Inspection Reports for The Preserve at Woodland Hills Assisted Living & Memory Care
6221 Fallbrook Ave, Woodland Hills, CA 91367, United States, CA, 91367
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to resident supervision, medication management, staff training, and resident rights, with several substantiated complaints involving medication errors, elopements, and privacy violations. The facility faced immediate health and safety risks from incidents such as residents eloping due to inadequate supervision and medication administration errors, and it received civil penalties including a $250 and a $900 fine for repeated issues. Some serious events included staff abandoning the facility without proper notice in July 2024 and staff taking inappropriate photos of a resident in September 2024, leading to suspensions and terminations. The most recent report from September 25, 2025, cited a medication administration error but showed corrective actions like staff suspensions and increased supervision, indicating ongoing efforts to address issues. Several complaint investigations were unsubstantiated, and the facility’s record shows some improvement with no deficiencies found in the August 13, 2025 annual inspection.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
110% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
77% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 46
Capacity: 60
Deficiencies: 1
Date: Sep 25, 2025
Visit Reason
The visit was an unannounced case management - incident investigation regarding three self-reported incidents that occurred on 09/11/2025 and an unknown date approximately two months prior.
Complaint Details
The visit was complaint-related, investigating three self-reported incidents including alleged resident abuse, medication errors, and elopement. The medication error was substantiated and cited as a deficiency with a civil penalty assessed.
Findings
The investigation found incidents including a staff member pushing a resident onto a toilet causing it to break, a medication administration error where a resident was given another resident's medications, and a resident leaving the facility unassisted through a back door. The facility took corrective actions including suspending involved staff, conducting staff training, and increasing supervision and safety measures.
Deficiencies (1)
Resident #1 was administered Resident #2’s morning medications by Staff #3, posing a potential health and safety risk.
Report Facts
Civil penalty amount: 250
Previous citations: 2
Delayed egress time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced case management - incident visit and investigation. |
| Susan Weisbarth | Executive Director | Met with Licensing Program Analyst during visit and involved in incident investigations. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Staff #3 | Staff member who mistakenly administered wrong medications to Resident #1. | |
| Staff #1 | Staff member alleged to have pushed Resident #1 onto toilet. | |
| Staff #2 | Staff member who reported the incident involving Staff #1 and Resident #1. |
Inspection Report
Annual Inspection
Census: 43
Capacity: 60
Deficiencies: 0
Date: Aug 13, 2025
Visit Reason
The inspection was an unannounced Case Management - Annual Continuation visit to evaluate compliance with licensing requirements, continuing from a prior inspection that began on 2025-07-25.
Findings
The facility was found to be in compliance with all reviewed areas including staff records, infection control practices, emergency disaster planning, and fire safety systems. No deficiencies were cited during this inspection.
Report Facts
Staff records reviewed: 5
Capacity: 60
Census: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Weisbarth | Executive Director | Met with Licensing Program Analyst during the inspection. |
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced Case Management - Annual Continuation visit. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 60
Deficiencies: 0
Date: Aug 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that staff were not allowing a resident to have visitors or phone calls.
Complaint Details
The complaint alleged that staff were preventing Resident #1 from receiving phone calls or visitors based on the responsible party's request rather than the resident's decision. The investigation included interviews with the resident, responsible party, staff, and visitors, review of documentation, and wellness checks. The allegations were deemed unsubstantiated due to insufficient evidence.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Interviews with the resident, responsible party, staff, and visitors, as well as record reviews and wellness checks, indicated that residents have the right to receive visitors and phone calls and that the resident in question declined calls on their own accord.
Report Facts
Capacity: 60
Census: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Susan Weisbarth | Executive Director | Met with Licensing Program Analyst during the investigation and involved in interviews |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 47
Capacity: 60
Deficiencies: 4
Date: Jul 25, 2025
Visit Reason
The inspection was a required unannounced one-year visit to evaluate compliance with licensing regulations and ensure health and safety standards at the facility.
Findings
The facility was found to have several deficiencies including improper water temperature in resident sinks, lack of call systems in resident rooms and bathrooms, residents having access to restricted items, and staff response times to resident calls being inadequate. Medication storage and resident records were found to be in compliance. The facility was generally clean and well-maintained but had immediate health and safety risks due to the cited deficiencies.
Deficiencies (4)
Five out of six resident restroom sinks did not have hot water within the required temperature range of 105-120°F.
Facility did not have a call system in resident rooms and bathrooms.
Two residents had access to items their physician deemed as at risk, including razors and cleaning supplies.
Staff did not respond to residents' calls for assistance in a timely manner.
Report Facts
Number of resident calls logged: 76
Number of accidental repeat calls: 15
Number of calls with response under 15 minutes: 10
Number of resident medications reviewed: 5
Number of resident records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Weisbarth | Executive Director | Met with LPAs during inspection and involved in addressing deficiencies |
| Tony Nunez | Health and Services Director | Met with LPAs during inspection and involved in addressing deficiencies |
| Quoc Huynh | Licensing Program Analyst | Conducted the inspection and signed the report |
| Kristin Heffernan | Licensing Program Manager | Oversaw the licensing inspection process |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 60
Deficiencies: 0
Date: Jul 16, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff do not ensure a facility door is safe for the residents while in care.
Complaint Details
The allegation was that staff do not ensure a facility door is safe for residents. The complaint was unsubstantiated due to lack of evidence and no regulatory requirement for windows or cameras on doors. Previous related complaint visits and interviews were referenced.
Findings
The investigation found no evidence to substantiate the allegation. Observations included a surveillance camera installation and caution signs on the door. There were no regulatory requirements for such safety features, and no evidence of lack of supervision was found. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 60
Census: 46
Complaint Control Number: 29-AS-20250709121859
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susan Weisbarth | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 60
Deficiencies: 0
Date: Jun 9, 2025
Visit Reason
The visit was conducted as a complaint investigation following an allegation that the facility admitted residents without obtaining documentation of a medical assessment prior to acceptance.
