Inspection Reports for The Gardens at Laguna Springs
9750 Laguna Springs Dr, Elk Grove, CA 95757, United States, CA, 95757
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with the facility generally clean, well-maintained, and compliant with regulations. Several complaint investigations were unsubstantiated, including allegations related to medication administration, resident care, and staff behavior. However, earlier reports from 2022 and 2023 showed multiple deficiencies involving medication management, resident supervision, administrator qualifications, and personal rights, some posing immediate health and safety risks. The facility received a $500 civil penalty in June 2022 related to care and supervision failures. The most recent report from October 21, 2025, had no deficiencies, indicating improvement over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
67% 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: 47
Capacity: 70
Deficiencies: 0
Date: Oct 21, 2025
Visit Reason
The visit was a case management visit conducted by the Licensing Program Analyst to review documents related to a former resident, including meal logs, urine and bowel output records, and communications with medical professionals.
Findings
No deficiencies were cited during the visit. Staff reported that daily records of meals and urine/bowel output are not routinely kept unless ordered by a doctor or if there is a change in the resident's condition.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Ramirez | Executive Director/Administrator | Notified of the visit and participated in the case management visit. |
| Jordan Reymundi | Met with Licensing Program Analyst during the visit and provided information about recordkeeping practices. | |
| Arvin Villanueva | Licensing Program Analyst | Conducted the case management visit. |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 44
Capacity: 70
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The inspection was an unannounced annual required inspection conducted to ensure compliance with Title 22 regulations at the Gardens at Laguna Springs Memory Care facility.
Findings
No deficiencies were observed during the visit. The facility was found to be clean, well-maintained, and in compliance with regulations, including proper food supplies, locked medications, and safe emergency exits. Resident and staff files were up to date with required documentation and training.
Report Facts
Resident files reviewed: 4
Staff files reviewed: 4
Food supply duration: 7
Food supply duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Ramirez | Administrator | Met with Licensing Program Analyst during inspection and discussed incident report |
| Christina Valerio | Licensing Program Analyst | Conducted the annual inspection and authored the report |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 70
Deficiencies: 0
Date: Sep 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2024-08-19 regarding pest issues, specifically ants, in a resident's room.
Complaint Details
The complaint alleged that staff did not ensure that a resident's room was free from pests, specifically ants. The complaint was unsubstantiated after investigation, with no deficiencies cited.
Findings
The investigation included observations, records review, and interviews. Although ants were observed in a video submitted as evidence, no pests were found during the inspection visits. The facility has monthly pest control services and increased treatments recently. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 70
Census: 39
Pest control service dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Ramirez | Administrator | Met with Licensing Program Analyst during the investigation |
| Christina Valerio | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 30
Capacity: 70
Deficiencies: 0
Date: Dec 14, 2023
Visit Reason
An unannounced 1 Year Annual Inspection Visit was conducted to evaluate the facility's compliance with health and safety regulations.
Findings
The inspection found no violations; the facility met required standards for physical plant conditions, food storage, medication security, fire safety equipment, and staff background clearances.
Report Facts
Hot water temperature: 113.4
Facility temperature: 73
Fire extinguisher last inspection date: Dec 7, 2023
Number of resident files reviewed: 7
Number of staff files reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Ramirez | Administrator | Met with Licensing Program Analyst during inspection and assisted with visit |
| Ruth Wallace | Licensing Program Analyst | Conducted the inspection visit |
| Stephen Richardson | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 70
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-07-10 regarding multiple allegations about staff practices and resident care at the facility.
Complaint Details
The complaint included nine allegations: staff not ensuring pull cords are accessible, improper pest infestation management, preventing residents from accessing food, mismanagement of medication, inadequate supervision of fall-risk residents, inappropriate speech to residents, insufficient staff training, and failure to safeguard residents' belongings. The investigation concluded all allegations were unsubstantiated.
