Inspection Reports for The Village at Rancho Solano
3350 Cherry Hills Ct, Fairfield, CA 94534, United States, CA, 94534
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not confirmed. However, some substantiated complaints involved medication mismanagement, missed resident checks, delayed responses to call bells, and failure to follow care plans, with a few posing immediate health and safety risks. The facility has received multiple civil penalties totaling several thousand dollars over the past years, primarily related to medication errors, delayed emergency responses, and safety hazards. The most recent report from October 9, 2025, substantiated a deficiency for missed nighttime resident checks during a fall intervention plan, posing a potential health and safety risk. While some serious issues have occurred, recent inspections show ongoing efforts to address deficiencies, though medication management and timely resident observation remain key areas needing improvement.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
188% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
60% 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
Complaint Investigation
Census: 150
Capacity: 250
Deficiencies: 1
Date: Oct 9, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility was not following a resident's care plan after a change in condition requiring increased checks.
Complaint Details
The complaint was substantiated based on interviews, observations, and record reviews showing missed resident checks during a fall intervention period. The allegation was that the facility did not follow the resident's care plan after a change in condition requiring increased monitoring.
Findings
The investigation substantiated the allegation that the facility failed to follow the resident's care plan, missing three nighttime status checks during a 10-day fall intervention plan, including one instance where 22 hours and 40 minutes elapsed between checks, posing a potential health and safety risk.
Deficiencies (1)
Observation of the Resident 87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning. This requirement not met by licensee as evidenced by 3 instances of missed status check over the course of a 10 day fall intervention plan, including 1 instance of 22 hours and 40 minutes elapsing between checks which poses a potential health, safety or personal rights risk to persons in care.
Report Facts
Missed status checks: 3
Elapsed time between checks: 22.67
Facility capacity: 250
Census: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elias Magdaleno | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
| Jesse Sias | Regional Director | Met with the Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 250
Deficiencies: 0
Date: Sep 30, 2025
Visit Reason
Unannounced case management incident visit to follow up on a self-reported allegation of sexual abuse.
Complaint Details
Visit was triggered by a self-reported allegation of sexual abuse. Licensing Program Analyst obtained interviews with the alleging resident, spouse, and staff, as well as chart notes and internal emails. Facility was asked to submit SOC341 and Special Incident Report and to continue updating Community Care Licensing on developments.
Findings
No deficiencies were cited during the visit. Licensing Program Analyst obtained interviews and documentation related to the allegation and requested the facility to submit required reports and continue updates.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with during the inspection and participated in exit interview. |
| Star Stevenson | Licensing Program Analyst | Conducted the unannounced case management incident visit. |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 171
Capacity: 250
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
The visit was conducted as an unannounced case management - incident visit to gather further information regarding a Death Report submitted by the facility on 2025-09-12.
Findings
No deficiencies were cited during the visit. Interviews and document reviews were conducted, and an exit interview was held with the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with during the case management - incident visit. |
| Elias Magdaleno | Licensing Program Analyst | Conducted the unannounced case management - incident visit. |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 250
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that a resident was placed in memory care without their consent and did not meet memory care requirements.
Complaint Details
The complaint was unsubstantiated. Allegations included improper placement of a resident in memory care without consent and lack of access to communication devices or visitors. The investigation included interviews, record reviews, and observations.
Findings
The investigation found that although the resident did not have a dementia diagnosis and was able to care for themselves, the resident's Power of Attorney had authority to make medical decisions including placement. There was insufficient evidence to substantiate the complaint, and no deficiencies were cited.
Report Facts
Capacity: 250
Census: 171
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elias Magdaleno | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Whinery | Administrator | Met with investigator and involved in interviews regarding the complaint |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 250
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2025-09-02 alleging verbal abuse of a resident by staff.
Complaint Details
The complaint alleged verbal abuse of resident R1 by staff. Interviews with R1, roommates, and other residents did not confirm the allegation. The Health and Wellness Coordinator stated staff rotation practices. Review of care plans and notes showed no reports of abuse. The allegation was unsubstantiated due to lack of evidence.
Findings
The investigation included observations, record reviews, and interviews with residents and staff. No evidence was found to substantiate the allegation of verbal abuse, and the complaint was determined to be unsubstantiated.
Report Facts
Complaint Control Number: 21
Complaint Control Number Suffix: 20250902164435
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elias Magdaleno | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during investigation and exit interview. |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 250
Deficiencies: 1
Date: Sep 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were mismanaging a resident's medication and inappropriately increasing a resident's rent.
Complaint Details
The complaint investigation was substantiated for medication mismanagement, with evidence showing missed medication doses and refill errors. The rent increase allegation was unsubstantiated.
Findings
The investigation substantiated the allegation that staff mismanaged resident medication, with one resident missing fourteen doses over 31 days due to refill errors, posing an immediate health risk. The allegation regarding inappropriate rent increase was found to be unfounded, as the rate increase applied facility-wide and was not related to care needs.
Deficiencies (1)
Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by missed fourteen (14) doses of prescribed medication over thirty-one (31) days posing immediate health risk.
Report Facts
Missed medication doses: 14
Facility capacity: 250
Current census: 171
Civil penalty amount: 250
Days in period: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during investigation and exit interview. |
| Elias Magdaleno | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 250
Deficiencies: 1
Date: Sep 25, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff did not follow a resident’s prescribed medication orders, specifically administering higher dosages than ordered.
Complaint Details
The complaint was substantiated based on observations, record review, and interviews. The allegation involved staff not following prescribed medication orders, administering higher dosages than ordered. A civil penalty for a repeat violation was noted.
Findings
The investigation substantiated that staff administered multiple doses of medication in under 24 hours on five occasions, including three occasions where a full pill was given instead of the prescribed half dose, posing an immediate health and safety risk.
Deficiencies (1)
Incidental Medical and Dental Care 87465(a)(4) - The licensee failed to assist residents with self-administered medications as needed, resulting in administration of higher dosages than prescribed on five occasions.
Report Facts
Medication dosage errors: 5
Facility capacity: 250
Census: 171
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with during investigation and exit interview |
| Elias Magdaleno | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 250
Deficiencies: 0
Date: Sep 11, 2025
Visit Reason
The inspection was a case management visit conducted to obtain more information regarding a self-reported incident involving the death of a resident at the hospital.
Complaint Details
The visit was triggered by a self-reported incident report received on 2025-09-02 involving the death of a resident (R1) at the hospital. The Licensing Program Analyst conducted the visit to gather more information and requested the coroner's report.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst requested copies of the coroner's report, which the Administrator stated would be sent when released by the hospital.
Report Facts
Capacity: 250
Census: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during the inspection and provided information about the incident and coroner's report |
| Elias Magdaleno | Licensing Program Analyst | Conducted the case management-incident inspection |
| Bailey Malagon | Assistant Executive Director | Met with Licensing Program Analyst during the inspection and participated in the exit interview |
Inspection Report
Complaint Investigation
Census: 165
Capacity: 250
Deficiencies: 0
Date: Aug 28, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility administrator did not have an active administrator certification.
Complaint Details
The complaint alleged that the facility administrator did not have an active administrator certification. This allegation was found to be unfounded after verification with the Administrator Certification Bureau.
Findings
The investigation found that the administrator, Morgan Whinery, has a current and active certification valid from 09/18/2024 to 09/17/2026. The complaint allegation was determined to be unfounded and no deficiencies were cited.
Report Facts
Capacity: 250
Census: 165
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Named in complaint allegation and investigation findings |
| Elias Magdaleno | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 165
Capacity: 250
Deficiencies: 0
Date: Aug 28, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that facility staff were not adhering to proper food service guidelines, specifically regarding dating and rotation of incoming food and beverage products.
Complaint Details
Complaint was unsubstantiated due to lack of preponderance of evidence proving the alleged violations occurred. The complaint involved food service guideline adherence and food safety concerns.
Findings
The investigation found that food was generally labeled, dated, and stored in compliance with regulations, with minor observations such as unlabeled and uncovered cake slices explained as part of ongoing meal service. A photo showed molded hot peppers which were discarded before serving. Based on observations, interviews, and record review, there was insufficient evidence to substantiate the allegations, and no deficiencies were cited.
Report Facts
Capacity: 250
Census: 165
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with during investigation and named in findings |
| Elias Magdaleno | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 165
Capacity: 250
Deficiencies: 0
Date: Aug 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff does not ensure the facility is free of rodents.
Complaint Details
The complaint alleged that rats were present in a resident's room and that the facility was not taking proper actions to address the issue. The investigation included observations, interviews, and record reviews. The complaint was found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found no evidence of rodents during the visit, with pest control reports showing no captures or activity. Although there were allegations and some reports of rodents, the facility had taken corrective actions such as installing draft blockers and ordering a screen door. The complaint was determined to be unsubstantiated with no deficiencies cited.
Report Facts
Pest control captures: 0
Pest control captures: 0
Census: 165
Total capacity: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during complaint investigation. |
| Elias Magdaleno | Licensing Program Analyst | Conducted the complaint investigation. |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 165
Capacity: 250
Deficiencies: 0
Date: Aug 28, 2025
Visit Reason
Unannounced complaint investigation conducted due to allegations that staff do not timely respond to residents' alerts and that residents are left unattended.
Complaint Details
Complaint was unsubstantiated after investigation. Allegations included delayed response to resident call buttons and residents being left unattended due to understaffing. Evidence did not prove violations occurred.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Observations, interviews, and record reviews indicated that while some residents and staff expressed concerns about response times and staffing levels, no deficiencies were cited and the complaint was unsubstantiated.
Report Facts
Residents interviewed: 12
Staff interviewed: 5
Resident wait time: 47
Resident wait time: 45
Resident wait time: 15
Residents observed: 12
Staff observed: 6
Residents observed: 10
Caregivers observed: 5
Staff interviewed: 4
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Elias Magdaleno | Licensing Program Analyst | Conducted complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 250
Deficiencies: 0
Date: Aug 14, 2025
Visit Reason
The inspection was conducted as a case management visit to obtain more information regarding an Incident Report received on 2025-08-13 involving a resident being sent to the hospital and subsequent transfer to a skilled nursing facility.