Complaint Details
The complaint alleged that the facility admitted Resident #1 on 05/13/2025 and Resident #2 two to three months prior without medical assessments. After review of records and interviews, the allegation was unsubstantiated.
Findings
The investigation found that all reviewed resident files contained the required medical assessments, preplacement appraisals, and admission agreements. Staff interviews confirmed knowledge of admission procedures. The allegation was deemed unsubstantiated due to insufficient evidence to prove the violation occurred.
Report Facts
Resident files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and interviews. |
| Susan Weisbarth | Executive Director | Met with Licensing Program Analyst during the investigation. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 60
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The visit was an unannounced case management incident investigation regarding a self-reported medication error incident that occurred on 2025-04-17.
Complaint Details
The visit was triggered by a self-reported incident on 2025-04-17 involving medication being left unattended and mistakenly self-administered by another resident. The complaint was substantiated with a deficiency cited and corrective actions taken.
Findings
The investigation found that a staff member left Resident #1's medication unattended, which Resident #2 self-administered by mistake. No significant adverse effects were noted, but a deficiency was cited for improper medication storage and handling, and a civil penalty of $250 was assessed due to a repeat violation.
Deficiencies (1)
Resident #1's Benzonatate medication was left unattended by Staff #1, which Resident #2 self-administered, posing a potential health and safety risk.
Report Facts
Civil penalty amount: 250
Repeat violation date: Mar 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Weisbarth | Executive Director | Met during entrance interview and named in report |
| Antonio Nunez | Health and Services Director | Conducted staff training and named in report |
| Angela Barutyan | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 60
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff handled residents in a rough manner and yelled at residents in care.
Complaint Details
The complaint alleged that Staff #1 restrained and pushed Resident #1 and yelled at Resident #2. Interviews with residents and staff, review of training and physician reports, and observations did not corroborate these allegations. The allegations were deemed unsubstantiated.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Interviews with residents and staff, record reviews, and observations indicated that the allegations were unsubstantiated at this time.
Report Facts
Capacity: 60
Census: 42
Staff interviewed: 5
Residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Susan Weisbarth | Executive Director | Facility administrator met during investigation |
| Tony Nunez | Health and Services Director | Met during investigation and discussed allegations |
| Kristin Heffernan | Licensing Program Manager | Named in report signature and oversight |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 60
Deficiencies: 1
Date: Mar 11, 2025
Visit Reason
The visit was an unannounced case management - incident investigation regarding a self-reported incident on 02/26/2025 where a resident's morning Lorazepam medication dose was not administered.
Complaint Details
The visit was triggered by a verbal incident report received on 02/27/2025 about a missing medication dose on 02/26/2025. Resident #1 was monitored with no significant changes noted. Staff #1 was trained and no longer works at the facility as of 03/06/2025.
Findings
The investigation found that Staff #1 failed to administer Resident #1's prescribed Lorazepam medication, posing a potential health and safety risk. Staff #1 received one-on-one training and subsequently left the facility. The facility plans to audit medications and provide vendor medication training.
Deficiencies (1)
Resident #1's Lorazepam medication was not administered by Staff #1 as prescribed, posing a potential health and safety risk.
Report Facts
Capacity: 60
Census: 39
Plan of Correction Due Date: Apr 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Weisbarth | Executive Director | Met with Licensing Program Analyst during the visit |
| Tony Nunez | Health and Services Director | Conducted one-on-one trainings with Staff #1 on medication administration |
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced case management - incident visit and investigation |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 60
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff negligence caused injury to a resident and that a facility door posed a safety concern for residents.
Complaint Details
The complaint alleged that on 02/22/2025, a resident was hit by a facility door opened by staff, resulting in bruising and a laceration. The investigation included interviews, document review, and observations. The allegations were deemed unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations of staff negligence causing injury and safety concerns related to the facility door. The resident had minor injuries, and the facility had taken steps to minimize risk, including signage and staff reminders.
Report Facts
Facility capacity: 60
Resident census: 39
Complaint control number: 29
Number of staff interviewed: 5
Number of residents interviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Susan Weisbarth | Executive Director | Facility administrator met during investigation and involved in discussions |
| Tony Nunez | Health and Services Director | Discussed allegations with Licensing Program Analyst |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 60
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff retained a resident without proper admission procedures.
Complaint Details
The complaint alleged that staff retained a resident without proper admission procedures. The allegation was substantiated based on record review and interviews. The previous Executive Director admitted Resident #1 without proper admission documentation. Current administration has corrected the issue.
Findings
The investigation substantiated that Resident #1 was admitted without an admission agreement, pre-placement appraisal, or care plan, residing at the facility for five days without a contract. Current administration is knowledgeable and compliant with admission procedures.
Deficiencies (1)
Resident #1 was admitted without an admission agreement and appraisal which posed a potential health, safety, or personal rights risk to persons in care.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Feb 27, 2025
Resident stay duration without contract: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susan Weisbarth | Executive Director | Current Executive Director met with LPA during investigation |
| Michael Owens | Previous Executive Director | Admitted Resident #1 without proper admission procedures |
| Tony Nunez | Health and Services Director | Discussed allegation with LPA during investigation |
| Angelica Caton | Resident Care Coordinator | Interviewed during investigation; not employed during alleged incident |
Inspection Report
Census: 56
Capacity: 60
Deficiencies: 0
Date: Jan 10, 2025
Visit Reason
Unannounced case management visit regarding a self-reported incident on the relocation of 20 residents from Bentley Suites to Preserve at Woodland Hills due to mandatory evacuation orders from Fire Advisory.
Findings
During the visit, a health and safety check was conducted with no concerns observed. The facility has sufficient beds, hygiene supplies, linens, food supplies, and staffing to accommodate both existing and relocated residents. All relocated residents have designated rooms with ensuite bathrooms, and families have been notified.