Findings
The investigation found insufficient evidence to substantiate any of the allegations, including issues related to pull cords accessibility, pest infestation, food access, medication management, supervision of fall-risk residents, inappropriate speech, staff training, and safeguarding residents' belongings. The complaint was determined to be unsubstantiated.
Report Facts
Capacity: 70
Census: 35
Complaint Allegations: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Rose | Director of Resident Services | Met with Licensing Program Analyst during investigation |
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Follow-Up
Census: 36
Capacity: 70
Deficiencies: 4
Date: Oct 26, 2023
Visit Reason
The visit was a Non-Compliance Conference conducted to follow up with the facility after an initial NCC held on 9/30/2022, addressing six new complaints and four Type A deficiencies cited since the last meeting.
Complaint Details
Since the last meeting on 9/30/2022, six new complaints have been filed against the facility.
Findings
The facility was cited for deficiencies related to Personal Rights of Residents, Administrator Qualifications and Duties, Basic services care and supervision, and Plan of Operation. The focus included oversight of staff, maintaining compliance, and updating policies regarding outside agency staff and admitting residents with behaviors.
Deficiencies (4)
Personal Rights of Residents in All Facilities
Administrator Qualifications and Duties
Basic services care and supervision
Plan of Operation
Report Facts
Complaints filed: 6
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen Sarine | Regional RCFE | Present in the Non-Compliance Conference meeting |
| Michelle Baker | VP of Operation | Present in the Non-Compliance Conference meeting |
| Barb Rose | Facility staff present in the Non-Compliance Conference meeting | |
| Kayleen August | Facility staff present in the Non-Compliance Conference meeting |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 70
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2023-07-03 regarding medication administration and food quality, as well as an allegation of uncleared staff.
Complaint Details
The complaint investigation was unsubstantiated for medication and food quality allegations, and unfounded for the uncleared staff allegation.
Findings
The investigation found the allegations regarding medication administration and food quality to be unsubstantiated, with evidence showing staff ensured residents took medications as prescribed and food quality met residents' needs. The allegation of uncleared staff was found to be unfounded, with staff background checks verified as cleared.
Report Facts
Capacity: 70
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Ramirez | Administrator | Met with Licensing Program Analyst during investigation and discussed findings |
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Follow-Up
Census: 34
Capacity: 70
Deficiencies: 4
Date: Sep 7, 2023
Visit Reason
The visit was an unannounced case management follow-up to deficiencies found during a complaint investigation dated 2022-09-19.
Complaint Details
The visit followed up on deficiencies identified during a complaint investigation dated 2022-09-19, control number 27-AS-20220919221525.
Findings
The facility was found to have multiple deficiencies including blocking a resident's doorway with a couch, inadequate administrator qualifications, failure to provide adequate supervision resulting in resident injuries, and failure to follow the plan of operation regarding combative and aggressive resident behavior.
Deficiencies (4)
Staff blocked resident's doorway with a couch to prevent leaving, posing immediate health and safety risk.
Designated administrator denied responsibility, posing immediate health and safety risk.
Facility did not provide adequate care and supervision resulting in resident sustaining multiple injuries from falls.
Facility failed to follow plan of operation prohibiting admission of residents with combative or dangerous behavior.
Report Facts
Capacity: 70
Census: 34
Plan of Correction Due Date: Sep 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the inspection and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the inspection |
| Steve Sarine | Facility representative met during the visit | |
| Guadalupe Ramirez | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 70
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2022-11-22 alleging that a resident was injured while in care.
Complaint Details
Complaint was unsubstantiated; although the allegation may have been valid, there was insufficient evidence to prove the violation occurred.
Findings
The investigation found that the resident sustained a witnessed fall in the bathroom on 2022-10-20 and received medical attention the same day. There was no evidence that blood glucose levels contributed to the fall, and the resident had several chronic health conditions that could have contributed to multiple falls. The complaint was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 27-AS-20221122143318
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Guadalupe Ramirez | Administrator | Facility administrator named in report header |
| Steve Sarine | Facility representative met during the visit | |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 70
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff physically assaulted a resident resulting in injuries.
