substantiated based on interviews and record reviews. Six residents' insurance invoices were confirmed by the Executive Director to have not been processed timely due to management changes.
Findings
The allegation was substantiated. The investigation found that six residents' insurance invoices were not processed timely due to a change in management, posing a potential health and safety risk to clients in care. The deficiency was cited under Title 22 California Code of Regulations.
Deficiencies (1)
Failure to timely process residents' insurance invoices for reimbursements, posing a potential health and safety risk to clients.
Report Facts
Residents with delayed insurance invoices: 6
Facility census: 102
Facility capacity: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and interviews. |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation. |
| Francine Taitano | Administrator/Executive Director | Interviewed during investigation; confirmed delayed processing of insurance invoices. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 123
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff does not ensure resident's medical information is confidential.
Complaint Details
The complaint was substantiated based on interviews with staff and observations that staff publicly discussed resident’s medical information at the front desk on 08/06/25, violating residents’ personal rights.
Findings
The allegation was substantiated after interviews and observations confirmed that staff publicly discussed resident’s medical information at the front desk, violating residents’ personal rights and posing a potential health and safety risk.
Deficiencies (1)
Staff failed to ensure resident’s medical information is confidential, violating residents’ personal rights and posing a potential health and safety risk.
Report Facts
Capacity: 123
Census: 103
Deficiency Type B: 1
Plan of Correction Due Date: Sep 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
| Angela Caldera | Manager on Duty | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 103
Capacity: 123
Deficiencies: 0
Date: Jul 11, 2025
Visit Reason
The visit was an unannounced annual required inspection conducted by the Licensing Program Analyst to assess compliance with licensing requirements.
Findings
The inspection found no deficiencies. The facility was observed to have proper infection control measures, emergency plans, sufficient food and PPE supplies, operational safety equipment, and monthly fire and earthquake drills.
Report Facts
PPE supply duration: 30
Perishable food supply duration: 2
Non-perishable food supply duration: 7
Hot water temperature: 115
Facility temperature: 74
Fire extinguisher last inspection date: Oct 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francine Taitano | Executive Director/Administrator | Met with Licensing Program Analyst during inspection and identified as infection control leader |
| Daisy Panlilio | Licensing Program Analyst | Conducted the inspection visit |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 123
Deficiencies: 2
Date: May 15, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff administered unauthorized medication to a resident and disclosed personal information about a resident.
Complaint Details
The complaint investigation was substantiated. Staff administered unauthorized medication to a resident on 04/16/25 at 12PM and disclosed personal information about the resident on the same date. The investigation included interviews with staff and review of resident and medication records.
Findings
Both allegations were substantiated after interviews and record reviews. Staff administered unauthorized medication to a resident due to a delayed prescription refill and publicly disclosed a resident's personal medication information in a common area.
Deficiencies (2)
Staff administered unauthorized medication to a resident which posed a potential health and safety risk.
Staff publicly disclosed resident's personal information which posed a potential health and safety risk.
Report Facts
Census: 105
Total Capacity: 123
Plan of Correction Due Date: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francine Taitano | Executive Director | Met with Licensing Program Analyst during investigation |
| Daisy Panlilio | Licensing Program Analyst | Conducted complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 123
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-11-21 alleging that staff did not afford a resident privacy while in care.
Complaint Details
Allegation: Staff did not afford a resident privacy while in care. Investigation Finding: Unsubstantiated. The reporting party stated that on 08/01/24 a care provider was seen on video looking in a resident's closets and dresser drawers without permission. Staff denied the violation. The evidence was insufficient to prove the allegation.
Findings
The investigation included interviews with facility staff and the responsible party, review of resident documents and video evidence. The allegation was found to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the visit.
Report Facts
Capacity: 123
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Francine Taitano | Executive Director | Met with during the investigation |
| Brittany Karlinski | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 123
Deficiencies: 1
Date: Jan 22, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff mismanaged a resident's medication.
Complaint Details
The complaint was substantiated. The investigation included interviews with facility staff and the resident's responsible party, and review of resident documents including hospital discharge summaries, medication administration records, and emails. The resident was administered two anti-psychotic medications simultaneously from December 16, 2023, to January 22, 2024, due to misfiling of hospital discharge reports and lack of medication re-evaluation.
Findings
The investigation substantiated the allegation that staff mismanaged a resident's medication, resulting in the resident receiving two anti-psychotic medications simultaneously due to misfiling of hospital discharge reports and lack of medication re-evaluation.
Deficiencies (1)
There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all required information, instructions regarding discontinuation, and indication for medication reevaluation. This requirement was not met as evidenced by staff mismanaged resident’s medication which posed a potential health & safety risk.