Report Facts
Number of relocated residents: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Weisbarth | Administrator | Met with Licensing Program Analyst during the visit and provided information about the relocation and facility status. |
| Belen Taico | Administrator | Administrator from Bentley Suites who confirmed notification of families and responsible parties regarding relocation. |
| Emily Peraldi | Licensing Program Analyst | Conducted the unannounced case management visit and health and safety check. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 60
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
The visit was an unannounced case management incident investigation regarding two self-reported elopement incidents involving residents that occurred on 12/05/2024 and 12/22/2024.
Complaint Details
The visit was complaint-related, investigating two incidents of resident elopement. The complaint was substantiated as the facility failed to provide adequate supervision and care, resulting in elopements and safety risks.
Findings
The investigation found that two residents eloped from the facility unassisted through the same back egress door, with one resident sustaining a fall and requiring hospital transport. Facility staff failed to provide necessary care and supervision, allowing the elopements, which posed an immediate health and safety risk. The delayed egress door and alarm system were tested and found functioning during the visit.
Deficiencies (1)
Facility staff failed to provide the necessary care and supervision to R1 and R2 which allowed the residents to elope from the facility unassisted, posing an immediate health and safety risk to residents in care.
Report Facts
Capacity: 60
Census: 36
Plan of Correction Due Date: Jan 8, 2025
Number of alarms per door: 3
Number of staff interviewed: 5
Number of residents attempted to interview: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Weisbarth | Executive Director | Met with during entrance interview and provided information about incidents |
| Angela Barutyan | Licensing Program Analyst | Conducted the inspection and investigation |
| Tony Nunez | Health and Services Director | Interviewed regarding incidents and alarm system |
| Kristin Heffernan | Licensing Program Manager | Supervisor of the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 60
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not ensure residents received medications according to physician instructions, among other complaints.
Complaint Details
The complaint investigation was substantiated regarding medication administration failures. Other allegations about call buttons, staff response times, and medication ordering were unsubstantiated.
Findings
The investigation substantiated that staff failed to properly assist a resident with self-administered medications per physician's orders, posing an immediate health and safety risk. Other allegations regarding operable call buttons, timely staff response, and timely medication ordering were unsubstantiated.
Deficiencies (1)
Facility staff did not properly assist with Resident #1's self-administered medications per physician's order, posing an immediate health and safety risk.
Report Facts
Residents interviewed: 5
Staff interviewed: 4
Residents interviewed: 4
Staff interviewed: 2
Residents reviewed for medication: 4
Medication ordering timeframe: 7
Medication ordering timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Trevin R Willis | Administrator | Administrator during initial visit and named in investigation |
| Susan Weisbarth | Executive Director | Met with Licensing Program Analyst during complaint visit |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 60
Deficiencies: 0
Date: Dec 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations regarding resident care, facility cleanliness, and safety concerns at The Preserve at Woodland Hills.
Complaint Details
The complaint included allegations that staff did not follow the resident's care plan, failed to inform authorized persons of care changes, did not meet toileting and hygiene needs, failed to maintain laundry and safeguard personal items, did not ensure adequate feeding, and that the facility was unclean and in disrepair. The investigation was unsubstantiated due to lack of sufficient evidence.
Findings
After multiple unannounced visits and interviews with staff, residents, and administrators, the investigation found insufficient evidence to substantiate the allegations. Resident #1 exhibited behaviors related to dementia, including agitation and refusal of care, but no deficiencies were observed at the time of the visits.
Report Facts
Capacity: 60
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Yee | Licensing Program Analyst | Conducted the complaint investigation visits |
| Trevin R Willis | Administrator | Facility administrator involved in investigation |
| Lorrain Walters | Business Office Manager | Met with Licensing Program Analyst during visits |
| Susan Weisbarth | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 60
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted due to an allegation that the facility does not have enough staff to meet the needs of residents in care.
Complaint Details
The complaint alleged insufficient staffing to meet resident needs. Multiple interviews and record reviews were conducted, including observations of staff on duty and resident care. Despite concerns expressed by residents, family members, and staff, staffing records showed adequate coverage. The allegation was unsubstantiated.
Findings
The investigation found insufficient evidence to support the allegation of inadequate staffing. Observations, interviews, and record reviews showed that staffing levels met regulatory requirements and no citations were issued. The allegation was deemed unsubstantiated.
Report Facts
Staff on shift: 4
Staff on shift: 3
Residents requiring two-person assist: 2
Staff hired and onboarded: 14
Care staff per shift: 3
Care staff per shift: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and delivered final findings |
| Tony Nunez | Health and Services Director | Interviewed during the investigation |
| Susan Weisbarth | Executive Director | Interviewed during the investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 60
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident was physically abused while in care.
Complaint Details
The complaint alleged that on 10/08/2024, Resident #1 was observed in distress and crying, claiming to have been beaten. Interviews with the complainant, responsible party, and staff indicated the resident's aggressive behavior and a small bruise unrelated to abuse. Police wellness check confirmed the resident's safety. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to corroborate the allegation of physical abuse. The resident was noted to have severe dementia and exhibited aggressive behavior during showers. No deficiencies were cited and the allegation was deemed unsubstantiated.
Report Facts
Facility capacity: 60
Resident census: 35
Complaint control number: 29-AS-20241015125318
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Susan Weisbarth | Administrator / Executive Director | Facility administrator interviewed during investigation |
| Antonio Nunez | Health and Services Director | Facility Health and Services Director interviewed during investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 60
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff overmedicated residents in care.
Complaint Details
The complaint alleged that staff overmedicated residents, specifically that medication technicians administered painkillers that were too strong. The investigation found medications were administered as prescribed and no violations were observed. The allegation was unsubstantiated.