Complaint Details
The complaint alleged staff physically assaulted a resident causing injuries. The investigation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to support the allegation of staff assault. Interviews and record reviews indicated the resident had multiple falls and bruising, but no evidence staff caused injuries. The complaint was determined to be unsubstantiated.
Report Facts
Complaint Control Number: 27-AS-20220919221525
Facility Capacity: 70
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Stephen Sarine | Administrator | Facility representative met during the investigation |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 70
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-03-09 regarding resident injury due to staff neglect, inadequate staffing, and falsification of incident reports.
Complaint Details
The complaint included allegations that a resident sustained a severe head injury due to staff neglect, the facility did not have enough staff to meet residents' needs, and staff were falsifying incident reports. The findings were unsubstantiated for the first two allegations and unfounded for the third.
Findings
The investigation found the allegations of a resident sustaining a severe head injury due to staff neglect and inadequate staffing to be unsubstantiated, and the allegation of staff falsifying incident reports to be unfounded. Interviews and record reviews did not support the complaints.
Report Facts
Capacity: 70
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Ramirez | Administrator | Met with during the investigation and discussed complaint allegations |
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 70
Deficiencies: 0
Date: May 10, 2023
Visit Reason
The inspection was an unannounced visit to investigate a complaint received on 2023-02-23 regarding allegations of resident injuries, falls, overmedication, neglect in medication administration, and residents being left soiled.
Complaint Details
The complaint included allegations that a resident sustained injuries, suffered falls, was over medicated, was left soiled for a long period, and that staff were not administering medications. The investigation found these allegations to be unfounded.
Findings
After conducting interviews and reviewing records, the Licensing Program Analyst determined that the allegations were unfounded with no supporting information discovered. The complaint was deemed false and without reasonable basis.
Report Facts
Capacity: 70
Census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Steve Sarine | Regional Director of Operations | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Routine
Census: 33
Capacity: 70
Deficiencies: 0
Date: May 3, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced quarterly health and safety visit to the facility to ensure compliance with health and safety regulations.
Findings
The facility was found to be clean and in sanitary condition with no health and safety concerns. Hot water and indoor temperatures were within required ranges, fire extinguishers were up to date, and staff training and first-aid certifications were current. No deficiencies were observed.
Report Facts
Staff files reviewed: 3
Hot water temperature: 116.4
Indoor temperature: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Ramirez | Administrator | Met with Licensing Program Analyst during inspection |
| Tung Truong | Licensing Program Analyst | Conducted the inspection visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report header |
Inspection Report
Census: 32
Capacity: 70
Deficiencies: 0
Date: Feb 7, 2023
Visit Reason
The visit was an unannounced quarterly health and safety case management visit to ensure compliance with Title 22 regulations.
Findings
The facility was found to be clean, sanitary, and in compliance with all applicable regulations. No deficiencies were observed during the inspection.
Report Facts
Hot water temperature: 118.8
Facility temperature: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Ramirez | Administrator | Met with Licensing Program Analyst during inspection |
| Tung Truong | Licensing Program Analyst | Conducted the inspection visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 70
Deficiencies: 1
Date: Feb 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/23/2022 regarding medication dispensing and medication log accuracy at the facility.
Complaint Details
The complaint investigation was substantiated for inaccurate medication logging but unsubstantiated for failure to follow modified diets and glucose testing orders. The substantiated allegation was related to medication logs not being accurately maintained, posing a potential health and safety risk.
Findings
The investigation substantiated that staff did not accurately log medication administration records (MARs) for resident R1, with multiple missing staff signatures on MARs for September 2022. The allegation that staff were not dispensing medication as prescribed was previously substantiated and resolved. Other allegations regarding modified diet and glucose testing were found unsubstantiated.