Complaint Details
The visit was triggered by an incident report involving a resident (R1) who was sent to the hospital and then transferred to a skilled nursing facility. No deficiencies were found related to this incident.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst obtained copies of the resident's care plan and face sheet and conducted an exit interview with the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elias Magdaleno | Licensing Program Analyst | Conducted the case management-incident inspection. |
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during the inspection and participated in the exit interview. |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 250
Deficiencies: 1
Date: Jul 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-04-14 regarding staff mismanaging residents' medications and other care concerns.
Complaint Details
The complaint investigation was substantiated for medication mismanagement involving two residents (R1 and R2). Other allegations including inadequate supervision resulting in resident elopements, improper staff training for catheter care, bed bug infestation, infectious disease protocol violations, and improper resident assessments prior to admission were unsubstantiated or unfounded based on interviews, record reviews, and observations.
Findings
The complaint that staff were mismanaging residents' medications was substantiated due to medication errors involving two residents. Other allegations including inadequate supervision, improper staff training, bed bug infestation, infectious disease protocol violations, and improper resident assessments were found to be unsubstantiated or unfounded. No deficiencies were cited except for the medication error.
Deficiencies (1)
Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by medication error of not discontinuing one of R1’s 2 anti-seizure medications as indicated by Dr., which poses an immediate health, safety or personal rights risk to persons in care.
Report Facts
Capacity: 250
Census: 161
Medication training hours: 8
Preventative elopement training drills: 17
Staffing counts: 3
Staffing counts: 20
Caregivers: 70
Resident assistants - 2 person assists: 17
Resident assistants - 1 person assist: 50
Resident assistants - no assist: 94
Residents with schizophrenia diagnosis: 2
Residents receiving catheter care: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during inspection and involved in findings |
| Elias Magdaleno | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 250
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility unlawfully evicted a resident and that staff retaliated against a resident.
Complaint Details
The complaint alleged unlawful eviction of a resident and staff retaliation. The investigation reviewed Special Incident Reports from January 2023 to May 2025, identifying 34 incidents involving 23 residents. Three residents had multiple altercations; one resident was evicted due to aggressive behavior with documented incidents. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the allegations were unsubstantiated. Documentation and interviews showed multiple resident altercations, with interventions attempted by the facility, but there was insufficient evidence to prove unlawful eviction or retaliation.
Report Facts
Incident reports reviewed: 34
Residents involved in incidents: 23
Capacity: 250
Census: 161
Altercations for Resident 1: 9
Altercations for Resident 2: 9
Altercations for Resident 3: 13
Incidents cited in eviction notice for Resident 3: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ali Deniz | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Whinery | Administrator | Facility administrator interviewed during investigation |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 250
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff do not ensure residents are able to come and go freely and that staff are limiting residents' visits.
Complaint Details
The complaint alleged that the facility locks the front doors at 5:30pm restricting residents' freedom of movement and limiting visits. Interviews with residents, family members, and the administrator revealed no substantiated issues. The complaint was determined to be unsubstantiated.
Findings
The investigation found that while some residents waited 5-6 minutes to be let in after hours and calls sometimes went to voicemail, there was no preponderance of evidence to substantiate the allegations. The facility locks the front doors at 5:30pm at the request of some residents concerned about safety, and visitors are instructed to call an after-hours phone for entry. No deficiencies were cited.
Report Facts
Capacity: 250
Census: 161
Complaint Control Number: 21-AS-20250303122510
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with during investigation and provided information about door locking policy |
| Ali Deniz | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Conducted the complaint investigation and signed the report |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 250
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were not properly assessing residents in care and not providing adequate food service to residents.
Complaint Details
The complaint alleged that a resident's care level was raised without assessment or consultation, and that food quality had declined, including a dinner meal served without teriyaki sauce due to dietary restrictions. Interviews and record reviews did not substantiate these allegations.
Findings
The investigation found that the allegations regarding improper resident assessment and inadequate food service were unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited.
Report Facts
Facility capacity: 250
Census: 161
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met during investigation and provided information regarding allegations |
| Ali Deniz | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 165
Capacity: 250
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
Unannounced complaint investigation conducted due to allegations that the licensee did not ensure proper food safety protocols and was not preventing rodents from being in the facility.
Complaint Details
Complaint alleged improper food safety practices such as undated food, improper storage, expired water filters, malfunctioning cooking equipment, falsified temperature logs, and lack of sanitizer pH testing. Also alleged presence of rats in the kitchen. Investigation found no evidence to substantiate these claims.
Findings
The investigation found that food safety protocols were being followed, including proper labeling, dating, and storage of food, and temperature logs were maintained. No evidence of rodents or vermin was observed, and pest control measures were in place. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 250
Census: 165
Pest sighting date: Jun 13, 2025
Pest control visit start date: May 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with during investigation |
| Elias Magdaleno | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 250
Deficiencies: 0
Date: May 29, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding the allegation that staff were not following the general food service requirements.
Complaint Details
The allegation was that staff were not following general food service requirements, specifically that dining menus were posted but changed daily without notice, constituting false advertisement. The complaint was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that menu postings were visible and staff communicated last-minute menu changes due to supplier delivery issues. Resident interviews provided conflicting information about the frequency of unavailable menu items. No evidence supported a violation, and the allegation was unsubstantiated.
Report Facts
Complaint Control Number: 21-AS-20250519145314
Capacity: 250
Census: 173
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ali Deniz | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Morgan Whinery | Administrator | Facility administrator unavailable during investigation |
| Tony Ibarra | Business Office Director | Met with investigators during the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 173
Capacity: 250
Deficiencies: 1
Date: May 29, 2025
Visit Reason
The visit was an unannounced case management inspection conducted to follow up on a self-reported medication error that occurred on 2025-05-16 involving a medication technician dispensing oral antibiotics instead of the prescribed topical antibiotic.
Findings
The inspection found a medication error that posed an immediate health, safety, or personal rights risk to a resident. The facility submitted an incident report and corrective actions were reviewed. No adverse reactions were observed in the resident.
Deficiencies (1)
Incidental Medical and Dental Care 87465(a)(4) - The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by a medication error posing immediate health, safety or personal rights risk.
Report Facts
Capacity: 250
Census: 173
Plan of Correction Due Date: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Named in relation to the inspection and medication error |
| Tony Ibarra | Business Office Director | Met with Licensing Program Analysts during inspection |
| Ali Deniz | Licensing Program Analyst | Conducted the inspection and signed the report |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 171
Capacity: 250
Deficiencies: 0
Date: May 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not following a resident's care plan and were not ensuring residents' personal rights.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not following a resident's care plan and not ensuring residents' personal rights. The Licensing Program Analyst conducted multiple visits, interviews, and document reviews but was unable to find evidence of violations.
Findings
The investigation found no evidence to substantiate the allegations. Staff were found to be following the resident's care plan appropriately, and there was no violation regarding residents' personal rights after implementation of door key management in the memory care unit.
Report Facts
Complaint Control Number: 21-AS-20250210131006
Number of visits conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 250
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2025-03-19 regarding staff responses to Resident Council concerns, posting of Resident Council meetings, and presence of a staff liaison to assist the Resident Council.
Complaint Details
The complaint included three main allegations: 1) Staff did not respond in writing to Resident Council concerns within the required timeframe; 2) Staff did not post Resident Council meeting notices in a central location; 3) There was no staff liaison to assist the Resident Council. The first two allegations were found to be unfounded, meaning the allegations were false or without reasonable basis. The third allegation was unsubstantiated, meaning there was insufficient evidence to prove or disprove the allegation.
Findings
The investigation found all allegations to be either unfounded or unsubstantiated. Staff responded to Resident Council concerns in writing within an appropriate timeframe, Resident Council meeting notices were posted in multiple central locations, and the Executive Director serves as the staff liaison to the Resident Council.
Report Facts
Complaint received date: Mar 19, 2025
Number of unannounced visits: 2
Copies of Town Hall meeting documents: 35
Facility capacity: 250
Facility census: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analysts during investigation and named in findings |
| Shannan Hansen | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 250
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not provide resident medication as needed.
Complaint Details
The complaint alleged that staff did not provide resident medication as needed. The allegation was unsubstantiated after investigation, as there was not a preponderance of evidence to prove the violation occurred.
Findings
The investigation found that the resident was administered PRN medication on 4/24/2025 and there was no record of a PRN request on 4/25/2025. Staff interviews and record reviews indicated that PRN medications were administered appropriately. The allegation was determined to be unsubstantiated due to insufficient evidence of a violation.
Report Facts
Facility capacity: 250
Census: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analysts during complaint investigation |
| Shannan Hansen | Licensing Program Analyst | Conducted complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 250
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The visit was conducted as a case management review of a self-reported incident involving a resident (R1) who expressed thoughts of self-harm, following an incident report received on 2025-03-19.
Complaint Details
The visit was triggered by a self-reported incident report indicating that resident R1 expressed thoughts of self-harm. The case management review found no deficiencies.
Findings
The Licensing Program Analyst reviewed records and the facility's plan to ensure the care and supervision of the resident. No deficiencies were cited during the visit.
Report Facts
Capacity: 250
Census: 161
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with during the inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the case management review |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 161
Capacity: 250
Deficiencies: 0
Date: Mar 19, 2025
Visit Reason
The visit was an unannounced office Non-Compliance Conference conducted to review concerns identified by the Community Care Licensing Agency, including multiple complaint investigations and issues related to personnel requirements, medication discrepancies, personal rights, elopements, and call bell response times.