Findings
The investigation included interviews, medication reviews, and record audits which found no evidence of medication errors or overmedication. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Residents reviewed in medication audit: 5
Residents reviewed in medication audit: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and medication review |
| Michael Owens | Administrator | Facility administrator named in report header |
| Susan Weisbarth | Executive Director | Met with Licensing Program Analyst during investigation |
| Antonio Nunez | Health and Services Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Follow-Up
Census: 34
Capacity: 60
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
The inspection was conducted as a follow-up on a self-reported incident involving Staff #1 placing a cloth over Resident #1's mouth after the resident attempted to bite the staff member.
Findings
The Licensing Program Analyst conducted interviews and a file review related to the incident report. An exit interview was conducted and the report was issued. Additional reports may follow if warranted.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Weisbarth | Executive Director | Met with Licensing Program Analyst during the inspection and involved in interviews regarding the incident. |
| Emily Peraldi | Licensing Program Analyst | Conducted the unannounced case management visit and interviews. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 60
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff violated a resident's personal rights by taking a photograph of a resident in the bathroom.
Complaint Details
The complaint was substantiated based on photo evidence from a credible witness, interviews, and document review. Staff members S1, S2, and S3 were suspended and are in the process of termination for involvement in taking and sharing a photograph of a resident in the bathroom.
Findings
The investigation substantiated the allegation that three staff members took a selfie with a resident exposed on the toilet and shared the photo among personal circles. The involved staff were suspended and are in the process of termination. The facility was cited for violating residents' personal rights under CCR 87468.1(a)(1).
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by three staff members not respecting a resident's dignity which poses an immediate personal rights risk.
Report Facts
Capacity: 60
Census: 35
Deficiency Type Count: 1
Plan of Correction Due Date: Sep 5, 2024
Staff Involved: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Trevin Willis | Executive Director | Met with Licensing Program Analysts during the investigation and informed about the visit |
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 60
Deficiencies: 0
Date: Sep 4, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the licensee does not ensure that staff are adequately trained.
Complaint Details
The complaint alleged that the licensee does not ensure that staff are adequately trained. The allegation was substantiated. The facility had two citations from a prior visit for incomplete initial and annual training, with plans of correction pending and due 09/06/2024.
Findings
The allegation was substantiated based on record review and interviews. The facility had two pending citations from a prior annual visit for incomplete staff training, with plans of correction still pending. Evidence was provided that in-service training has been conducted since the prior visit and personnel are allotted time to complete online training. No new deficiency was cited at this time.
Report Facts
Capacity: 60
Census: 35
Citations: 2
Training hours incomplete: 40
Training hours incomplete: 20
Plan of correction due date: Sep 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Trevin Willis | Executive Director | Met with LPAs during the investigation and provided evidence of in-service training |
| Michael Owens | Administrator | Named as facility administrator |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 60
Deficiencies: 0
Date: Sep 4, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that a resident was locked in their room, staff did not provide meals in a timely manner, and staff did not meet the resident's care needs.
Complaint Details
The complaint included allegations that a resident was locked in their room, meals were delayed causing weight loss, and staff failed to meet care needs. After review of records, interviews, and observations, all allegations were found unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations and interviews confirmed that residents could exit their rooms freely, meal service was timely under the circumstances, and staff conducted regular checks on residents. Therefore, all allegations were deemed unsubstantiated.
Report Facts
Capacity: 60
Census: 35
Meal delay allegation: 2
Resident room checks: 1
Resident room checks: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Angela Barutyan | Licensing Program Analyst | Participated in the complaint investigation and prior related interviews |
| Trevin Willis | Executive Director / Administrator | Facility representative met during the investigation |
| Michael Owens | Administrator | Named as facility administrator |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 60
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
The visit was conducted as an unannounced case management investigation regarding two self-reported incidents involving staff misconduct and privacy violations at the facility.
Complaint Details
The visit was complaint-related based on incident reports received on 08/17/2024 and 08/20/2024. The allegations included physical abuse of a resident and violation of resident privacy. The substantiation status is not stated as further investigation is needed.
Findings
The investigation found that two staff members were witnessed slapping a resident and that several staff took and shared an inappropriate selfie exposing a resident. Staff involved were placed on leave pending further investigation by company HR, and families were notified.
Report Facts
Staff placed on leave: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Owens | Administrator/Director | Named as previous Executive Director who was informed of the incident |
| Trevin Willis | Executive Director | Met with Licensing Program Analyst during visit and received incident reports |
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
Inspection Report
Annual Inspection
Census: 40
Capacity: 60
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
The visit was an unannounced Case Management - Annual Continuation inspection to review compliance with licensing requirements.
Findings
The inspection included review of resident files and medication storage. All resident files reviewed were complete, medications were properly labeled and stored, and no deficiencies were observed during the inspection.
Report Facts
Resident files reviewed: 5
Medications reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Trevin Willis | Executive Director | Met with Licensing Program Analysts during inspection |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 60
Deficiencies: 2
Date: Aug 13, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that the facility admitted a resident beyond their level of care and failed to ensure the resident's diabetic needs were met.
Complaint Details
The complaint alleged that Resident #1, who is diabetic and requires twice daily finger prick blood sugar testing, was admitted despite lacking capacity to self-test and the facility lacking skilled staff to perform the test. The complaint was substantiated based on record review and staff interviews.
Findings
The investigation substantiated that the facility admitted a diabetic resident who could not perform self-glucose testing and lacked a skilled professional to perform the test, resulting in the resident's blood sugar not being tested daily. The resident was moved out of the facility due to unmet diabetic care needs.
Deficiencies (2)
Facility accepted a resident who could not perform own glucose testing and did not have skilled professional to perform the glucose test, posing an immediate health risk.
Facility did not comply with diabetes care requirements by accepting a resident unable to perform glucose testing or have it administered by a skilled professional.