Deficiencies (1)
Facility staff did not accurately log resident R1’s Medication Administration Records (MARs), with multiple dates missing staff signatures.
Report Facts
Capacity: 70
Census: 32
Deficiency Type: 1
Plan of Correction Due Date: Feb 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Guadalupe Ramirez | Facility representative met during the investigation | |
| Stephen Sarine | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 32
Capacity: 70
Deficiencies: 0
Date: Dec 15, 2022
Visit Reason
An unannounced 1 Year Annual Inspection Visit was conducted to evaluate compliance with regulatory requirements and ensure health and safety standards at the facility.
Findings
The facility was found to be in compliance with no violations cited. Observations included COVID-19 mitigation measures, adequate food supplies, locked medication storage, functional fire extinguishers and detectors, and proper staff background checks and training.
Report Facts
Hot water temperature: 117
Facility temperature: 69
Resident files reviewed: 5
Staff files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Ramirez | Administrator | Met with Licensing Program Analysts and assisted with the inspection visit |
| Tung Truong | Licensing Program Analyst | Conducted the inspection and signed the report |
| Pang Lee | Licensing Program Analyst | Conducted the inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 70
Deficiencies: 0
Date: Dec 13, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a resident was being overmedicated with Norco and Morphine.
Complaint Details
The complaint alleged that a resident was being overmedicated with Norco and Morphine. The allegation was found to be unfounded after investigation.
Findings
The investigation found that the resident was on hospice and the facility was following hospice orders for medication administration. The allegation was determined to be unfounded.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Guadalupe Ramirez | Administrator met with Licensing Program Analyst during the investigation and exit interview. |
Inspection Report
Census: 30
Capacity: 70
Deficiencies: 0
Date: Sep 30, 2022
Visit Reason
The visit was a Case Management - Legal/Non-compliance conference held to discuss the facility's non-compliance issues and bring the facility back into compliance.
Complaint Details
The facility had 8 Type A citations and 8 Type B citations substantiated against it within the last 12 months.
Findings
Since licensure in December 2020, the facility has been cited 16 times in the last year for various issues including basic services, medical care, criminal record clearance, administrator qualifications, personal rights, storage space, and resident AWOL. No deficiencies were cited during this visit, but increased monitoring and technical support were planned.
Report Facts
Citations: 16
Type A citations: 8
Type B citations: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen Sarine | Administrator | Facility Administrator present during the Non-Compliance Conference |
| Kirk Goodin | Executive Director | Facility Executive Director present during the Non-Compliance Conference |
| Czarrina A Camilon-Lee | Licensing Program Manager | Licensing Program Manager involved in the conference and report |
| Tung Truong | Licensing Program Analyst | Licensing Program Analyst involved in the conference and report |
Inspection Report
Follow-Up
Census: 30
Capacity: 70
Deficiencies: 1
Date: Aug 4, 2022
Visit Reason
The visit was a Case Management follow-up to an incident report regarding a resident (R1) who was absent without leave (AWOL) from the facility on 7/25/2022.
Findings
The facility failed to properly secure the delayed egress door, allowing R1 to exit unsupervised for approximately 9-10 minutes, posing an immediate health and safety risk. The door has since been fixed and staff received in-service training on door security and resident checks.
Deficiencies (1)
Failure to be aware of the resident's general whereabouts, allowing R1 to leave the facility unassisted, violating basic service requirements.
Report Facts
Deficiency due date: Aug 5, 2022
Census: 30
Total Capacity: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen Sarine | Interim Administrator | Met with Licensing Program Analyst during visit and acknowledged the AWOL incident |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 70
Deficiencies: 0
Date: Jul 29, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff handled a resident in a rough manner and yelled at a resident.