Report Facts
Facility Capacity: 123
Census: 88
Medication Dosage: 25
Plan of Correction Completion Date: Jan 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bennett Fong | Licensing Program Manager | Oversaw the complaint investigation |
| Diane Taylor | Director of Health Services | Met with Licensing Program Analyst during investigation |
| Brittany Karlinski | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 123
Deficiencies: 2
Date: Jan 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to allegations including inadequate supervision resulting in resident elopement and unsecured medication storage.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not ensure adequate supervision resulting in residents eloping and that medications were not securely stored. Other allegations regarding reporting requirements, staff training in emergency evacuation, fire drills, and resident privacy were unsubstantiated.
Findings
Two allegations were substantiated: staff failed to provide adequate supervision leading to residents eloping due to a faulty delayed egress system, and staff failed to securely store residents' medications as the medication room door was found unlocked. Other allegations related to reporting, staff training on emergency evacuation, fire drills, and resident privacy were unsubstantiated.
Deficiencies (2)
Staff do not ensure adequate supervision resulting in residents eloping from the facility.
Staff do not ensure residents' medications are securely stored; medication room door was unlocked.
Report Facts
Capacity: 123
Census: 88
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bennett Fong | Licensing Program Manager | Oversaw licensing program and signed report |
| Diane Taylor | Director of Health Services | Met with Licensing Program Analyst during investigation |
| Brittany Karlinski | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 123
Deficiencies: 1
Date: Jan 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff left a resident on the floor for an extended period of time, did not ensure resident hydration resulting in dehydration, and failed to communicate with the resident's responsible party.
Complaint Details
The complaint investigation was substantiated for the allegation that staff left a resident on the floor for an extended period of time. The resident had an unwitnessed fall on 11/29/24 and was found confused and lethargic with blood on his elbow. The resident was hospitalized for altered mental status due to dementia precipitated by dehydration and rhabdomyolysis. The allegations that staff did not ensure hydration and did not communicate with the resident's responsible party were unsubstantiated.
Findings
The allegation that staff left a resident on the floor for an extended period was substantiated based on interviews, document reviews, and observations. The allegations that staff did not ensure resident hydration and did not communicate with the resident's responsible party were found to be unsubstantiated.
Deficiencies (1)
Staff left resident on floor for an extended period of time which posed a potential health & safety risk to residents in care.
Report Facts
Capacity: 123
Census: 89
Plan of Correction Due Date: Jan 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Diane Taylor | Director of Health Services | Met with Licensing Program Analyst during investigation |
| Angela Caldera | Memory Care Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 123
Deficiencies: 0
Date: Sep 25, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 2023-05-16 regarding staffing sufficiency, resident falls, and assistance with activities of daily living.
Complaint Details
Complaint control number 15-AS-20230516162748 involved allegations that the facility did not have sufficient staff to meet resident needs, residents sustained multiple unwitnessed falls resulting in injury, and staff did not assist residents with activities of daily living in a timely manner. The investigation concluded these allegations were unsubstantiated.
Findings
The complaint allegations were found to be unsubstantiated during the investigation. No deficiencies were cited, and amended reports were re-delivered as unsubstantiated.
Report Facts
Complaint control number: 15-AS-20230516162748
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit and amended the reports. |
| Diane Taylor | Director of Wellness | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 123
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including improper COVID-19 control protocols, failure to prevent and properly care for residents' pressure injuries, and failure to ensure the facility is free of pests.
Complaint Details
The complaint included allegations that staff did not follow proper COVID-19 control protocols, did not prevent residents from developing pressure injuries, did not properly care for residents' pressure injuries, and did not ensure the facility was free of pests. All allegations were found to be unsubstantiated.
Findings
All allegations were investigated through staff interviews, document reviews, and facility inspections. The investigation found no preponderance of evidence to substantiate any of the allegations. The facility was found to follow COVID-19 protocols, provide proper wound care, and address pest issues effectively.
Report Facts
Capacity: 123
Census: 109
COVID-19 positive staff: 4
COVID-19 positive residents: 2
Pressure injury treatment frequency for R1: 2
Pressure injury treatment frequency for R2: 3
Pest control report dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bennett Fong | Licensing Program Manager | Oversaw the complaint investigation |
| Brittany Karlinski | Administrator | Facility administrator mentioned in report header |
| Roezi Vermouth | Director of Wellness (MOD) | Met with Licensing Program Analyst during investigation |
| ED | Executive Director interviewed during investigation | |
| S1 | Staff interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 123
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-05-16 regarding staffing sufficiency, resident falls, and timely assistance with activities of daily living.
Complaint Details
The complaint included allegations that the facility did not have sufficient staff to meet resident needs, a resident sustained multiple unwitnessed falls resulting in injury, and staff did not assist residents with activities of daily living in a timely manner. Each allegation was investigated and found unsubstantiated due to lack of preponderance of evidence.