Report Facts
Capacity: 60
Census: 40
Deficiencies cited: 2
Plan of Correction Due Date: Aug 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Trevin Willis | Executive Director | Facility representative involved in investigation and exit interview |
| Michael Owens | Administrator | Facility administrator named in report |
| Ana Gutierrez | Resident Care Coordinator | Interviewed during initial visit |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 60
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff handled residents in a rough manner.
Complaint Details
The complaint alleged that Staff 1 or Staff 2 handled residents roughly, causing a skin tear. Interviews with staff and residents did not corroborate the allegation. The complaint was deemed unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegation of rough handling by staff. Interviews with staff and residents did not reveal concerns, and the allegation was deemed unsubstantiated.
Report Facts
Capacity: 60
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Emily Peraldi | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Trevin Willis | Executive Director | Met with investigators during the visit |
| Michael Owens | Administrator | Named as facility administrator |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 40
Capacity: 60
Deficiencies: 2
Date: Aug 7, 2024
Visit Reason
The inspection was an unannounced required annual visit conducted to ensure the facility's compliance with Title 22 regulations and to evaluate health and safety conditions.
Findings
The facility was generally found to be in compliance with health and safety standards, including clean and well-maintained common areas, kitchen, bedrooms, bathrooms, and outdoor spaces. However, deficiencies were cited related to staff training requirements, with some staff lacking the required initial 40 hours and annual 20 hours of training.
Deficiencies (2)
Three out of five staff did not have their 40 hours of initial training as required, posing a potential health, safety, and personal rights risk to persons in care.
Two out of five staff did not have their 20 hours of annual training as required, posing a potential health, safety, and personal rights risk to persons in care.
Report Facts
Staff missing initial training hours: 3
Staff missing annual training hours: 2
Food supply duration: 2
Food supply duration: 7
Resident bedrooms observed: 10
Resident bathrooms water temperature range: 107.8-113.2
Staff interviewed: 4
Residents interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Trevin Willis | Executive Director | Met with during inspection and involved in facility tour |
| Kristin Heffernan | Licensing Program Manager | Supervisor and named in report |
| Angela Barutyan | Licensing Program Analyst | Conducted inspection and signed report |
| Emily Peraldi | Licensing Program Analyst | Conducted inspection |
| Michael Owens | Administrator/Director | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 60
Deficiencies: 1
Date: Jul 31, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility's Executive Director/Administrator abandoned the facility without proper notice.
Complaint Details
The complaint alleged that the Executive Director/Administrator Michael Owens abandoned the facility without proper notice. The allegation was substantiated based on evidence including a resignation letter dated 07/22/2024 and staff interviews confirming the Administrator's absence and lack of response. The management company was notified and sent personnel to manage the facility.
Findings
The investigation substantiated the allegation that the Administrator, Michael Owens, resigned without proper notice and abandoned the facility, leaving management vacancies and posing an immediate health and safety risk to residents. The management company intervened to assist, and the facility is working to fill vacancies.
Deficiencies (1)
Administrator Qualifications and Duties. The Administrator quit without proper notice, abandoning the facility which posed an immediate health and safety risk to residents in care.
Report Facts
Capacity: 60
Census: 39
Deficiencies cited: 1
Plan of Correction Due Date: Aug 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Owens | Executive Director / Administrator | Named in allegation and findings for abandoning the facility |
| Trevin Willis | Staff member met during investigation and interviewed | |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Plan of Correction
Census: 45
Capacity: 60
Deficiencies: 1
Date: May 24, 2024
Visit Reason
An unannounced Plan of Correction (POC) visit was conducted to issue a civil penalty for a POC that had not been corrected within the required timeframe.
Findings
The facility had not issued a refund as required by a previous complaint visit and POC. The refund check was issued late and for an incorrect amount, with an additional $561.25 owed. A civil penalty of $900 was issued during this visit.
Deficiencies (1)
Failure to issue a refund per the resident's Admission Agreement within the required timeframe.
Report Facts
Civil penalty amount: 900
Additional amount owed: 561.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the Plan of Correction visit and issued the civil penalty. |
| Michael Owens | Executive Director | Met with Licensing Program Analyst during the visit. |
| Edie Cano | Business Office Manager | Met with Licensing Program Analyst and provided information about the refund check. |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 60
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not adhering to a resident's Admission Agreement regarding refund issuance following the resident's death and removal of personal belongings.
Complaint Details
The complaint alleged that following Resident #1's death and removal of personal belongings, no refund was issued to the resident's family/estate as required by the Admission Agreement. The allegation was substantiated based on interviews and record review.
Findings
The investigation substantiated that the facility failed to issue a refund to the resident's estate within 15 days after the removal of personal belongings as required by the Admission Agreement. The resident's account showed a carried over credit that was owed to the estate, and despite a refund request made by the Administrator, the refund had not been issued as of the visit date.
Deficiencies (1)
Failure to issue a refund of fees paid in advance covering the time after the resident’s personal property was removed from the facility to the resident’s estate within 15 days, violating HSC 1569.652(c).
Report Facts
Refund amount requested: 2289
Capacity: 60
Census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Michael Owens | Executive Director | Interviewed during the investigation and involved in refund request. |
| Trevin R Willis | Administrator | Requested refund to corporate office; named in findings. |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation report. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 60
Deficiencies: 1
Date: Mar 29, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2023-08-11 regarding failure to report an incident and allegations of sexual assault of a resident by staff.
Complaint Details
The complaint alleged that staff failed to report an incident of sexual assault involving resident #1. The investigation confirmed that the former Administrator was aware of the alleged sexual assault but did not report it to Community Care Licensing as required. The sexual assault allegation itself was unsubstantiated after interviews and review of evidence.
Findings
The investigation substantiated that staff failed to report an alleged sexual assault incident in a timely manner, violating mandated reporting requirements. However, the allegation that two staff sexually assaulted a resident was unsubstantiated due to insufficient evidence.
Deficiencies (1)
Failure to submit a written report to the licensing agency within 7 days of an incident threatening the welfare, safety, or health of a resident as required by CCR 87211.