Complaint Details
Community Care Licensing Agency investigated 14 complaints in 2024 and 6 complaint investigations in 2025, with 2 substantiated and 4 still under investigation.
Findings
No deficiencies were cited during the Non-Compliance Conference. The report summarizes ongoing investigations and concerns but does not document any new deficiencies.
Report Facts
Complaints investigated in 2024: 14
Complaint investigations in 2025: 6
Facility capacity: 250
Facility census: 161
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator/ED | Named as facility administrator present during Non-Compliance Conference |
| Chris Hollister | Chair/CEO | Named as facility Chair/CEO present during Non-Compliance Conference |
| Richard Williams | Co-President/COO | Named as facility Co-President/COO present during Non-Compliance Conference |
| Erica Ogle | Regional VP Operations | Named as Regional VP Operations present during Non-Compliance Conference |
| Sangeeta Devi | Regional Director of Health & Wellness | Named as Regional Director of Health & Wellness present during Non-Compliance Conference |
| Dr. Sandi Petersen | SVP Health & Wellness | Named as SVP Health & Wellness present during Non-Compliance Conference |
| Jay Stowers | QA/Risk Manager | Named as QA/Risk Manager present during Non-Compliance Conference |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager conducting the Non-Compliance Conference |
| Shannan Hansen | Licensing Program Analyst | Named as Licensing Program Analyst conducting the Non-Compliance Conference |
Inspection Report
Complaint Investigation
Census: 159
Capacity: 250
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
Unannounced visit/investigation of a complaint received on 01/07/2025 regarding alleged failure to properly notify resident or representative of rate increase and failure to maintain facility cleanliness.
Complaint Details
Complaint was unsubstantiated based on statements, documents, and observations. Allegations included failure to notify resident or representative of rate increase and failure to maintain facility cleanliness.
Findings
The investigation found that the facility provided proper notice of rate increase to the resident, and the facility was found to be clean and sanitary during multiple unannounced visits. There was insufficient evidence to substantiate the allegations, and therefore the complaint was unsubstantiated.
Report Facts
Complaint Control Number: 21
Capacity: 250
Census: 159
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Whinery | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 159
Capacity: 250
Deficiencies: 1
Date: Mar 18, 2025
Visit Reason
Unannounced visit/investigation of a complaint received on 2025-02-21 regarding personal rights violations at the facility.
Complaint Details
Complaint was substantiated based on videos and statements showing Resident R2 entering Resident R1's bed uninvited, compromising R1's personal rights.
Findings
The investigation substantiated that Resident R2 repeatedly entered Resident R1's space and bed, violating R1's personal rights as evidenced by videos and witness statements. Facility staff had attempted hourly wellness checks to prevent this.
Deficiencies (1)
Personal Rights of residents shall be free from interference with daily living functions such as sleeping. Resident R2 repeatedly entered Resident R1's space and bed while R1 was occupying it, violating R1's personal rights.
Report Facts
Capacity: 250
Census: 159
Plan of Correction Due Date: Mar 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Whinery | Administrator | Facility administrator met during the investigation |
| Carla Martinez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 250
Deficiencies: 1
Date: Mar 6, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that facility staff did not follow physician's orders in a timely manner.
Complaint Details
The complaint was substantiated based on evidence that staff delayed following a physician's order for a urine culture test by 12 days due to miscommunication.
Findings
The allegation that facility staff did not follow physician's orders in a timely manner was substantiated. Records and interviews confirmed a 12-day delay in obtaining a urine culture test for a resident due to miscommunication.
Deficiencies (1)
87465(a)(1) Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. Medical tests ordered for resident on 1/24/2025 were not made until 2/4/2025, posing an immediate risk to the health of the resident.
Report Facts
Deficiency Plan of Correction Due Date: Mar 7, 2025
Census: 178
Total Capacity: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation |
| Tony Ibarra | Business Office Director | Met with Licensing Program Analyst during investigation |
| Morgan Whinery | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 178
Capacity: 250
Deficiencies: 2
Date: Mar 6, 2025
Visit Reason
The inspection was an unannounced continuation of a 1 Year Required Visit (annual inspection) to evaluate compliance with regulations for an assisted living and memory care facility.
Findings
The inspection found that resident care plans and medical assessments were up to date and well organized. However, personnel records were not readily available for review, posing a potential health and safety risk. Additionally, a resident with dementia eloped from the facility due to an unarmed alarm door, which was cited as a deficiency but cleared during the visit after staff training and corrective actions.
Deficiencies (2)
Personnel records were not readily available for Licensing review during the visit, including updated personnel records, posing a potential health and safety risk.
Resident with dementia eloped from the facility due to safety measures not being met, posing an immediate health and safety risk.
Report Facts
Residents reviewed: 10
Staff files reviewed: 10
Staff members on-site: 43
Residents in Assisted Living: 118
Residents in Memory Care: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Named as Administrator not available during inspection |
| Tony Ibarra | Business Office Director | Met with Licensing Program Analysts during inspection |
| Ieshaa Ragland | Health and Wellness Director | Met with Licensing Program Analysts during inspection |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
| Shannan Hansen | Licensing Program Analyst | Licensing evaluator conducting the inspection |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 250
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 12/04/2024 regarding staff not providing assistance for resident council meetings, untimely meal service, and failure to follow special diet orders, as well as missing required postings at the facility.
Complaint Details
The complaint investigation was unannounced and conducted by Evaluator David Leibert. The complaint control number is 21-AS-20241204123831. The allegations included failure to assist residents with council meetings, untimely meal service, failure to follow special diet orders, and missing required postings. The investigation included interviews, document reviews, and multiple unannounced site visits. The allegations about assistance, meal service, and diet were unsubstantiated, while the posting deficiency was substantiated.
Findings
The investigation found the allegations about assistance to resident council meetings, meal service timeliness, and special diet compliance to be unsubstantiated based on interviews, document reviews, and multiple unannounced site visits. However, the allegation regarding missing required postings was substantiated, with a deficiency cited for failure to post personal rights and complaint information as required by regulation. The deficiency was corrected at the time of the visit.
Deficiencies (1)
87468© Personal Rights. Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. Inspection on 12/10/24 found complaint sign posting was not required size and no residents’ rights posted, posing a potential denial of residents’ personal rights.
Report Facts
Facility capacity: 250
Census: 162
Number of unannounced site visits: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Oversaw the complaint investigation |
| Morgan Whinery | Administrator | Facility administrator named in the report |
| Tony Ibarra | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 250
Deficiencies: 3
Date: Feb 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including failure to prevent a physical altercation between residents, insufficient staffing, failure to provide adequate notice of rate increases, resident elopement due to neglect, and failure to follow reporting requirements.
Complaint Details
The complaint investigation was unannounced and conducted due to allegations including failure to prevent a physical altercation, insufficient staffing, failure to provide adequate notice of rate increases, resident elopement due to neglect, and failure to follow reporting requirements. The investigation concluded some allegations were substantiated and others unsubstantiated.
Findings
The investigation found some allegations unsubstantiated, such as failure to prevent a physical altercation and insufficient staffing, but substantiated others including failure to provide timely written notice of rate increases, resident elopement without staff knowledge, and failure to follow reporting requirements. A civil penalty of $500 was issued for zero tolerance of absence of supervision.
Deficiencies (3)
Facility personnel were insufficient in numbers and competence to prevent resident elopement on 10/13/2024, posing immediate risk to resident safety.
Failure to provide written notice of rate increases within two business days as required by H&S Code 1569.657(a), posing potential risk to resident personal rights.
Failure to submit required written reports within seven days for incidents threatening resident welfare, safety, or health, violating CCR 87211(a).
Report Facts
Civil Penalty: 500
Facility Capacity: 250
Resident Census: 174
Staff present during incidents: 5
Staff present during altercation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Whinery | Administrator | Facility administrator named in the report |
| Tony Ibarra | Business Office Director | Met with Licensing Program Analyst during inspection |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 161
Capacity: 250
Deficiencies: 2
Date: Feb 20, 2025
Visit Reason
The inspection was conducted as a required unannounced 1-year inspection of the assisted living facility.
Findings
The facility was generally found to be in compliance with regulations, including safe food handling, fire safety, and disaster drills. However, deficiencies were noted related to hot water temperatures exceeding regulatory limits and an unlocked laundry room with cleaning chemicals accessible to residents in memory care.
Deficiencies (2)
Hot water temperature controls were not maintained within regulation in 7 out of 11 faucets accessible to residents, with temperatures ranging from 120.2 to 125.2 degrees Fahrenheit, posing an immediate health and safety risk.
Laundry room was found unlocked with cleaning chemicals on shelves accessible to residents with dementia, posing a potential health and safety risk.
Report Facts
Residents in assisted living portion: 110
Residents in memory care portion: 52
Residents receiving Hospice Services: 13
Hot water faucets out of compliance: 7
Total faucets tested: 11
Fire extinguisher last serviced: Jan 9, 2025
Fire safety system last inspected: Dec 11, 2024
Disaster drills last conducted: Feb 10, 2025
Plan of Correction due date for hot water issue: Feb 21, 2025
Plan of Correction due date for chemical storage issue: Feb 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Met with Licensing Program Analysts during inspection and involved in observations |
| Frank Taitano | Maintenance | Accompanied Licensing Program Analysts during facility tour |
| Shannan Hansen | Licensing Program Analyst | Conducted inspection and signed report |
| Bethany Moellers | Licensing Program Manager | Supervised inspection and signed report |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 250
Deficiencies: 0
Date: Feb 11, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that Memory Care staff left residents unattended in the dining area on 11/26/2024.
Complaint Details
The complaint alleged inadequate assistance to residents and that Memory Care staff left residents unattended in the dining area for a 10-minute period on 11/26/2024. The allegation was unsubstantiated after investigation.
Findings
The investigation included four unannounced site visits, document review, and interviews with family members and staff. The allegation was found to be unsubstantiated due to lack of preponderance of evidence despite some observations and statements.