Findings
All allegations investigated were found to be unsubstantiated after review of resident records, staff and resident interviews, and documentation. No deficiencies were cited during the visit.
Report Facts
Capacity: 123
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Administrator / Executive Director | Met with during investigation and mentioned in relation to findings |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Roezi Vermouth | Director of Wellness (MOD) | Met with during investigation |
Inspection Report
Annual Inspection
Census: 107
Capacity: 123
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
The visit was an unannounced annual required inspection conducted to evaluate the facility's compliance with regulatory standards.
Findings
The inspection found no deficiencies. The facility was observed to have proper infection control measures, emergency plans, adequate supplies, and operational safety equipment.
Report Facts
Capacity: 123
Census: 107
Inspection duration: 3.5
Hot water temperature: 116
Room temperature: 76
Fire extinguisher last inspection date: Oct 23, 2023
PPE supply duration: 30
Perishable food supply duration: 2
Non-perishable food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director/Administrator | Met with Licensing Program Analyst during inspection |
| Diane Taylor | Health Services Manager | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 123
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not providing adequate housekeeping services to residents and were not ensuring residents were provided with toiletries.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate housekeeping services and failure to provide toiletries. The department found no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found both allegations to be unsubstantiated after interviews, records review, and observations. Housekeeping services were found adequate and residents were responsible for their own toiletries as per admission agreements.
Report Facts
Capacity: 123
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director/Administrator | Met with during investigation and provided documents |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 123
Deficiencies: 2
Date: Aug 15, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not ensure medication was dispensed as prescribed and medication records were not properly maintained.
Complaint Details
Complaint investigation was substantiated based on evidence including interviews, incident reports, and medication records showing incorrect medication dosage and improper record maintenance.
Findings
Both allegations were substantiated after interviews, record reviews, and observations. Medication was administered at incorrect dosages and medication records were not properly updated, posing potential health and safety risks to residents.
Deficiencies (2)
Facility staff did not ensure medication was dispensed as prescribed, posing a potential health and safety risk to residents.
Facility staff did not ensure medication records were properly maintained, posing a potential health and safety risk to residents.
Report Facts
Capacity: 123
Census: 107
Deficiencies cited: 2
Plan of Correction Due Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director | Met with Licensing Program Analyst during investigation |
| Daisy Panlilio | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Bennett Fong | Licensing Program Manager | Oversaw complaint investigation |
| Director of Health Services | Director of Health Services | Confirmed medication record errors during investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 123
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff were mismanaging resident medication and not meeting resident needs.
Complaint Details
The complaint alleged staff mismanagement of resident medication and failure to meet resident needs. Both allegations were investigated and found unsubstantiated, meaning there was insufficient evidence to prove the violations occurred.
Findings
The investigation found both allegations to be unsubstantiated after reviewing medication administration records, conducting staff and resident interviews, and observing facility operations. No deficiencies were cited.
Report Facts
Capacity: 123
Census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director/Administrator | Met with during investigation and mentioned in relation to findings |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 123
Deficiencies: 2
Date: Aug 7, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not keep the facility free from bedbugs and pests.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to keep the facility free from bedbugs and pests. Evidence showed bed bug infestations in resident apartments and memory care areas, and mice presence in kitchen and resident bedroom areas. Corrective actions were documented and deficiencies cleared during the visit.
Findings
The investigation substantiated the allegations of bed bug infestation and pest presence in the facility, posing potential health and safety risks to residents. The facility took corrective actions including scheduling extermination treatments and addressing mice infestation.
Deficiencies (2)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by bed bug infestation in memory care which posed a potential health and safety risk to residents in care.
All persons shall be protected against hazards within the facility. This requirement was not met as evidenced by presence of pest in the memory care areas which posed a potential health & safety risk to residents in care.
Report Facts
Capacity: 123
Census: 105
Deficiency count: 2
Plan of Correction Due Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Brittany Karlinski | Executive Director | Facility administrator interviewed during investigation and named in findings |
| Bennett Fong | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 123
Deficiencies: 0
Date: Aug 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-02-23 regarding illegal eviction of a resident and failure to ensure the resident's call system was operable.
Complaint Details
The complaint involved two allegations: 1) Facility illegally evicted a resident in care, and 2) Facility did not ensure that resident's call system was operable. Both allegations were found unsubstantiated after review of documentation, interviews, and incident reports.
Findings
Both allegations were investigated and found to be unsubstantiated. The facility followed proper procedures for eviction with a 30-day written notice due to resident's noncompliance, and the call system issue was promptly repaired with monthly checks in place. No deficiencies were cited.
Report Facts
Capacity: 123
Census: 105
Complaint Control Number: 15-AS-20240223165313
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director | Met with during investigation and involved in eviction and call system findings |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 123
Deficiencies: 1
Date: Aug 1, 2024
Visit Reason
An unannounced Case Management visit was conducted regarding an incident reported on 2024-06-14 where a resident (R1) eloped from the memory care unit.