Report Facts
Capacity: 60
Census: 43
Plan of Correction Due Date: Apr 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Trevin R Willis | Administrator | Named in relation to the failure to report incident |
| Michael Owens | Acting Executive Director | Met with Licensing Program Analyst during investigation |
| Eileen Esquivel | Former Administrator | Was aware of alleged sexual assault but failed to report |
| Douglas Real | Special Investigator | Conducted interviews related to sexual assault allegation |
| Zabel Chochian | Licensing Program Analyst | Conducted complaint investigation and authored report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 60
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
The inspection was conducted as a follow-up on two self-reported Reports of Suspected Dependent Adult/Elder Abuse submitted on 12/18/2023 and 12/20/2023.
Complaint Details
The visit was triggered by two self-reported incidents of suspected dependent adult/elder abuse. The substantiation status is not stated.
Findings
No immediate health and safety concerns were observed during the inspection. Further investigation is required and additional reports may follow if warranted.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Trevin R Willis | Administrator | Met with Licensing Program Analyst during inspection and involved in interview and physical plant tour. |
| Emily Peraldi | Licensing Program Analyst | Conducted the unannounced Case Management - Incident inspection. |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 60
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that the facility failed to conform with fire safety regulations.
Complaint Details
The complaint was substantiated. The allegation was that the facility failed to conform with fire safety regulations due to a locked door without delayed egress. The investigation confirmed this deficiency.
Findings
The investigation found that a glass door separating the residents' dining room from the main entry lobby was locked and did not have delayed egress as required by fire safety regulations. The Los Angeles Fire Department had informed the facility that the door was not in compliance. The facility was put on notice to correct this deficiency.
Deficiencies (1)
Failure to maintain fire safety compliance as the door to exit the dining room to the lobby was locked and did not have delayed egress, posing an immediate health and safety risk to residents.
Report Facts
Capacity: 60
Census: 50
Deficiency Type: 1
Plan of Correction Due Date: Dec 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Trevin R Willis | Administrator | Facility administrator involved in the investigation and exit interview |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Annual Inspection
Census: 51
Capacity: 60
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
The inspection was a required annual unannounced visit to evaluate the facility's compliance with licensing regulations.
Findings
The inspection found the facility to be in good condition with no deficiencies noted at the time of the visit. Areas inspected included common areas, resident rooms, kitchen, and outside areas, all of which were clean, well-maintained, and properly supplied.
Report Facts
Fire extinguisher last serviced date: Jun 2, 2023
Facility temperature: 71
Hot water temperature range: Hot water temperature maintained within required range of 105-120 degrees Fahrenheit
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Trevin R Willis | Executive Director | Met with Licensing Program Analyst during the annual inspection |
| Zabel Chochian | Licensing Program Analyst | Conducted the required annual visit and inspection |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations that staff handled a resident in a rough manner and that the resident sustained a fall while in care.
Complaint Details
The complaint alleged that staff handled a resident roughly and that the resident sustained a fall while in care. The allegations were deemed unsubstantiated based on interviews, medical reports, and observations.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff were placed on administrative leave pending an internal investigation, and a skin assessment showed bruising was due to the resident bumping into objects. Interviews with staff and the resident's family supported that the resident was not abused or mistreated. Further training on elder abuse, mandated reporting, and dementia behavior interventions was recommended.
Report Facts
Facility capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Trevin R Willis | Administrator / Executive Director | Met during investigation and provided information about the incident and staff status |
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 60
Deficiencies: 0
Date: May 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-05-11 regarding staff neglect, leaving a resident unattended in soiled clothing, and failure to meet a resident's needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff neglecting a resident by leaving them unattended in soiled clothing and failing to meet care needs. Interviews, observations, and record reviews confirmed regular staff checks and care provision. The resident's incontinence was linked to prescribed medications. No evidence supported the claims of neglect.
Findings
The investigation found insufficient evidence to substantiate the allegations of staff neglect, leaving the resident unattended in soiled clothing, or failure to meet the resident's needs. Staff regularly checked on the resident, who had incontinence issues related to medication, and care was provided accordingly. All allegations were deemed unsubstantiated.
Report Facts
Capacity: 60
Census: 33
Showers per week: 7
Medication adjustment date: May 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Trevin R Willis | Administrator / Executive Director | Facility administrator met with investigator and provided information |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Annual Inspection
Census: 18
Capacity: 60
Deficiencies: 1
Date: Aug 24, 2022
Visit Reason
The inspection was an unannounced required annual visit with an emphasis on infection control practices and procedures.
Findings
The facility was found to be generally in compliance with health and safety regulations, infection control practices were adequate, and the environment was clean and well maintained. However, a deficiency was noted regarding incomplete documentation of centrally stored medications for one resident.
Deficiencies (1)
Medications were not documented on the centrally stored medication and destruction record for one of two residents (Resident #1), posing a potential health and safety rights risk.
Report Facts
Capacity: 60
Census: 18
Water temperature: 116.9
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eileen Esquivel | Executive Director | Facility administrator met during inspection and involved in findings |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 17
Capacity: 60
Deficiencies: 3
Date: Aug 17, 2022
Visit Reason
The inspection was conducted due to a complaint alleging neglect/lack of supervision resulting in Resident #1 sustaining facial fractures, staff getting into trouble for calling 911, failure to obtain timely medical care, lack of supervisor availability, and failure to notify the authorized representative of resident injury.
Complaint Details
The complaint was received on 2022-04-11 alleging neglect/lack of supervision resulting in facial fractures to Resident #1, staff being reprimanded for calling 911, failure to obtain timely medical care, lack of supervisor availability, and failure to notify the authorized representative. The investigation was conducted through multiple visits and interviews, concluding with substantiation of some allegations and unsubstantiation of others.