Report Facts
Family members surveyed: 20
Family members positive responses: 18
Staff interviewed: 5
Staff indicating no residents left unattended: 5
Number of unannounced site visits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Whinery | Administrator | Facility administrator met during the investigation |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 250
Deficiencies: 1
Date: Jan 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that facility staff were not providing residents with a reasonable amount of privacy in common areas due to video cameras recording audio as well as video.
Complaint Details
The complaint was substantiated based on statements from the complainant, the administrator, and observations by the Licensing Program Analyst. The audio function on cameras was activated without the administrator's initial knowledge and was turned off during the investigation.
Findings
The investigation substantiated the complaint that the facility had video cameras with audio activated in common areas, violating residents' personal rights. The audio function was deactivated on January 11, 2025, and the facility agreed to use video only going forward.
Deficiencies (1)
Cameras placed in common areas had the audio function activated, posing an immediate violation of residents' personal rights.
Report Facts
Capacity: 250
Census: 169
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Whinery | Administrator | Interviewed regarding the complaint and deficiency related to audio recording on cameras |
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Follow-Up
Census: 179
Capacity: 250
Deficiencies: 0
Date: Dec 10, 2024
Visit Reason
The visit was an unannounced follow-up on an incident reported by the facility on 2024-11-06 involving a possible infection in a resident.
Findings
Staff assessed the resident and called 911 despite the spouse's objection. The resident was transferred to a medical facility and then to skilled nursing. No citations were issued during this visit.
Report Facts
Capacity: 250
Census: 179
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the unannounced follow-up visit |
| Morgan Whinery | Administrator/Director | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 250
Deficiencies: 1
Date: Nov 19, 2024
Visit Reason
An unannounced complaint investigation was conducted due to allegations that facility staff did not respond to residents' calls for assistance in a timely manner.
Complaint Details
The complaint alleging that facility staff did not respond timely to residents' calls for assistance was substantiated after review of call bell records, observations, and interviews. The evidence showed delayed response times and a non-responsive pull cord in a bathroom.
Findings
The investigation found that most calls were answered within 3-8 minutes, but multiple calls each day from 11/1/2024 through 11/15/2024 took between 15 to 31 minutes to be answered. Additionally, one bathroom pull cord was found non-responsive. The complaint was substantiated based on the preponderance of evidence.
Deficiencies (1)
Facility personnel were insufficient in numbers and unable to respond to call buttons in a timely manner, with multiple call buttons having response times of 20 minutes or more, posing an immediate risk to resident health and safety.
Report Facts
Census: 169
Total Capacity: 250
Response Time: 15
Response Time: 31
Plan of Correction Due Date: Nov 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Kimberley Mota | Licensing Program Manager | Oversaw complaint investigation |
| Morgan Whinery | Administrator | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 250
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
The visit was an unannounced Case Management inspection conducted in response to a self-reported incident involving a resident's allegation of rape.
Complaint Details
The complaint involved a resident in care reporting that they were raped. The allegation was substantiated by notification to local authorities and involved parties.
Findings
The Licensing Program Analyst verified that local police, responsible party, and Ombudsman were notified regarding the incident. No citations were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the Case Management visit and investigation. |
| Morgan Whinery | Executive Director | Reported the resident's allegation and cooperated with the investigation. |
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Follow-Up
Census: 169
Capacity: 250
Deficiencies: 1
Date: Nov 5, 2024
Visit Reason
Licensing Program Analyst Leibert arrived unannounced to conduct a proof of correction visit to review the citation issued on October 01, 2024 for H&S 1569 and the documentation submitted by the Administrator.
Findings
The citation issued on October 01, 2024 for H&S 1569 was reviewed and found to be cleared based on the documentation submitted by the Administrator.
Deficiencies (1)
Citation issued for H&S 1569
Report Facts
Capacity: 250
Census: 169
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the proof of correction visit |
| Agustin Samaniego | Administrator | Reviewed citation and documentation with Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 250
Deficiencies: 1
Date: Nov 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2024-10-28 regarding maintenance issues including resident shower maintenance, tripping hazards, and mold in the facility.
Complaint Details
The complaint investigation was triggered by allegations that facility staff were not ensuring resident shower maintenance, not ensuring the facility was free of tripping hazards, and not properly addressing mold in the facility. The shower maintenance and tripping hazard allegations were unsubstantiated, while the mold allegation was substantiated.
Findings
Two complaints were investigated: one regarding shower maintenance and tripping hazards which was unsubstantiated, and another regarding mold in a resident's shower which was substantiated based on photographs and statements. A deficiency was cited for failure to maintain the facility in a clean, safe, and sanitary condition due to mold.
Deficiencies (1)
87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Based upon photographs and statements, this requirement not met as evidenced by: 10/25/24 photographs of R1’s shower depict mold on the floor and wall. This poses an immediate risk to the health of R1.
Report Facts
Capacity: 250
Census: 169
Deficiency Type A count: 1
Plan of Correction Due Date: Nov 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Named in relation to the licensing program management and oversight |
| Agustin Samaniego | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 250
Deficiencies: 0
Date: Nov 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging that facility staff were not meeting clients' dietary needs.
Complaint Details
The complaint alleged that facility staff were not meeting clients' dietary needs. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found that although the complainant suggested insufficient nutrition for Resident 1, the evidence was inconclusive. Resident 1's physician cleared them for a regular diet, and care notes showed a pattern of meal refusal or partial consumption. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 159
Capacity: 250
Deficiencies: 1
Date: Oct 29, 2024
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff did not ensure reporting requirements were followed and that medications were not dispensed as prescribed or properly managed.
Complaint Details
The complaint alleged failure to follow reporting requirements and medication errors. The medication error was substantiated with evidence that Resident 1 received an incorrect dose and medication not ordered. The complaint regarding reporting requirements was found to be unfounded.
Findings
The investigation found that a medication error occurred on 10/14/2024 involving Resident 1 receiving an incorrect dose and medication not ordered. The medication administration record was inaccurate. The allegations were substantiated based on statements and documents. A deficiency was cited related to incidental medical care and medication administration.
Deficiencies (1)
87465(a)(4) Incidental Medical and Dental Care. The licensee failed to assist residents with self-administered medications as needed. On 10/14/24 Resident 1 was administered a medication not ordered and the wrong dose of a medication that was ordered. The ordered medication dosage was incorrectly listed in the Medication Administration Record. This posed an immediate risk to the health of Resident 1.
Report Facts
Capacity: 250
Census: 159
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Named in relation to the complaint investigation and plan of correction |
| Agustin Samaniego | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 250
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility illegally evicted a resident who was refused return following hospitalization.
Complaint Details
The complaint alleged that the facility refused the return of resident R1 following hospitalization due to a prohibited condition. The investigation found that the resident's condition (use of a Perm-Cath CVC catheter) was not a prohibited condition and that the resident was illegally evicted. The allegation was substantiated.
Findings
The investigation substantiated that the resident was illegally evicted when not allowed to return to the facility after hospitalization due to a medical condition that is not prohibited. The facility was cited for violating eviction procedures under California Code of Regulations.
Deficiencies (1)
Eviction Procedures. The licensee may evict a resident only for reasons listed in Section 87224(a)(1) through (5) with thirty (30) days written notice except as otherwise specified. The facility failed to allow resident R1 to return from hospitalization due to a medical condition that is not prohibited, violating personal rights.
Report Facts
Capacity: 250
Census: 161
Plan of Correction Due Date: Oct 15, 2024
Written Notice Period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 250
Deficiencies: 0
Date: Oct 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility was not meeting a resident's care needs, charging for services not provided, and that staff were not trained.
Complaint Details
The complaint alleged that the facility was not meeting resident R1's care needs, staff were not trained in Hoyer lift and Body Mechanics, and that R1 was charged for services not provided. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that the resident had a pattern of refusal of care, the facility provided staff training records, and no evidence was found to prove or disprove the allegations. Therefore, the allegations were unsubstantiated.
Report Facts
Facility capacity: 250
Census: 161
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 250
Deficiencies: 3
Date: Oct 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-08-22 regarding the facility's compliance with resident care, notification of rate increases, dietary orders, incident reporting, and billing practices.
Complaint Details
The complaint investigation was triggered by allegations including failure to provide written notice of rate increase, failure to meet resident's incontinent care needs, failure to follow dietary orders, failure to provide written incident reports, and failure to provide detailed explanations and itemization of charges. The allegation regarding rate increase notice was unfounded; incontinent care needs allegation was unsubstantiated; allegations regarding dietary orders, incident reports, and billing explanations were substantiated with cited deficiencies.
Findings
The investigation found one allegation substantiated related to failure to provide detailed explanations and itemization of charges for additional services and failure to follow a resident's special diet, resulting in cited deficiencies. Other allegations, including failure to provide written notice of rate increase and failure to meet resident's incontinent care needs, were found unsubstantiated or unfounded. The facility was cited for deficiencies under California Code of Regulations and Health and Safety Codes with plans of correction required.
Deficiencies (3)
Facility did not provide resident and responsible person with a detailed explanation of additional services and itemization of charges as required by H&S code section 1569.657.
Kitchen staff failed to follow the special diet prescribed by resident's physician, posing a potential risk to resident's health.
Facility failed to provide written incident reports to the resident's responsible person as required by CCR 87211(a)(1), posing a potential risk to personal rights and health.
Report Facts
Capacity: 250
Census: 174
Deficiency count: 3
Plan of Correction Due Date: Oct 8, 2024
Plan of Correction Due Date: Oct 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Oversaw the complaint investigation |
| Agustin Samaniego | Administrator | Facility administrator involved in investigation findings and statements |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 250
Deficiencies: 1
Date: Oct 1, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including lack of care resulting in a pressure injury, billing for services not rendered, failure to ensure daily activities and adequate feeding, and failure to provide showers as per care plan.