Complaint Details
Complaint investigation regarding an incident of resident elopement on 2024-06-14. The incident was substantiated by findings of staff delay in response.
Findings
The licensee did not comply with staff responding timely before R1 eloped outside the building and across the street, posing a potential health and safety risk. The deficiency was cited but cleared during the visit after review of policies and corrective actions.
Deficiencies (1)
Failure to provide care, supervision, and meet individual needs by staff sufficient in numbers, qualifications, and competency, evidenced by staff not responding timely before R1 eloped outside the building and across the street.
Report Facts
Capacity: 123
Census: 103
Deficiency Type B: 1
Plan of Correction Due Date: Aug 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director | Met with Licensing Program Analyst during visit and named in report |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bennett Fong | Licensing Program Manager | Named as supervisor and licensing program manager |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 123
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
An unannounced Case Management visit was conducted regarding an incident reported to CCLD on 06/18/2024 concerning a resident delinquent with monthly rent payments.
Complaint Details
The complaint involved a resident delinquent with monthly rent payments since move-in, with the Responsible Party failing to comply with offered payment plans.
Findings
The visit found that the resident's Responsible Party was offered payment arrangements but continued to miss payments. No deficiencies were issued during the visit.
Report Facts
Capacity: 123
Census: 103
Payment plans offered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director | Met with Licensing Program Analyst during the visit |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 123
Deficiencies: 0
Date: Jun 13, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff do not follow proper food sanitation and safety practices.
Complaint Details
The complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
The investigation included interviews with staff and review of relevant documents. Observations and staff statements indicated proper hand washing and glove changing practices. The allegation was found to be unsubstantiated with no deficiencies cited.
Report Facts
Capacity: 123
Census: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Grace Luk | Licensing Program Analyst | Conducted complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 123
Deficiencies: 0
Date: Feb 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations including questionable death and staff not dispensing medication to residents in a timely manner.
Complaint Details
The complaint included allegations of questionable death and staff not dispensing medication to residents in a timely manner. Both allegations were investigated and found to be unsubstantiated based on records review, interviews, and observations.
Findings
The investigation found both allegations to be unsubstantiated after review of medical records, medication logs, interviews with staff and residents, and observations. There was no evidence of neglect or improper medication administration.
Report Facts
Capacity: 123
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Administrator | Met with Licensing Program Analyst during investigation |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 123
Deficiencies: 0
Date: Feb 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including resident falls due to staff neglect, improper COVID-19 isolation, inadequate food service, improper sanitizing methods, delayed response to call buttons, and unclean resident rooms.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included multiple residents falling due to staff neglect, failure to isolate COVID-19 residents, inadequate food service, improper sanitizing, untimely response to call buttons, and failure to clean residents' rooms. Investigations included interviews, document reviews, and observations, all resulting in unsubstantiated findings.
Findings
All allegations investigated were found to be unsubstantiated after review of records, interviews, and observations. The department found no preponderance of evidence to prove any violations regarding resident falls, COVID-19 isolation, food service adequacy, sanitizing methods, call button response times, or cleanliness of resident rooms.
Report Facts
Capacity: 123
Census: 86
Incident reports: 4
Incident reports: 3
Housekeeping staff: 5
Maintenance staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Administrator | Met with Licensing Program Analyst during investigation |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 123
Deficiencies: 2
Date: Oct 25, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-06-15 regarding staff mismanagement of resident's medication and untimely medication refills.
Complaint Details
The complaint investigation was substantiated for allegations of medication mismanagement and untimely medication refills. Other allegations including resident lost severe weight, sustained a fall, sustained UTIs, dehydration, and insufficient staffing were investigated and found unsubstantiated.
Findings
The investigation substantiated allegations that staff mismanaged a resident's medication and did not order medication refills in a timely manner, posing potential health and safety risks. Other allegations including resident weight loss, falls, UTIs, dehydration, and insufficient staffing were found to be unsubstantiated.
Deficiencies (2)
Staff mismanaging resident’s medication which posed a potential health & safety risk to residents in care.
Staff not timely ordering medication refills which posed a potential health & safety risk to residents in care.
Report Facts
Capacity: 123
Census: 96
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Administrator/Executive Director | Met with Licensing Program Analyst during investigation and named in report |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 123
Deficiencies: 4
Date: Oct 25, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-09-09 regarding staff overmedicating a resident and not following doctor's orders, among other complaints.
Complaint Details
The complaint investigation was substantiated for allegations that staff overmedicated a resident and did not follow doctor's orders. Other allegations including failure to safeguard resident's property, failure to notify POA of changes or incidents, failure to respond to POA, and failure to ensure hygiene care were unsubstantiated.