Findings
The investigation found the allegations of neglect/lack of supervision causing facial fractures and staff being reprimanded for calling 911 to be unsubstantiated. However, the allegations that staff failed to obtain timely medical care for Resident #1, a supervisor was not available for guidance, and staff did not notify the authorized representative of the resident's injury were substantiated. A $500 immediate civil penalty was assessed.
Deficiencies (3)
Licensee did not take timely action to have Resident #1 transported to a medical facility, posing an immediate health and safety risk.
Licensee failed to notify Resident #1's responsible party of change in condition immediately upon discovery.
Administrator was not available for immediate guidance during the incident, posing an immediate health and safety risk.
Report Facts
Capacity: 60
Census: 17
Civil penalty amount: 500
Plan of Correction Due Date: Aug 19, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eileen Esquivel | Administrator | Named in findings related to failure to notify authorized representative and failure to ensure timely medical care |
| Elsie Campos | Licensing Program Analyst | Conducted complaint investigation and visits |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw complaint investigation |
| Olivia Spindola | Investigator | Conducted interviews and reviewed records during investigation |
| Ashley Smith | Licensing Program Analyst | Conducted subsequent complaint visit |
| Megan Cordova | Business Office Manager | Met with LPAs during subsequent complaint visit |
Inspection Report
Complaint Investigation
Census: 18
Capacity: 60
Deficiencies: 4
Date: Jul 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-12-03 concerning multiple allegations including resident injuries, insufficient staffing, inadequate feeding and hydration, inadequate staff training, and failure to reposition a resident.
Complaint Details
The complaint investigation was substantiated. Allegations included multiple injuries to a resident, insufficient staffing, inadequate feeding and hydration, inadequate staff training, and failure to reposition a resident. Evidence included hospital and home health records, staff interviews, file reviews, and medication audits.
Findings
The investigation substantiated all allegations, finding that Resident #1 sustained multiple pressure injuries while in care, the facility had insufficient staffing to meet resident needs, staff failed to ensure adequate feeding and hydration, staff were inadequately trained, and staff failed to reposition the resident contributing to pressure injuries. Immediate civil penalties were assessed and plans of correction were required.
Deficiencies (4)
Retention of Resident #1 with unstageable pressure injuries, violating prohibited health conditions.
Failure to maintain sufficient and competent staff to meet resident needs.
Failure to provide care, supervision, and services meeting individual resident needs due to insufficient staff qualifications and numbers.
Failure to ensure staff completed required 40 hours of initial training within the first four weeks of employment.
Report Facts
Capacity: 60
Census: 18
Civil penalty: 500
Staff training files audited: 12
Staff with insufficient training: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eileen Esquivel | Executive Director | Met with Licensing Program Analysts during the investigation |
| Celeste Williams | Administrator | Facility administrator named in the report and responsible for plan of correction |
| Elsie Campos | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
Inspection Report
Complaint Investigation
Census: 20
Capacity: 60
Deficiencies: 2
Date: Jul 7, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that residents' rooms were not being cleaned regularly and that residents' toilet paper supply was not being replenished regularly.
Complaint Details
The complaint investigation was substantiated. Allegations included residents' rooms not being cleaned regularly and toilet paper supplies not being replenished regularly. Observations and staff interviews confirmed these issues.
Findings
The investigation substantiated both allegations. Four out of 20 bedrooms were found unclean with debris and dried urine residue, and four out of 20 bathrooms lacked toilet paper in the dispensers. Staff interviews revealed unclear responsibilities for cleaning and replenishing supplies, contributing to the deficiencies.
Deficiencies (2)
Four out of 20 bedrooms were observed unclean, posing a potential health and safety risk.
Four out of 20 bathrooms lacked toilet paper in the dispensers, posing a potential health and safety risk.
Report Facts
Bedrooms observed unclean: 4
Bathrooms lacking toilet paper: 4
Census: 20
Total capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Owens | Health Service Director | Met with Licensing Program Analyst during investigation |
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 13
Capacity: 60
Deficiencies: 4
Date: Jun 3, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including multiple resident falls, delayed staff response to pendants, disrepair of the pendant system, and inadequate cleaning of residents' rooms.
Complaint Details
The complaint investigation was substantiated. Allegations included multiple falls by a resident, delayed staff response to pendants, malfunctioning pendant system, and inadequate cleaning of residents' rooms. The investigation included interviews, observations, and record reviews confirming these issues.
Findings
The investigation substantiated all allegations: a resident sustained multiple falls due to delayed staff response; staff response to pendants was not timely due to insufficient staffing; the facility pendant system was sometimes nonfunctional; and residents' rooms were not cleaned regularly due to lack of housekeeping staff.
Deficiencies (4)
Residents were not properly supervised due to insufficient staff, leading to falls and delayed assistance.
Staff did not respond to residents' pendant signals within the expected time frame due to insufficient staffing.
The facility's signal system was not functioning properly, posing an immediate personal rights risk to residents.
Housekeeping staff was not hired at the time of the visit, resulting in residents' rooms not being cleaned regularly and posing an immediate health and safety risk.
Report Facts
Resident falls: 5
Facility capacity: 60
Census: 13
Rooms toured: 6
Plan of Correction due date: Jun 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
| Celeste Williams | Administrator | Facility Administrator interviewed during investigation |
| Eileen Esquivel | Executive Director | Facility Executive Director interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 15
Capacity: 60
Deficiencies: 2
Date: May 10, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2021-12-03 regarding staff failing to assist a resident with self-administration of medication and incomplete staff and resident files.
Complaint Details
The complaint was substantiated. Allegations included failure to assist a resident with medication self-administration and incomplete files. Evidence included medication administration records showing missed dosages and incomplete staff files lacking valid certifications and health screenings.
Findings
The investigation substantiated that staff failed to assist Resident #1 with self-administration of medications due to missing medications and staff turnover. Additionally, staff and resident files were found to be incomplete, with missing CPR certifications, job applications, and health screenings for some staff members.