Complaint Details
Complaint investigation was unannounced and triggered by multiple allegations including pressure injury due to lack of care, improper billing, failure to ensure daily activities and feeding, and failure to provide showers. The shower allegation was substantiated; others were unsubstantiated.
Findings
The investigation found the initial allegations regarding pressure injury, billing, activities, and feeding to be unsubstantiated based on statements and document reviews. However, the allegation that staff failed to provide showers to a resident as required by the care plan was substantiated, with documentation showing lack of showers from 8/16 to 8/31/2024. A deficiency was cited for failure to provide basic services including bathing, posing an immediate risk to the resident's health and personal rights.
Deficiencies (1)
Failure to provide showers to resident R1 from 8/16 thru 8/31/2024 as required by care plan, violating basic services regulations.
Report Facts
Capacity: 250
Census: 174
Deficiency Type A count: 1
Shower omission dates: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Carla Martinez | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 250
Deficiencies: 1
Date: Sep 17, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff were not providing laundry services to a resident and that meals were not served in a timely manner.
Complaint Details
The complaint investigation was based on allegations that staff were not providing laundry services and that meals were not served timely. The laundry service allegation was unsubstantiated, while the meal service allegation was substantiated based on resident interviews and administrator statements.
Findings
The laundry service allegation was unsubstantiated as observations and resident interviews confirmed clean clothing and satisfaction with laundry services. The meal service allegation was substantiated, with evidence that residents waited up to 2 hours for food service, though recent improvements were noted.
Deficiencies (1)
General Food Service Requirements. Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. Residents have waited up to 2 hours for food service in the dining room, posing an immediate violation of residents' rights.
Report Facts
Deficiencies cited: 1
Capacity: 250
Census: 143
Estimated Days of Completion: 3
Residents interviewed: 18
Residents reporting wait time: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Named in relation to the Plan of Correction and report management |
| Agustin Samaniego | Administrator | Interviewed regarding meal service delays and staffing |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 250
Deficiencies: 1
Date: Sep 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not giving residents showers, not assisting with oral hygiene, and not noticing a resident's change in condition.
Complaint Details
The complaint investigation was initiated based on allegations received on 07/26/2024. The first two allegations regarding showers and oral hygiene were unsubstantiated due to insufficient evidence. The third allegation regarding failure to notice a resident's change in condition was substantiated based on statements and documentation indicating staff did not observe the resident's fever and need for medical treatment.
Findings
The investigation found the allegations regarding showers and oral hygiene to be unsubstantiated due to lack of evidence. However, the allegation that staff failed to notice a resident's change in condition was substantiated, with evidence showing staff did not observe a resident's fever and need for medical attention, posing an immediate health risk.
Deficiencies (1)
Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. On 4/22/2024, staff did not note that R1 was feverish and required medical attention for UTI, posing an immediate risk to the health of R1.
Report Facts
Capacity: 250
Census: 143
Deficiencies cited: 1
Plan of Correction Due Date: Sep 9, 2024
Resident temperature: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Oversaw the complaint investigation process |
| Agustin Samaniego | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 250
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
An unannounced complaint investigation was conducted following allegations that a resident did not receive timely medical attention and that staff failed to follow infection control practices.
Complaint Details
The complaint was unsubstantiated due to lack of direct evidence and unidentified involved parties.
Findings
The investigation found no substantiated evidence to support the allegations. The complainant had no direct knowledge and the administrator reported no matching infection cases in the past six months. No citations were issued.
Report Facts
Capacity: 250
Census: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
Inspection Report
Follow-Up
Census: 142
Capacity: 250
Deficiencies: 1
Date: Aug 8, 2024
Visit Reason
The visit was an unannounced follow-up to investigate two incident reports involving medication errors where residents missed scheduled injections.
Findings
The inspection found that on July 22 and 23, 2024, two residents missed scheduled injections due to a nurse not showing up and med techs not notifying management. Additional training was provided to 17 staff members, and no apparent harm occurred to the residents.
Deficiencies (1)
Failure to administer physician-ordered injections to residents R1 and R2 on July 23 and July 24, posing an immediate risk to resident health.
Report Facts
Staff trained: 17
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Carla Martinez | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report. |
| Agustin Samaniego | Administrator | Facility Administrator involved in discussion of incidents. |
| Morgan Whinery | Person met with during the inspection. |
Inspection Report
Annual Inspection
Census: 148
Capacity: 250
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
The inspection was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care at the assisted living facility.
Findings
The facility was observed to be clean, in good repair, and odor-free with no immediate health, safety, or personal rights violations noted. However, three out of five staff files reviewed did not include first aid training, which was cited as a deficiency.
Deficiencies (1)
Three out of five staff records reviewed did not have first aid training, posing a potential health, safety, or personal rights risk to persons in care.
Report Facts
Staff files reviewed: 5
Staff files without first aid training: 3
Residents files reviewed: 5
Hot water temperature range (F): 105-120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaynae Boyles | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lauren Crocker | Licensing Program Manager | Supervisor of the inspection |
| Francine Taitano | Administrator Assistant | Met with Licensing Program Analyst during inspection |
| Agustin Samaniego | Administrator | Facility Administrator |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 250
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2023-09-26 regarding alleged rude behavior by staff towards a resident during hygiene care.
Complaint Details
The complaint alleged personal rights violation due to staff speaking rudely to a resident during hygiene care. The allegation was unsubstantiated after investigation.
Findings
The investigation found no preponderance of evidence to substantiate the allegation of rude behavior by staff towards the resident. Witnesses were interviewed, and the resident denied the allegation in private, resulting in the complaint being unsubstantiated with no citations issued.
Report Facts
Complaint Control Number: 21
Complaint Control Number Suffix: 20230926122904
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 106
Capacity: 250
Deficiencies: 1
Date: Oct 26, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on a substantiated complaint investigation regarding failure to seek timely medical care for a resident resulting in multiple injuries.
Complaint Details
The visit was complaint-related and substantiated. The complaint involved staff not seeking timely medical care for resident R1 after a fall, resulting in multiple injuries.
Findings
The investigation confirmed that staff delayed responding to a resident's call for help and failed to follow facility policy to seek medical treatment after a fall, resulting in serious bodily injury and hospitalization. A civil penalty was issued for the violation.
Deficiencies (1)
Failure to seek timely medical care for a resident after an unwitnessed fall and failure to report a change in condition when bruising developed.
Report Facts
Civil penalty amount: 9500
Response time: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agustin Samaniego | Administrator | Met during the visit and acknowledged receipt of appeal rights. |
| Dominic Tobola | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Kimberley Mota | Licensing Program Manager | Named in the report as Licensing Program Manager. |
| Nurse Practitioner (N1) | Reported on the resident's bruising and medical condition. |
Inspection Report
Follow-Up
Census: 106
Capacity: 250
Deficiencies: 0
Date: Oct 26, 2023
Visit Reason
The visit was an unannounced case management follow-up on a self-reported SOC341 Report of Suspected Abuse involving a resident observed engaging in inappropriate sexual behavior with two other residents.
Findings
The facility implemented additional supervision and increased activities for the residents involved. All families were notified, and appropriate reporting was timely submitted. A recent death report was also followed up with an ongoing police investigation. No deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agustin Samaniego | Administrator | Met during the visit and involved in reviewing interventions for resident behaviors. |
| Dominic Tobola | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Kimberley Mota | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 168
Capacity: 250
Deficiencies: 3
Date: Aug 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-06-14 regarding staffing adequacy, cleanliness, bathing assistance, medication administration, call response times, and facility repair.
Complaint Details
The complaint investigation was unannounced and conducted by Evaluator David Leibert. Allegations included inadequate staffing, unclean mattresses, lack of bathing assistance, medication administration issues, delayed call response, and facility disrepair. Some allegations were unsubstantiated due to insufficient evidence, while others were substantiated based on statements, documents, photographs, and observations. Civil penalties were issued for repeat and zero tolerance violations.
Findings
The investigation found some allegations unsubstantiated due to lack of preponderance of evidence, such as staffing adequacy and medication administration. However, other allegations were substantiated, including delayed staff response to resident calls, facility not being in good repair, loose medication on the floor, furniture blocking outdoor passageways, and electrical cords across beds posing immediate safety risks. Civil penalties totaling $750 were issued for repeat and zero tolerance violations.
Deficiencies (3)
Extension and assorted electrical cords were noted across the bed and pillows of residents, and loose medication was found on the floor and furniture of a resident's room, posing immediate health and safety risks.
Call response times for resident assistance were excessively delayed, with some calls taking over 3 hours, posing immediate risk to health and safety.
Furniture was observed blocking outdoor passageways in the Memory Care Unit, posing immediate risk to resident safety.
Report Facts
Civil penalty: 250
Civil penalty: 500
Call response times: 39.85
Call response times over 20 minutes: 8
Call response time: 69
Call response time: 215
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Named in relation to licensing program management and oversight |
| Agustin Samaniego | Administrator | Facility administrator named in the report |
Inspection Report
Census: 151
Capacity: 250
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
The inspection was conducted as a Case Management-Incident visit following a death report received by the Community Care Licensing (CCL) regarding a resident who passed away while transitioning to hospice care.
Findings
No deficiencies were observed or cited during this Case Management-Incident inspection. The resident's care plan had been updated prior to passing, and all appropriate parties were notified. The resident's private room was empty and belongings retrieved by the responsible party.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agustin Samaniego | Administrator | Met with Licensing Program Analyst during the inspection. |
| Francine Tatiano | Assistant Administrator | Participated in the Case Management-Incident inspection. |
| Lauren Cottman | Assistant Administrator | Participated in the Case Management-Incident inspection. |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident inspection. |
| Hope DeBenedetti | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 150
Capacity: 250
Deficiencies: 0
Date: May 15, 2023
Visit Reason
The inspection was an unannounced Case Management-Other visit to follow up on an Order of Immediate Exclusion letter issued on April 27, 2023.