Findings
The investigation substantiated allegations that staff overmedicated a resident and did not follow doctor's orders, citing medication errors and failure to verify physician's orders. Other allegations related to safeguarding resident property, notifying POA of changes or incidents, responding to POA, and ensuring hygiene care were found unsubstantiated.
Deficiencies (4)
A record of each dose is maintained in the resident's record including date, time, dosage, and resident's response.
Facility staff shall contact the resident's physician prior to each dose, describe symptoms, and receive direction to assist in self-administration.
Staff mismanaged resident's medication posing a potential health and safety risk.
Staff did not timely order medication refills posing a potential health and safety risk.
Report Facts
Capacity: 123
Census: 96
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Administrator/Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 87
Capacity: 123
Deficiencies: 0
Date: Aug 4, 2023
Visit Reason
The visit was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with regulatory standards.
Findings
The facility was found to be clean, in good repair, and compliant with infection control and safety requirements. No deficiencies were cited during the visit.
Report Facts
Food supply duration: 2
Food supply duration: 7
PPE supply duration: 30
Hot water temperature: 111.3
Fire extinguisher last inspection date: Oct 10, 2022
Number of staff files reviewed: 5
Number of resident files reviewed: 5
Number of staff interviews conducted: 5
Number of resident interviews conducted: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Administrator | Named as facility administrator |
| Brenda Layfield | Manager on Duty | Met with Licensing Program Analyst during inspection |
| Diane Taylor | Resident Care Director | Met with Licensing Program Analyst during inspection |
| Daisy Panlilio | Licensing Program Analyst | Conducted the inspection |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 123
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
The inspection was conducted as a result of the department receiving a priority 1 complaint to perform a health and safety check.
Complaint Details
The visit was triggered by a priority 1 complaint. No deficiencies were cited and no imminent health or safety concerns were found.
Findings
During the health and safety check, 25 staff members and 83 residents were observed. The facility was toured including bedrooms, kitchen, bathroom, and common areas. Residents appeared safe with no imminent health or safety concerns and no deficiencies were cited.
Report Facts
Staff members observed: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director | Met with during the inspection and toured the facility |
| Daisy Panlilio | Licensing Program Analyst | Conducted the health and safety check |
| Bennett Fong | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 123
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility does not ensure residents have meals in a designated dining area with other residents and does not ensure planned social activities are available for residents in care.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations lacked reasonable basis. The complaint was dismissed.
Findings
The investigation found both allegations to be unfounded due to compliance with COVID-19 mitigation protocols, including temporary suspension of communal dining and social activities as recommended by Local Public Health authorities. No deficiencies were cited.
Report Facts
Capacity: 123
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director | Met with during the complaint investigation and provided information regarding COVID-19 protocols |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 123
Deficiencies: 3
Date: Feb 17, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2021-01-14 regarding inadequate resident care including hygiene assistance, clean clothing, and timely medication administration.
Complaint Details
The complaint investigation was substantiated for allegations related to failure to assist residents with hygiene needs, failure to ensure residents had clean clothing, and residents being left in soiled clothing for extended periods. The allegations related to medication administration, response to authorized representatives, facility cleanliness, and safe environment were unsubstantiated.
Findings
The investigation substantiated allegations that staff failed to assist residents with hygiene needs, ensure residents had clean clothing, and left residents in soiled clothing for extended periods due to insufficient staffing. Other allegations related to medication administration, response to authorized representatives, facility cleanliness, and safety were unsubstantiated.
Deficiencies (3)
Staff failing to assist residents hygiene needs which posed a potential health & safety risk to residents in care.
Staff did not ensure resident had clean clothing which posed a potential health & safety risk to resident in care.
Resident left in soiled clothing for an extended period of time which posed a potential health & safety risk to resident in care.
Report Facts
Capacity: 123
Census: 83
Deficiencies cited: 3
Plan of Correction Due Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Andrews | Executive Director | Met with Licensing Program Analyst during inspection and acknowledged findings |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 83
Capacity: 123
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
The visit was an unannounced case management visit conducted while at the facility for another reason.
Findings
No deficiencies were cited during the visit. The executive director confirmed that a former staff member was no longer employed at the facility.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 123
Deficiencies: 1
Date: Jan 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2021-08-02 regarding inadequate cleaning and care practices at the facility.
Complaint Details
The complaint investigation was triggered by allegations including staff not cleaning residents' rooms, residents left in soiled diapers for extended periods, residents not receiving showers, and feces found on a resident's carpet. The allegation of uncleaned rooms was substantiated, while the others were unsubstantiated.
Findings
The investigation substantiated that staff failed to clean resident R3's room, posing a potential health and safety risk. Other allegations regarding residents left in soiled diapers, lack of showers, and feces on carpet were unsubstantiated due to insufficient evidence.