Complaint Details
The complaint involved allegations that staff handled a resident roughly and yelled at a resident. The investigation included interviews with multiple staff, a resident, and a family member. The allegations were determined to be unsubstantiated due to lack of evidence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews and observations indicated that the staff did not handle residents roughly or yell at them, and no deficiencies were cited.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Nekia Xavier | Director of Nursing | Met with Licensing Program Analyst during investigation |
| Mary Keaton | Administrator | Facility administrator named in report |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 70
Deficiencies: 1
Date: Jul 26, 2022
Visit Reason
The visit was conducted to address issues identified during a separate complaint investigation regarding the absence of a diabetic diet menu and lack of a diabetic care plan at the facility.
Complaint Details
The visit was triggered by a complaint investigation concerning the lack of a diabetic diet menu and absence of a diabetic care plan at the facility.
Findings
During the visit, the Licensing Program Analyst observed the Diet and Nutrition Care Manual and reviewed care plans for five diabetic residents. It was found that the facility does not have a specific diabetic diet menu but follows guidelines from the Diet and Nutrition Care Manual and diabetic protocols. No violations or deficiencies were issued during this visit.
Deficiencies (1)
Based on interviews and record reviews, the Licensee did not ensure a diabetic menu is in place. Facility has five diabetic residents. LPA observed no Diet Menu regarding this matter. This poses a potential health and safety risk to residents in care.
Report Facts
Number of diabetic residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen Sarine | Administrator Designee | Met during the visit and participated in the exit interview |
| Kirk Goodin | Acting Executive Director | Met during the visit and participated in the exit interview |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 70
Deficiencies: 1
Date: Jun 23, 2022
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to allegations that the facility was not providing residents' medication as prescribed and that facility staff were rude and slammed a door in front of a family member.
Complaint Details
The complaint investigation was substantiated for the medication administration allegation, confirming that resident R1 received insulin two hours late on 4/29/2022. The allegation that staff were rude and slammed a door in front of a family member was unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated the allegation that a resident (R1) was given insulin two hours late on 4/29/2022 by staff (S3), violating physician's orders. The allegation regarding rude staff behavior and slamming a door was found to be unsubstantiated due to insufficient evidence.
Deficiencies (1)
Staff S3 did not provide insulin to resident R1 at the prescribed time by physician’s order.
Report Facts
Capacity: 70
Census: 31
Time late for insulin administration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Keaton | Administrator | Met with Licensing Program Analyst during the investigation |
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 70
Deficiencies: 2
Date: Jun 23, 2022
Visit Reason
An unannounced complaint investigation was conducted following allegations including resident missed medications and staff not following physician's orders.
Complaint Details
The complaint investigation was substantiated for allegations that resident missed medications and staff did not follow physician's orders. The allegation that staff falsified medication records was unsubstantiated.
Findings
The investigation substantiated that resident R1 missed his morning insulin dose and was given insulin two hours late on another occasion, posing an immediate health and safety risk. Another allegation of staff falsifying medication records was found unsubstantiated due to insufficient evidence.
Deficiencies (2)
Facility did not ensure medications were provided to resident R1, who missed his morning insulin dose when leaving the facility.
Facility staff did not ensure insulin was given according to physician's directions; resident R1 was given insulin two hours late.
Report Facts
Capacity: 70
Census: 31
Deficiencies cited: 2
Plan of Correction Due Date: Jun 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Keaton | Administrator | Met with Licensing Program Analyst during investigation |
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 70
Deficiencies: 2
Date: Jun 20, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility did not follow a resident's care plan and had insufficient staffing to meet residents' needs.
Complaint Details
The complaint was substantiated based on evidence including review of resident care records, medication administration records, observations of insufficient staffing during activities and meals, and interviews. The preponderance of evidence supported the allegations.
Findings
The investigation found that care was not completed on some days for resident 0, medications were not administered as required, and the facility lacked adequate staff to meet residents' needs during activities and meal times. Residents were observed unsupervised or not properly assisted, posing potential health and safety risks. The allegations were substantiated.