Findings
The Assistant Executive Director confirmed that the Excluded Staff Member is not working, residing, or has ever worked at the facility. No deficiencies were observed or cited during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the unannounced Case Management-Other inspection. |
| Francine Taitano | Assistant Executive Director | Met with Licensing Program Analyst and confirmed status of Excluded Staff Member. |
| Augustin Samaniego | Prospective Administrator | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 250
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
The inspection was conducted as a Case Management-Incident visit following two incident reports received by the Community Care Licensing (CCL) regarding residents choking on food, one on April 9, 2023, and another on April 13, 2023.
Complaint Details
The visit was complaint-related due to two incident reports of residents choking on food. Resident #2 was unavailable for interview. No substantiation status was explicitly stated.
Findings
No deficiencies were observed or cited during this Case Management-Incident inspection. The Licensing Program Analyst reviewed relevant documents and conducted an exit interview with the Assistant Administrator.
Report Facts
Capacity: 250
Census: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Cottman | Assistant Administrator | Met during inspection and recipient of report copy |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection |
| Hope DeBenedetti | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 250
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-04-10 regarding staff ignoring residents, not meeting residents' care needs, and not providing toilet paper for residents.
Complaint Details
Complaint control number 21-AS-20230410131207 involved allegations that facility staff ignored residents, did not meet residents' care needs, and did not provide toilet paper. The findings were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found the allegations unsubstantiated as there was insufficient evidence to prove or disprove the claims. Observations and interviews showed residents engaged with staff and toilet paper was available in all resident rooms.
Report Facts
Capacity: 250
Census: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lauren Cottman | Assistant Administrator | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 250
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were not administering residents' medication as prescribed and that the facility did not have sufficient staff to meet residents' needs.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove or disprove the allegations that staff were not administering medication as prescribed and that there was insufficient staffing to meet residents' needs.
Findings
The investigation found that medication delivery delays were due to pharmacy issues and proper dispensing was resumed on March 1, 2023. The staff schedule and roster were found to be appropriate and up-to-date. The Licensing Program Analyst could not prove or disprove the allegations, resulting in the complaints being unsubstantiated.
Report Facts
Capacity: 250
Census: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Ramandeep Kaur | Administrator | Facility administrator mentioned in the report |
| Francine Taitano | Assistant Executive Director | Met with Licensing Program Analyst during investigation |
| Brittany Andrews | Executive Director | Participated in delivery of complaint findings |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 250
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 2023-02-14 regarding food service, personal rights, and physical plant issues including no heat in room and a leaking kitchen sink.
Complaint Details
Complaint allegations included food service, personal rights, and physical plant issues such as no heat in resident rooms and a leaking kitchen sink. The Licensing Program Analyst conducted multiple inspections and interviews but could not corroborate the allegations. The findings were unsubstantiated.
Findings
The investigation included interviews, record reviews, and facility tours. The allegations related to food service, personal rights, and physical plant issues were found to be unsubstantiated due to inconsistent statements and lack of corroborating evidence.
Report Facts
Complaint Control Number: 21-AS-20230214161618
Capacity: 250
Census: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Francine Taitano | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Brittany Andrews | Executive Director | Participated in delivery of complaint findings |
| Ramandeep Kaur | Administrator | Facility Administrator named in report header |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 155
Capacity: 250
Deficiencies: 1
Date: Apr 4, 2023
Visit Reason
The inspection was an unannounced Case Management-Deficiencies visit conducted to evaluate compliance related to resident safety and care.
Findings
The inspection found a deficiency related to safety measures for residents with dementia, specifically a resident who eloped from the facility without staff knowledge despite being unable to leave unassisted. A plan of correction was required.
Deficiencies (1)
Care of Persons with Dementia - Safety measures to address behaviors such as wandering were not met, evidenced by a resident eloping from the facility without staff knowledge.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the inspection |
| Lauren Cottman | Administrator | Facility administrator present during inspection |
| Francine Tattiano | Assistant Administrator | Facility assistant administrator present during inspection |
Inspection Report
Plan of Correction
Census: 87
Capacity: 250
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
The inspection was an unannounced Plan of Correction (POC) inspection conducted to review the facility's submitted Plan of Correction.
Findings
The Plan of Correction submitted was observed to be appropriate at the time of the inspection. No deficiencies were observed or cited during this Plan of Correction inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Plan of Correction inspection |
| Francine Tattiano | Assistant Administrator | Met with Licensing Program Analyst during inspection |
| Lauren Cottman | Assistant Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 250
Deficiencies: 3
Date: Feb 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-01-30 regarding staff response times to resident calls, staff training adequacy, and after-hours phone line responsiveness.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not respond timely to resident calls, staff training was inadequate, and after-hours phone calls were missed. The allegation that staff did not ensure residents' hygiene needs were met was unsubstantiated due to inconsistent statements and lack of evidence.
Findings
The investigation substantiated that staff did not respond to resident call pendants in a timely manner, staff training was inadequate for 10 staff members including the former Administrator, and after-hours phone calls were missed and not returned timely. One allegation regarding residents' hygiene needs was unsubstantiated due to inconsistent evidence.
Deficiencies (3)
Facility personnel were unable to respond to resident care needs and call buttons in a timely manner from January 20 through January 23, 2023, with multiple call buttons having response times of 20 minutes or longer and missing December 2022 call pendant logs.
Ten staff members including the former Administrator did not have the proper training hours necessary as required for dementia care staff.
Facility telephones, including the after-hours phone line, were not answered promptly; phone calls on January 20 and January 24, 2023 were missed and not returned timely.
Report Facts
Census: 150
Total Capacity: 250
Staff with inadequate training: 10
Call pendant response times: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Oversaw the complaint investigation |
| Ramandeep Kaur | Administrator | Facility Administrator named in relation to training deficiencies and complaint findings |
| Francine Taitano | Assistant Executive Director | Met with Licensing Program Analyst during inspection and involved in investigation |
Inspection Report
Complaint Investigation
Census: 149
Capacity: 250
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations regarding inadequate supervision resulting in injury and failure to seek timely medical attention.
Complaint Details
The complaint was unsubstantiated based on interviews and document review. Allegations included inadequate supervision and failure to seek timely medical attention. No citations were issued.
Findings
The investigation found that although the allegations may be true, there was not a preponderance of evidence to prove them true or untrue. Staff were aware of the resident's fall risk and checked on the resident, who was found injured after a fall. Staff called 911 and remained with the resident until paramedics arrived. The allegations were determined to be unsubstantiated.
Report Facts
Complaint Control Number: 21
Complaint Control Number Full: 21-AS-20220829163730
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and discussed findings. |
| Rammy Kaur | Met with the evaluator during the investigation. | |
| Josef Dunham | Administrator | Facility administrator named in the report header. |
| Carla Martinez | Licensing Program Manager | Named in report signature section. |
Inspection Report
Annual Inspection
Census: 152
Capacity: 250
Deficiencies: 1
Date: Dec 15, 2022
Visit Reason
The inspection was an unannounced required 1-year annual inspection of the Village at Rancho Solano Assisted Living facility to assess compliance with regulatory standards.
Findings
The facility was found to be generally clean and safe with proper maintenance of exits, pathways, and fire extinguishers. However, the elevators were last inspected in 2019 and had expired inspection certificates, posing a potential safety risk. The facility is currently on a Fire Watch plan due to a non-functioning fire alarm system. Staff have received PPE training but have not been recertified for N95 fit testing.
Deficiencies (1)
Failure to comply with elevator inspection requirements; 3 out of 3 elevators were last inspected on August 9, 2019 with an expiration of August 9, 2020, posing potential health, safety, or personal rights risks.
Report Facts
Elevators inspected: 3
Capacity: 250
Census: 152
POC Due Date: Jan 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ramandeep Kaur | Administrator | Met with Licensing Program Analyst during inspection and involved in facility operations |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 150
Capacity: 250
Deficiencies: 1
Date: Nov 21, 2022
Visit Reason
The inspection was an unannounced Case Management - Other visit conducted to evaluate the facility, including a fire safety review of the Memory Care Unit on the second floor.
Findings
The Fire Alarm system was completely inoperable, and the fire clearance for the second floor Memory Care Unit was denied. Residents were observed residing in the unit without approved fire clearance, resulting in deficiencies and a civil penalty citation.
Deficiencies (1)
Fire clearance was not approved due to the Fire Alarm system being inoperable during the inspection, and residents were observed in the Memory Care Unit without approved fire clearance.
Report Facts
Residents observed in Memory Care Unit without fire clearance: 16
Residents observed in Memory Care Unit without fire clearance: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ramandeep Kaur | Administrator | Met with Licensing Program Analyst and Fire Inspector during inspection |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and signed the report |
| Bryan Just | Fairfield Fire Department Inspector | Conducted fire safety inspection and identified fire alarm system deficiency |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 250
Deficiencies: 1
Date: Nov 18, 2022
Visit Reason
The inspection was conducted as a Case Management-Incident visit regarding a medication error reported on November 9, 2022, where a resident was over-medicated on insulin due to a nurse not checking the Medication Assessment Record.
Complaint Details
The visit was triggered by a complaint regarding a medication error. The error was substantiated as the nurse over-medicated a resident on insulin due to not checking the Medication Assessment Record. Responsible party and prescribing physician were notified.
Findings
The facility nurse over-medicated a resident on insulin, posing an immediate health, safety, and personal rights risk to residents. Deficiencies were cited under California Code of Regulations Title 22, Division 6, Chapter 8, and the Health and Safety Code.
Deficiencies (1)
Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by a nurse over-medicating a resident on insulin.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Nov 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ramandeep Kaur | Administrator | Met with Licensing Program Analyst during inspection and involved in interview regarding medication error |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 250
Deficiencies: 1
Date: Nov 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the licensee did not maintain the facility free from hazard.