Deficiencies (1)
Failure to clean resident R3's room, violating maintenance and operation requirements for cleanliness and safety.
Report Facts
Capacity: 123
Census: 86
Deficiency Type B: 1
Plan of Correction Due Date: Jan 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| Brittany Karlinski | Executive Director | Met with Licensing Program Analyst during investigation and agreed to conduct training for housekeeping staff |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 123
Deficiencies: 0
Date: Jan 6, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations received on 2021-03-04 regarding resident falls, medication mismanagement, and unequal treatment of residents.
Complaint Details
The complaint involved allegations that a resident sustained multiple falls resulting in injuries, staff were mismanaging residents' medication, and staff were not treating residents equally. The investigation reviewed incident reports, medication administration records, care plans, and conducted interviews. The findings were unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Records showed a resident fall incident but no medication errors or unequal treatment were confirmed. The allegations were determined to be unsubstantiated.
Report Facts
Complaint Control Number: 15-AS-20210304145418
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ibo | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Diane Taylor | Director of Health and Services | Met with Licensing Program Analyst during investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 123
Deficiencies: 1
Date: Jan 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-03-25 regarding staff not answering residents' call pendents in a timely manner and other related complaints.
Complaint Details
The complaint investigation was substantiated for the allegation that staff do not answer residents' call pendents in a timely manner. Other allegations including insufficient staff, untimely medication dispensing, unmet incontinence needs, lack of dignity in treatment, and untimely meal provision were unsubstantiated.
Findings
The investigation substantiated that staff failed to respond to residents R1 and R2's pendant calls in a timely manner, with 21 calls responded to after more than 30 minutes. Other allegations including insufficient staffing, medication administration, incontinence care, dignity, and meal delivery were unsubstantiated based on interviews and record reviews.
Deficiencies (1)
Facility staff failed to respond to R1 & R2’s pendant call for assistance in a timely manner which poses a potential risk to the health and safety of resident under care.
Report Facts
Number of calls responded to after more than 30 minutes: 21
Facility capacity: 123
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Taylor | Director of Health Services | Met with Licensing Program Analyst during investigation and involved in findings |
| Leslie Ibo | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 123
Deficiencies: 1
Date: Dec 29, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation of insufficient number of competent facility personnel present at all times to meet resident needs.
Complaint Details
The complaint was substantiated based on record reviews and interviews confirming short staffing and medication administration issues.
Findings
The investigation substantiated the allegation that a medication technician was assigned two medication carts to pass medications due to short staffing, posing a potential health and safety risk to residents.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by short staffing which posed a potential health & safety risk to residents in care.
Report Facts
Capacity: 123
Census: 90
Deficiency due date: Jan 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
| Diane Taylor | Interim Health Director | Met with Licensing Program Analyst during investigation and agreed to submit plan of correction |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 123
Deficiencies: 0
Date: Dec 29, 2022
Visit Reason
The visit was conducted to follow up on a self-reported theft incident that occurred on 12/21/2022 and another theft incident on 12/27/2022 involving residents' credit/debit cards.
Complaint Details
The visit was complaint-related, following up on theft incidents reported by residents' family members. The incidents are under internal investigation and police involvement.
Findings
The facility is investigating two theft incidents involving residents' credit/debit cards totaling approximately $6,700, with police reports filed and incident reports submitted to the licensing division.
Report Facts
Amount stolen: 6300
Amount stolen: 400
Capacity: 123
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Taylor | Interim Health Director | Met with Licensing Program Analyst to discuss theft incidents |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 123
Deficiencies: 2
Date: Dec 29, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/19/2022 regarding staff mishandling a resident's medication and failure to seek timely medical attention for a resident.
Complaint Details
The complaint investigation was substantiated. The medication error involved a double dose administered for 14 days due to system update failure. Staff did not seek timely medical attention for the resident after the error was discovered. The Executive Director confirmed the findings and staff notified the hospice nurse and resident's family accordingly.
Findings
Both allegations were substantiated. Staff administered a double dose of a discontinued medication to a resident for 14 days due to failure to update the medication system. Additionally, staff failed to seek timely medical attention for the resident after the medication error was discovered.
Deficiencies (2)
Staff mishandling resident's medication which posed an immediate health & safety risk to resident in care.
Staff failing to timely seek medical attention to resident which posed an immediate health & safety risk to resident in care.
Report Facts
Capacity: 123
Census: 90
Medication error duration: 14
Staff terminated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bennett Fong | Licensing Program Manager | Oversaw the complaint investigation |
| Diane Taylor | Interim Health Director | Met with Licensing Program Analyst during the visit |
| Brittany Karlinski | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 123
Deficiencies: 1
Date: Nov 1, 2022
Visit Reason
The visit was a case management investigation triggered by records indicating that facility staff assisted a resident in self-administering Morphine without hospice authorization, which was against the resident's Hospice Care Plan instructions.