Deficiencies (2)
Licensee failed to assist residents with self-administered medications as needed, posing an immediate health and safety risk to residents (R1, R2, R3).
Personnel records were incomplete for three out of thirteen staff members, posing a potential health and safety risk to residents.
Report Facts
Missed medication dosages: 9
Missed medication dosages: 12
Missed medication dosages: 11
Staff files audited: 13
Staff with incomplete files: 3
Residents with PRN medications: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and medication audit |
| Eileen Esquivel | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
| Celeste Williams | Administrator | Facility Administrator named in report and responsible for plan of correction |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Mar 16, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-03 regarding facility staff failing to supervise a resident, resulting in the resident eloping from the facility.
Complaint Details
The complaint alleged that facility staff failed to supervise a resident, resulting in the resident eloping from the facility on two occasions (12/31/2021 and 2/23/2022). The investigation substantiated the allegation based on interviews and observations.
Findings
The investigation substantiated that staff failed to properly supervise resident R1, who eloped twice from the facility due to delayed egress doors being inoperable and staff not responding promptly to door alarms. The facility took corrective actions including fixing the door, installing cameras and alarms, and conducting elopement training and drills.
Deficiencies (2)
Residents were not properly supervised which led to an elopement, posing an immediate personal rights risk to residents in care.
One out of three delayed egress doors were inoperable, posing an immediate health and safety risk to residents in care.
Report Facts
Residents present in dining room during second elopement: 8
Care staff present in dining room during second elopement: 3
Delayed egress doors inoperable: 1
Elopement drills conducted: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Michael Owens | Resident Care Director | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 9
Capacity: 60
Deficiencies: 1
Date: Feb 2, 2022
Visit Reason
The inspection visit was conducted due to deficiencies observed during the investigation of complaint control #29-AS-20220103170508.
Complaint Details
The visit was complaint-related based on complaint control #29-AS-20220103170508. The report does not explicitly state substantiation status.
Findings
The licensing program analyst observed accessible cleaning supplies under the kitchenette sink and accessible alcoholic beverage bottles in the kitchenette mini fridge in the resident dining area, which violated regulations requiring these items to be inaccessible to residents with dementia.
Deficiencies (1)
Accessible over-the-counter medication, nutritional supplements, alcohol, cigarettes, and toxic substances such as cleaning supplies and disinfectants were found accessible to residents with dementia, posing an immediate health and safety risk.
Report Facts
Accessible alcoholic beverage bottles: 4
Capacity: 60
Census: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the inspection and cited deficiencies. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as supervisor and licensing program manager. |
Inspection Report
Complaint Investigation
Census: 8
Capacity: 60
Deficiencies: 3
Date: Dec 10, 2021
Visit Reason
The inspection visit was conducted due to deficiencies observed during the investigation of complaint control #29-AS-20211203112208.
Complaint Details
The visit was triggered by a complaint investigation under control #29-AS-20211203112208. Deficiencies were substantiated as noted in the report.
Findings
The facility was found to have multiple deficiencies including failure to have the required Residential Care Facility for the Elderly Complaint Poster, accessible wine in the Discovery Room, accessible gardening tools and planting soil in the outdoor courtyard, and a staff member (S1) working without appropriate criminal record clearance after separation from the community.
Deficiencies (3)
Staff member S1 worked at the facility without appropriate criminal record clearance after separation from the community on 10/5/2021, posing an immediate health and safety risk.
Items such as alcohol and gardening supplies were accessible to residents with dementia, posing an immediate health and safety risk.
Facility did not have the required Residential Care Facility for the Elderly Complaint Poster for resident observation.
Report Facts
Days worked without clearance: 11
Capacity: 60
Census: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and cited deficiencies. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection and cited deficiencies. |
Inspection Report
Original Licensing
Capacity: 60
Deficiencies: 0
Date: Aug 26, 2021
Visit Reason
The visit was a prelicensing inspection for a new facility application for 60 residents, including a Hospice Waiver requested for 10 residents.
Findings
The facility was toured and found to be adequately equipped and furnished with appropriate infection control measures, safety equipment, and emergency preparedness. The facility is cleared for 60 non-ambulatory residents, including 10 bedridden residents, with adequate rooms, bathrooms, and safety features.
Report Facts
Capacity: 60
Census: 0
Hospice Waiver: 10
Fire Extinguishers: 10
Hot Water Temperature: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celeste Williams | Executive Director | Met during the prelicensing visit and mentioned in the narrative |
| Celeste Lozano | Assistant Executive Director | Met during the prelicensing visit and mentioned in the narrative |
| Sandra Urena | Licensing Program Analyst | Conducted the prelicensing visit and signed the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report header and narrative |
Inspection Report
Original Licensing
Capacity: 60
Deficiencies: 0
Date: Aug 20, 2021
Visit Reason
The visit was an initial licensing evaluation conducted via telephone interview with the administrator to verify identification and confirm understanding of California Code Title 22 Regulations and facility operation requirements.
Findings
The administrator demonstrated understanding of licensing requirements including facility operation, admission policies, staffing, restrictive health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness. No deficiencies or violations were noted in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celeste Williams | Administrator | Participated in COMP II interview and confirmed understanding of regulations. |
| Mirella Quaranta | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Anna Barrios | Licensing Program Analyst | Conducted the COMP II interview and signed the report. |
Inspection Report
Original Licensing
Capacity: 60
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
Initial licensing evaluation conducted via telephone interview with the administrator to verify understanding of California Code Title 22 Regulations and pre-licensing readiness.
Findings
The administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness during the COMP II telephone interview.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Buchanan | Administrator | Participated in COMP II telephone interview confirming understanding of regulations. |
| Mirella Quaranta | Licensing Program Manager | Named as Licensing Program Manager on report. |
| Anna Barrios | Licensing Program Analyst | Conducted COMP II interview and signed report. |
Report
March 11, 2026
Report
November 24, 2025
Report
March 11, 2025
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