Complaint Details
The complaint was substantiated. The allegation was that the licensee did not maintain the facility free from hazard, specifically related to uneven flooring caused by a metal plate which resulted in a resident fall and fracture.
Findings
The investigation substantiated that a metal plate causing uneven flooring was present on November 7, 2022, which led to a resident falling and sustaining a fracture. The deficiency was corrected by the time of the November 18, 2022 visit, with the metal plate removed and the floor aligned.
Deficiencies (1)
87303(a) Maintenance and Operation: The facility was not clean, safe, sanitary and in good repair due to the presence of a metal plate causing uneven flooring, posing a potential health, safety and personal rights risk to residents.
Report Facts
Capacity: 250
Census: 150
Deficiency Type: 1
Plan of Correction Due Date: Nov 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Hope DeBenedetti | Licensing Program Manager | Oversaw the complaint investigation report |
| Ramandeep Kaur | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 250
Deficiencies: 0
Date: Nov 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was in disrepair, specifically concerning a door.
Complaint Details
The complaint alleged that the facility was in disrepair (door). The allegation was found to be unsubstantiated after investigation and interviews with the Administrator and Maintenance Director.
Findings
The investigation found the facility to be clean and all exits unobstructed. The door leading into Memory Care was fixed appropriately and in a timely manner. The complaint allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 250
Census: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation |
| Ramandeep Kaur | Administrator | Facility Administrator interviewed during investigation |
| Kyle Benavidez | Maintenance Director | Accompanied the Licensing Program Analyst during facility tour |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 153
Capacity: 250
Deficiencies: 3
Date: Oct 25, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 07/12/2022 concerning neglect, staff conduct, food service, hygiene, and mask compliance at the facility.
Complaint Details
The complaint investigation was unannounced and conducted by Evaluator David Leibert. Allegations included neglect resulting in fractures, staff pushing resident, falsified incident reports, inadequate food service, hygiene neglect, and mask non-compliance. The initial allegations were unsubstantiated. A separate complaint about cleanliness, rent notice, and linen changes was substantiated with deficiencies cited.
Findings
The investigation found the initial allegations of neglect, pushing, falsified reports, inadequate food service, hygiene neglect, and mask non-compliance to be unsubstantiated due to lack of preponderance of evidence. However, a separate complaint regarding unclean resident rooms, failure to provide proper rent increase notice, and inadequate linen changes was substantiated with deficiencies cited.
Deficiencies (3)
R1’s room was observed to be dirty from feces, including floor and bedding, posing an immediate risk to resident health.
Facility failed to provide notice of fee increase to R1 as specified in the Admission Agreement, posing a potential risk to personal rights.
R1 has not been provided adequate clean linens, posing a potential risk to resident health.
Report Facts
Capacity: 250
Census: 153
Deficiencies cited: 3
Refund amount: 11000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Evaluator | Conducted the complaint investigation and made findings |
| Josef Dunham | Administrator | Facility administrator named in the report |
| Pam Hardesty | Met with evaluator during the investigation | |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 156
Capacity: 250
Deficiencies: 6
Date: Sep 16, 2022
Visit Reason
The visit was an unannounced case management inspection conducted to close a complaint investigation and to review related deficiencies observed during the investigation.
Complaint Details
The visit was conducted to close a complaint investigation regarding delayed call bell responses and other related deficiencies. The complaint was substantiated with findings of delayed alarm responses and multiple regulatory violations.
Findings
The inspection found multiple deficiencies including delayed response to call bell alarms, lack of updated care plans for residents, insufficient staff training and certification, staff not associated with the facility, missing criminal record clearances, and failure to conduct timely resident reappraisals.
Deficiencies (6)
Facility alarm system calls were not answered timely, with 22% answered in 10-29 minutes and 9.6% taking 30 minutes to over an hour.
Four out of four resident files lacked updated care plans as required by Title 22 Regulations.
One out of three staff did not have fingerprint clearance and was not associated with the facility, posing immediate health and safety risks.
Three out of three staff files lacked proof of required training including medication training, CPR, and first aid certifications.
Three out of three staff had no proof of CPR and first aid certification, and no staff with CPR was on premises on 2/17/22.
Four out of four residents had no reappraisals or reappraisals were overdue by more than 12 months.
Report Facts
Residents present: 156
Total licensed capacity: 250
Percentage of calls answered in 10-29 minutes: 22
Percentage of calls answered in 30 minutes to 1 hour 18 minutes: 9.6
Number of assisted living residents on 2/17/2022: 102
Civil penalty amount: 200
Number of staff files reviewed lacking training: 3
Number of residents without updated care plans: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Blaine Lyons | Acting Executive Director | Met during inspection and provided information about staffing |
| Josef Dunham | Administrator | Facility administrator named in report header |
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted inspection and authored report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Complaint Investigation
Census: 156
Capacity: 250
Deficiencies: 0
Date: Sep 16, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations that staff left residents unattended and did not respond to call bells in a timely manner.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred. The investigation included multiple visits, interviews, and documentation review. Records showed delayed response times to call bells and a resident left unattended for 49 minutes, but evidence was insufficient to confirm violations.
Findings
The investigation found that although call bell alarms were not answered timely and there was a period with only one staff on duty, there was insufficient evidence to prove or disprove the allegations. Therefore, the complaint was unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 250
Census: 156
Call bell response times: 22
Call bell response times: 9.6
Wait time: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Fernandes-Goes | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Blaine Lyons | Acting Executive Director | Met with during investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
| Jillian Hunter | Acting Executive Director | Provided email regarding staffing on 2/25/2022 |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 250
Deficiencies: 1
Date: Sep 2, 2022
Visit Reason
The visit was an unannounced case management inspection related to an incident report submitted by the facility regarding a medication error that occurred on 08/13/2022.
Complaint Details
The visit was triggered by a complaint/incident report regarding a medication error. The violation was substantiated, and a civil penalty was issued.
Findings
The facility staff administered the wrong medication to a resident, which was identified as an immediate health and safety risk. The facility contacted the primary care physician and responsible party, and the resident was placed on alert charting with no side effects reported. A civil penalty of $250 was issued for this repeated violation within a 12-month period.
Deficiencies (1)
The licensee failed to assist residents with self-administered medications as needed, evidenced by a staff member administering the wrong medication to a resident.
Report Facts
Civil penalty amount: 250
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francine Taitano | Assistant Executive Director | Met with Licensing Program Analyst during the visit and reviewed records. |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Bethany Moellers | Licensing Program Manager | Named as supervisor and licensing program manager in the report. |
Inspection Report
Follow-Up
Census: 155
Capacity: 250
Deficiencies: 1
Date: Aug 25, 2022
Visit Reason
The visit was an unannounced Plan of Correction (POC) follow-up to verify correction of a previously cited deficiency regarding a non-functional door to the Memory Care Program entrance.
Findings
The door to the Memory Care Program entrance remained non-functional at the time of the visit. The facility is in the process of repairs and switching to a new security system. A civil penalty of $200 was issued for failure to correct the deficiency.
Deficiencies (1)
Non-functional door to the entrance to the Memory Care Program
Report Facts
Civil Penalty Amount: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Blaine Lyons | Acting Administrator | Met with Licensing Program Analyst during the visit and discussed repair status |
| David Leibert | Licensing Program Analyst | Conducted the unannounced POC visit and issued the civil penalty |
| Carla Martinez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 250
Deficiencies: 1
Date: Aug 9, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation due to the main entrance door to the Memory Care Unit not functioning, requiring staff and visitors to enter through the dining room entrance.
Complaint Details
The visit was complaint-related, investigating the non-functioning main entrance door to the Memory Care Unit. The deficiency was substantiated as the door was under repair and non-functional for at least four months.
Findings
The main entrance door to the Memory Care Unit had not been functioning properly for at least four months due to electrical problems, posing a potential risk to resident safety. Deficiencies related to maintenance and operation were cited.
Deficiencies (1)
Main entrance door to Memory Care facility has not been functioning properly for at least 4 months, posing a potential risk to the safety of the residents.
Report Facts
Capacity: 250
Census: 155
Deficiency Type Count: 1
Plan of Correction Due Date: Due date for Plan of Correction is 08/23/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Named in relation to the complaint investigation and deficiency observation |
| Carla Martinez | Licensing Program Manager | Named as supervisor and licensing program manager |
| Josef Dunham | Administrator | Facility administrator mentioned in report header |
Inspection Report
Follow-Up
Census: 152
Capacity: 250
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
The visit was an unannounced follow-up on an incident report regarding a medication error that occurred on July 12, 2022, at the Village at Rancho Solano Assisted Living.
Complaint Details
The visit was triggered by an incident report of a medication error involving Resident #1 on July 12, 2022. The Responsible Party and prescribing doctor were notified. The medication error was substantiated.
Findings
The inspection found that a staff member administered the wrong dosage of medication to Resident #1, which posed an immediate health and safety risk. Deficiencies were cited under California Code of Regulations Title 22 and the Health and Safety Code.
Deficiencies (1)
The licensee failed to assist residents with self-administered medications as needed, resulting in a medication error where the wrong dosage was administered to Resident #1 on July 12, 2022.
Report Facts
Capacity: 250
Census: 152
Plan of Correction Due Date: Aug 10, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Josef Dunham | Administrator | Met with Licensing Program Analyst during the inspection and interviewed regarding medication error |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Hope DeBenedetti | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Capacity: 250
Deficiencies: 0
Date: Apr 21, 2022
Visit Reason
The visit was an unannounced Case Management visit to follow up on two special incident reports involving residents and to check on the status of the Change of Administrator.
Findings
No deficiencies were cited during this inspection. Follow-up was conducted on two incidents involving residents, including one with self-harm attempts and another involving inappropriate caregiver behavior. The facility is arranging re-evaluation and has removed the implicated caregiver. The Change of Administrator paperwork is pending submission.