Complaint Details
Investigation found that staff assisted resident R1 with Morphine from 5/17/22 to 5/21/22 despite hospice care plan stating 'Do not use until directed by hospice'.
Findings
A deficiency was cited for failure to comply with hospice care plan requirements, specifically for assisting a resident with Morphine administration without hospice direction, posing a potential health and safety risk.
Deficiencies (1)
Facility staff assisted resident for self-administering medicine Morphine without instruction by hospice agency, violating hospice care plan requirements.
Report Facts
Census: 90
Total Capacity: 123
Deficiency count: 1
Plan of Correction Due Date: Nov 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director | Met with Licensing Program Analyst during visit and participated in exit interview |
| Catherine Lin | Licensing Program Analyst | Conducted case management visit and investigation |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing the licensing program |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 123
Deficiencies: 0
Date: Nov 1, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 06/01/2022 regarding timely medical attention, resident care needs, and medication administration.
Complaint Details
Allegations included failure to seek timely medical attention, resident care needs not being met, and untimely medication administration. All were found unsubstantiated after investigation.
Findings
All allegations were investigated and found to be unsubstantiated based on records review and interviews. No deficiencies were cited, and the facility staff's actions were consistent with hospice care directives.
Report Facts
Capacity: 123
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Catherine Lin | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
| Brittany Karlinski | Executive Director | Met with Licensing Program Analyst during investigation |
| Micah Savage | Administrator | Facility Administrator named in report |
Inspection Report
Census: 89
Capacity: 123
Deficiencies: 0
Date: Sep 23, 2022
Visit Reason
The visit occurred for case management purposes and to discuss self-reported theft incidents involving two residents that occurred on 2022-09-07.
Findings
The report discussed two theft incidents involving residents' missing jewelry, with one item later found. Staff received retraining on safeguarding property and valuables. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Administrator | Met with during the visit and mentioned in relation to the theft incidents. |
| Daisy Panlilio | Licensing Program Analyst | Conducted the visit and discussed the theft incidents. |
| Bennett Fong | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 103
Capacity: 123
Deficiencies: 0
Date: Aug 19, 2022
Visit Reason
The visit was an infection control annual inspection conducted to evaluate compliance with COVID-19 and Monkeypox infection control practices.
Findings
The facility was found to have an effective mitigation plan for COVID-19, adequate PPE supplies, proper cleaning protocols, and operational fire safety equipment. No deficiencies were cited during this visit.
Report Facts
Staff wearing face masks: 7
Residents present: 14
Capacity: 123
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Administrator | Met with during inspection and discussed infection control practices |
| Daisy Panlilio | Licensing Program Analyst | Conducted the infection control annual inspection |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 123
Deficiencies: 1
Date: Aug 19, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-11-04 alleging that residents were not getting their needs met.
Complaint Details
The complaint was substantiated. The investigation found that residents' needs were not met due to staffing shortages, confirmed by interviews with residents, authorized representatives, staff, and acknowledgment by the former Executive Director during a prior visit on 2020-11-10.
Findings
The allegation was substantiated based on interviews and record reviews which found the facility failed to meet residents' needs due to being short staffed, resulting in residents not being changed timely, not receiving food or medications on time, late wake-ups, and missed scheduled showers.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by insufficient staff which posed a potential health & safety risk to residents in care.
Report Facts
Capacity: 123
Census: 92
Deficiency Type: 1
Plan of Correction Due Date: Sep 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Andrews | Administrator | Named as facility administrator during the investigation |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 123
Deficiencies: 4
Date: Aug 19, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations received on 2020-11-06 regarding inadequate care, insufficient staffing, lack of assistance with incontinence care, medication administration issues, and staff verbal abuse.
Complaint Details
The complaint investigation was substantiated for allegations of failure to provide basic services, insufficient staffing, lack of assistance with incontinence care, and medication administration errors. The allegation of staff verbally abusing residents was unsubstantiated due to lack of evidence.
Findings
The investigation substantiated allegations of failure to provide basic services, insufficient staffing, lack of assistance with incontinence care, and improper medication administration, all posing potential health and safety risks to residents. The allegation of staff verbally abusing residents was unsubstantiated.
Deficiencies (4)
Failure to provide basic services which posed a potential health & safety risk to residents in care
Insufficient staff which posed a potential health & safety risk to residents in care
Failure to assist residents with incontinence care which posed a potential health & safety risk to residents in care
Failure to administer residents' medications as prescribed which posed a potential health & safety risk to residents in care
Report Facts
Capacity: 123
Census: 92
Deficiencies cited: 4
Plan of Correction Due Date: Sep 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Andrews | Administrator | Facility administrator acknowledged issues during investigation |
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Bennett Fong | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 123
Deficiencies: 1
Date: Apr 29, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-02-03 alleging the facility failed to meet residents' needs and did not adhere to COVID-19 infection control protocols.