Deficiencies (2)
Facility did not have an adequate number of direct care staff to support each resident’s physical, social, emotional, and safety needs during activities and lunch, posing a potential health and safety risk.
Facility failed to meet resident 1's care needs as staff did not document care provision, posing a potential health and safety risk.
Report Facts
Facility census: 30
Facility capacity: 70
Plan of Correction due date: Jul 31, 2022
Additional caregiver hours added: 16
Number of residents observed during activity: 14
Number of caregivers serving meals: 2
Number of kitchen staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and facility visit |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw licensing program and signed report |
| Kirk Goodwin | Facility representative met during inspection and exit interview |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 70
Deficiencies: 1
Date: Jun 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-03-30 regarding resident behavior and safety concerns at the facility.
Complaint Details
The complaint investigation included three allegations: 1) Resident physically abusive to other residents (substantiated), 2) Resident being sexually inappropriate towards female residents (unsubstantiated), and 3) Resident eloped from facility (unfounded).
Findings
The investigation substantiated that resident 1 (R1) was physically aggressive towards other residents, posing a health and safety risk. The allegation of sexual misconduct by R1 was unsubstantiated due to lack of evidence. The allegation that R1 eloped from the facility was found to be unfounded as R1 only accessed a locked gated patio on facility premises and was redirected back inside.
Deficiencies (1)
Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as R1 was aggressive towards other residents posing an immediate health and safety risk.
Report Facts
Capacity: 70
Census: 31
Plan of Correction Due Date: Jun 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kirk Goodin | Facility representative met during the investigation | |
| Irene Charnell | Administrator | Facility administrator named in report header |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Arielle Pascua | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 70
Deficiencies: 3
Date: Jun 13, 2022
Visit Reason
The visit was conducted as a case management visit in response to learned deficiencies during a complaint investigation concerning Resident 1's significant physical, medical, and mental changes and the facility's failure to complete timely reassessments.
Complaint Details
The visit was triggered by a complaint investigation regarding Resident 1's care, including failure to reassess after significant health changes, suicidal ideations, falls, and elopement behaviors. The complaint was substantiated with findings of deficiencies and an immediate $500 civil penalty was assessed.
Findings
The facility failed to conduct reassessments after Resident 1's significant health changes, including suicidal ideations, multiple falls, and elopement behaviors, which resulted in a serious injury. Additionally, cleaning carts were left unlocked, making cleaning supplies accessible to residents, posing an immediate health and safety risk.
Deficiencies (3)
Facility did not provide care and supervision to meet Resident 1's exit/eloping seeking behaviors, leading to injury and suicidal ideations, posing an immediate health and safety risk.
Reappraisals were not conducted after Resident 1's significant health changes, posing a potential health and safety risk.
Cleaning carts compartments were left unlocked, making cleaning toxins accessible to residents, posing an immediate health and safety risk.
Report Facts
Civil penalty amount: 500
Number of falls: 7
Number of days with exit/elopement behaviors: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
| Kirk Goodin | Facility representative met during the visit |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 70
Deficiencies: 3
Date: Apr 7, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-01-03 regarding water leaks in a resident's room, safeguarding of residents' personal belongings, and adequacy of laundry services.
Complaint Details
The complaint investigation was triggered by allegations including a water leak in a resident's room, failure to safeguard residents' personal belongings, inadequate laundry service, failure to prevent inappropriate behaviors, a resident sustaining a rash, failure to notify authorized representatives of injury, and improper cleaning of resident rooms. The investigation substantiated the first three allegations but found insufficient evidence to substantiate the others.
Findings
The investigation substantiated that the facility failed to maintain a resident's AC unit in good repair, resulting in water leakage and unsanitary conditions, and failed to safeguard residents' clothing and provide adequate laundry services. Other allegations related to preventing inappropriate behaviors, notification of injuries, and room cleanliness were found unsubstantiated.
Deficiencies (3)
Facility did not maintain the AC unit in resident 1's room in good repair, causing water leakage and unsanitary conditions.