Complaint Details
The complaint investigation was substantiated for failure to meet residents' needs due to short staffing, with concerns about timely changing, food, showers, and medication administration. The COVID-19 infection control allegation was unsubstantiated.
Findings
The investigation substantiated the allegation that the facility failed to meet residents' needs due to short staffing, resulting in residents not being changed timely, not receiving food or medications on time, and other care deficiencies. The allegation regarding failure to adhere to COVID-19 infection control was unsubstantiated, with the facility found to be following appropriate infection control measures.
Deficiencies (1)
Personnel Requirements: Facility personnel were not sufficient in numbers and competent to meet resident needs, posing a potential health and safety risk.
Report Facts
Capacity: 123
Census: 103
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
| Micah Savage | Executive Director/Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 123
Deficiencies: 3
Date: Apr 29, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including a resident sustaining a fractured back, staff not seeking timely medical attention, and staff not assisting residents with activities of daily living (ADLs) in a timely manner.
Complaint Details
The complaint investigation was substantiated with findings that a resident sustained a lumbar spinal compression fracture due to improper use of a Hoyer lift by untrained staff, staff delayed seeking medical attention for the resident by two days, and staff failed to assist residents with ADLs in a timely manner due to insufficient staffing. One allegation that the incident was not reported to licensing was unfounded.
Findings
The investigation substantiated three allegations: a resident sustained a fractured back due to improper use of a Hoyer lift by untrained staff; staff did not seek timely medical attention for the injured resident; and staff did not assist residents with ADLs in a timely manner due to insufficient staffing. One allegation regarding failure to report the incident to licensing was found unfounded.
Deficiencies (3)
Facility personnel were not competent to provide necessary services, resulting in a resident sustaining a fractured back while in care.
Staff failed to seek timely medical attention for a resident, posing a potential health and safety risk.
Staff did not assist residents with ADLs in a timely manner due to insufficient staffing, posing a potential health and safety risk.
Report Facts
Civil penalty amount: 500
Capacity: 123
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Micah Savage | Executive Director/Administrator | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Annual Inspection
Census: 98
Capacity: 123
Deficiencies: 0
Date: Aug 30, 2021
Visit Reason
The inspection was an infection control annual inspection conducted to evaluate COVID-19 mitigation practices and overall infection control compliance at the facility.
Findings
The facility was found to have effective COVID-19 infection control measures in place, including staff training, vaccination of residents and staff, proper PPE usage, and social distancing. No deficiencies were cited during the visit.
Report Facts
Staff vaccinated: 82
Residents vaccinated: 98
Facility capacity: 123
Facility census: 98
Fire extinguisher last inspection date: Jul 29, 2021
Administrator onsite hours: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Britanny Andrews | Administrator | Facility administrator met during inspection and infection control designated leader |
| Daisy Panlilio | Licensing Program Analyst | Conducted the infection control annual inspection |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 97
Capacity: 123
Deficiencies: 1
Date: Aug 12, 2021
Visit Reason
The visit was an unannounced Case Management inspection conducted by Licensing Program Analyst G. Luk to evaluate compliance with licensing requirements.
Findings
A deficiency was observed where a staff member (S1) was fingerprint cleared but not associated with the facility, which violates California Code of Regulations, Title 22, posing an immediate health and safety risk.
Deficiencies (1)
Criminal Record Clearance. Request a transfer of a criminal record clearance as specified in Section 87355(c) or related requirements not met by not associating staff who works at the facility.
Report Facts
Capacity: 123
Census: 97
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection |
| Tracy Freudendahl | Interim Executive Director | Facility representative met during inspection |
Inspection Report
Complaint Investigation
Census: 9
Capacity: 123
Deficiencies: 0
Date: Feb 10, 2021
Visit Reason
The inspection was conducted as a health and safety check via tele-visit following receipt of a priority 1 complaint during the COVID-19 shelter in place order.
Complaint Details
The visit was triggered by a priority 1 complaint during the COVID-19 shelter in place order. No deficiencies were found and the complaint was effectively unsubstantiated based on the findings.
Findings
During the health and safety check, no deficiencies were cited and residents appeared safe with no imminent health or safety concerns observed.
Report Facts
Facility census observed during visit: 9
Facility total capacity: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Andrews | Administrator | Met with during the inspection and involved in the facility tour |
| Daisy Panlilio | Licensing Program Analyst | Conducted the health and safety check via tele-visit |
| Rajind Basi | Licensing Program Manager | Named in the report as Licensing Program Manager |
Report
February 12, 2026
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November 18, 2025
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