Facility did not ensure residents' clothing were properly returned to the correct resident, resulting in lost or misplaced clothing.
Facility did not ensure residents received adequate laundry services.
Report Facts
Capacity: 70
Census: 29
Deficiencies cited: 3
Plan of Correction Due Date: Apr 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tung Truong | Licensing Program Analyst | Conducted the complaint investigation and cited deficiencies |
| Mary Keaton | Administrator | Facility administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 70
Deficiencies: 2
Date: Mar 24, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations including unlawful eviction and staff lacking required training.
Complaint Details
The complaint was substantiated based on evidence that the eviction was unlawful and that staff did not meet dementia training requirements.
Findings
The investigation substantiated that a resident was unlawfully evicted without proper documentation and that the facility failed to comply with dementia training requirements for several employees.
Deficiencies (2)
Eviction letter did not contain required documents and resident was evicted unlawfully.
Three employees did not have supporting dementia training documentation as required.
Report Facts
Capacity: 70
Census: 30
Deficiencies cited: 2
Plan of Correction Due Date: Apr 14, 2022
Inspection Report
Census: 30
Capacity: 70
Deficiencies: 2
Date: Mar 24, 2022
Visit Reason
An unannounced case management visit was conducted to review compliance with licensing requirements, including staff fingerprint clearance and administrator certification.
Findings
The facility was found to have staff who were not fingerprint cleared as required and lacked a certified administrator, posing immediate health, safety, and personal rights risks to residents.
Deficiencies (2)
Staff S1, S2, and S3 are not fingerprint cleared as required, posing an immediate health and safety risk.
The facility does not have a certified administrator, posing an immediate health, safety, and personal rights risk to residents.
Report Facts
Capacity: 70
Census: 30
Plan of Correction Due Date: Mar 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irene Charnell | Executive Director | Met during the visit and involved in findings |
| Jennifer Valcazar | Office Manager | Met during the visit and involved in findings |
Inspection Report
Annual Inspection
Census: 19
Capacity: 70
Deficiencies: 0
Date: Dec 13, 2021
Visit Reason
The visit was an unannounced annual inspection conducted to ensure compliance with Title 22 regulations and to evaluate the facility's physical plant and infection control measures.
Findings
The facility was found to be clean, in good repair, and compliant with regulations. No deficiencies were cited during the visit. Infection control measures, including a COVID-19 mitigation plan, were in place and approved.
Report Facts
Hospice waiver approved: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Poole-Johnson | Administrator | Met with Licensing Program Analyst during inspection and explained the purpose of the visit |
| Tung Truong | Licensing Program Analyst | Conducted the annual inspection visit |
Inspection Report
Original Licensing
Capacity: 70
Deficiencies: 0
Date: Dec 22, 2020
Visit Reason
Pre-licensing visit conducted via Zoom to evaluate the facility prior to licensing.
Findings
The facility was found to be in compliance with no deficiencies observed during the pre-licensing visit. The facility has appropriate secured medication rooms, fire extinguishers, and suitable living and activity areas.
Report Facts
Fire extinguishers: 5
Rooms: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricky David Jr | Administrator | Met with during the pre-licensing visit |
Inspection Report
Original Licensing
Capacity: 70
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
Initial licensing evaluation conducted via telephone call to assess applicant and administrator understanding of Title 22 regulations and facility operation requirements.
Findings
Applicant and administrator successfully completed Component II, demonstrating understanding of facility operation, staff qualifications, program policies, and compliance requirements. No clients were in care at the time of the evaluation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricky David | Applicant/administrator | Participated in telephone call for licensing evaluation. |
| Donald Barber | Applicant/administrator | Participated in telephone call for licensing evaluation. |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager on report. |
| Maria Ejaz | Licensing Program Analyst | Named as Licensing Program Analyst on report. |
Report
December 23, 2025
Report
May 6, 2025
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