Report Facts
Capacity: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karina Loera Medina | Resident Care Coordinator | Named in relation to resident incident follow-up |
| Blaine Lyons | Facility Representative / Incoming Administrator | Met during visit and mentioned as incoming Administrator |
| Pamela Hardesty | Facility representative met during visit | |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection visit |
| Kimberley Mota | Licensing Program Manager | Named in report header |
Inspection Report
Census: 149
Capacity: 250
Deficiencies: 0
Date: Apr 11, 2022
Visit Reason
Licensing Program Analysts conducted an unannounced Case Management inspection and followed up on the status of the Change of Administrator and a self-reported incident involving missing resident items.
Findings
No deficiencies were cited during this inspection. The facility agreed to reimburse a resident for any missing items that could not be located, and a police report was filed regarding the incident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hardesty | Regional VP of Operations | Met with Licensing Program Analysts during the inspection. |
| Tommy Saxson | Met with Licensing Program Analysts during the inspection. |
Inspection Report
Census: 149
Capacity: 250
Deficiencies: 1
Date: Apr 6, 2022
Visit Reason
The visit was an unannounced Case Management review conducted by Licensing Program Analysts to follow up on an incident where a resident eloped from the facility unassisted and to review the current situation regarding a Change of Administrator.
Findings
The report found that a resident who was unable to leave the facility unassisted eloped, posing an immediate health and safety risk. Additionally, there were delays and ongoing changes related to the facility's Administrator position.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met based on document review showing that a resident who was unable to leave facility unassisted eloped the facility, posing an immediate health and safety risk to residents.
Report Facts
Capacity: 250
Census: 149
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberley Mota | Licensing Program Manager | Named as Licensing Program Manager and Supervisor in the report |
| Caitlynn Felias | Licensing Program Analyst | Conducted the inspection and signed the report |
| Blaine Lyons | Facility Representative | Met with Licensing Program Analysts during the visit |
Inspection Report
Census: 147
Capacity: 250
Deficiencies: 0
Date: Mar 16, 2022
Visit Reason
The visit was an unannounced Case Management - Incident Visit conducted to review incidents involving residents, including an elopement and a complaint about outside medical services.
Findings
The investigation found that Resident R1 eloped but was not diagnosed with dementia or wandering behavior and was moved to a higher level of care after reassessment. Resident R2 reported pain and discomfort during outside medical services, which led to a police investigation and changes in service provision. No deficiencies were cited during this visit.
Report Facts
Capacity: 250
Census: 147
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jillian Hunter | Acting Administrator | Met with Licensing Program Analysts during the visit and provided information about incidents and change of administrator |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 250
Deficiencies: 1
Date: Mar 16, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to allegations of neglect/lack of care including failure to call emergency services when a resident sustained fractures and failure to follow reporting requirements.
Complaint Details
The complaint investigation was substantiated for neglect/lack of care related to failure to call emergency services after a resident sustained fractures. The complaint regarding failure to call emergency services when a resident passed away and failure to follow reporting requirements was unsubstantiated.
Findings
The complaint that staff did not call emergency services when a resident sustained fractures was substantiated, resulting in an immediate civil penalty of $500. The complaint that staff failed to call emergency services when a resident passed away and failed to follow reporting requirements was found to be unsubstantiated.
Deficiencies (1)
Failure to immediately telephone 9-1-1 when an injury or other circumstance resulted in an imminent threat to a resident’s health, including complaints of pain and inability to walk.
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Plan of Correction due date: POC due date March 17, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Willis | Licensing Program Analyst | Conducted the complaint investigation and signed the report. |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Jillian Hunter | Acting Administrator/Executive Director | Met with Licensing Program Analysts during the investigation. |
Inspection Report
Annual Inspection
Census: 141
Capacity: 250
Deficiencies: 1
Date: Feb 25, 2022
Visit Reason
The inspection was an unannounced annual required inspection focused on infection control procedures and practices at the assisted living facility.
Findings
The facility had COVID-19 and face mask posters, hand sanitizer available, staff wearing masks, and housekeeping working 7 days a week. However, a deficiency was cited for failure to retain original records or photographic reproductions for a minimum of three years, posing a potential health and safety risk.
Deficiencies (1)
Facility did not have the available record when requested by CCL, violating the requirement to retain original records or photographic reproductions for a minimum of three years following termination of service to the resident.
Report Facts
Deficiency due date: Mar 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jillian Hunter | Acting Administrator | Met with Licensing Program Analysts during inspection and discussed infection control practices |
| Tommy Saxon | Administrator | Current Administrator until Acting Administrator receives their Administrator Certificate; documents requested for him |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 250
Deficiencies: 2
Date: Feb 24, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff did not seek timely medical care for a resident and neglect/lack of supervision resulting in the resident sustaining multiple injuries.
Complaint Details
The complaint was substantiated based on interviews, medical record reviews, and observations. Staff did not respond timely to a fall incident and failed to call 911 as required. Staff also failed to document and report pressure injuries and bruising on the resident. The preponderance of evidence standard was met.
Findings
The investigation substantiated the allegations that staff failed to seek timely medical care for Resident R1 after a fall and neglected to properly observe and report injuries including bruising and pressure injuries. An immediate civil penalty of $500 was assessed for the violation resulting in resident injury.
Deficiencies (2)
Failure to provide care, supervision, and services that meet individual needs, including timely medical care for resident R1.
Failure to observe and document changes in resident condition, including bruising and pressure injuries on resident R1.
Report Facts
Civil penalty amount: 500
Capacity: 250
Census: 141
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Willis | Licensing Program Analyst | Conducted the complaint investigation and signed the report. |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Jillian Hunter | Acting Administrator | Met with investigators during the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 250
Deficiencies: 0
Date: Feb 17, 2022
Visit Reason
Unannounced visit/investigation of a complaint received on 2022-01-11 regarding allegations of rough handling of a resident and neglect/lack of supervision resulting in an unwitnessed fall.
Complaint Details
Complaint was unsubstantiated based on interviews and document review; no citations were issued.
Findings
The investigation found that the resident had sustained injuries and bruising from multiple falls and has medical conditions putting them at high risk for falls. Facility records showed fall protocols were followed, and no witnesses to rough handling were identified. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager on report |
| Jillian Hunter | Met with during the investigation | |
| Noma Malik | Administrator | Facility administrator named in report |
Inspection Report
Capacity: 250
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
The visit was a case management incident following a self-reported theft of money from a resident's room between 10/02 and 10/04, with an amount between $1000 and $1700 reported stolen.
Findings
No citations for deficiencies were issued at this time. The facility held a Town Hall Meeting to caution residents about theft and loss, offered lock boxes for residents, and reviewed the theft and loss policy. Police and Ombudsman were notified.
Report Facts
Amount stolen: 1000
Amount stolen: 1700
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Met with facility staff for case management |
| Kayla Young | Assistant Executive Director | Met with Licensing Program Analyst for case management |
| Meri Vejar | Regional Director of Health and Wellness | Met with Licensing Program Analyst for case management |
| Kelli Roe | Operations Coordinator | Met with Licensing Program Analyst for case management |
| Blaine Lyons | Operations Specialist | Notified Police Department and Ombudsman about theft |
Inspection Report
Census: 145
Capacity: 250
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
The visit was a case management incident visit conducted due to a self-injury attempt by a resident (R1) reported by the facility.
Findings
The facility reported that resident R1 attempted self-injury and was found with a stocking tied to the neck and the grab bar in the bathroom. Emergency services were contacted and R1 was hospitalized. No deficiencies or citations were issued at this time.
Report Facts
Capacity: 250
Census: 145
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Nakagawa | Licensing Program Analyst | Conducted the case management visit |
| Kayla Young | Assistant Executive Director | Met with Licensing Program Analyst during the visit |
| Kelli Roe | Operations Coordinator | Met with Licensing Program Analyst during the visit |
| Meri Vejar | Regional Director of Health and Wellness | Met with Licensing Program Analyst and interviewed regarding the incident |
Inspection Report
Follow-Up
Census: 140
Capacity: 250
Deficiencies: 0
Date: Sep 29, 2021
Visit Reason
The inspection was an unannounced Case Management - Incident visit to follow up on a self-reported incident involving a resident's fall with injury.
Findings
The facility reported the fall incident and subsequent investigation, including contacting emergency services, responsible parties, and authorities. No deficiencies were cited during this inspection.
Report Facts
Capacity: 250
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Young | Assistant Executive Director | Met with Licensing Program Analyst during inspection and provided statements |
| Karen Lopez | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 250
Deficiencies: 2
Date: Sep 23, 2021
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that staff did not attend to a resident's pendant call in a timely manner and that the facility did not notify the licensing agency of the resident's incident.
Complaint Details
The complaint was substantiated based on statements, documents, and photographs. The resident experienced a delayed emergency response of over 30 minutes and the facility failed to timely report the serious injury fall to the licensing agency.
Findings
The investigation substantiated the allegations, finding that a resident suffered an unwitnessed fall and staff response to the emergency call was delayed over 30 minutes, which violated the residence care agreement. The facility also failed to report the serious injury incident to the licensing agency in a timely manner. A civil penalty of $250 was issued for a repeat violation within 12 months.
Deficiencies (2)
Failure to provide timely resident assistance as evidenced by call button logs, posing an immediate health and safety risk.
Failure to report serious injury to the Department within 7 days as required, posing an immediate risk to resident health and safety.
Report Facts
Civil penalty amount: 250
Resident census: 138
Facility capacity: 250
Response time: 35.8
Number of responses exceeding 30 minutes: 27
Number of responses exceeding 50 minutes: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Noma Malik | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 135
Capacity: 250
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
The inspection was an unannounced case management visit to follow up on current construction in the facility and to address Administrator questions regarding residents.
Findings
A few potential hazards were noted and addressed during the inspection. No deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noma Malik | Administrator | Met during inspection and involved in follow-up on construction and resident questions. |
Inspection Report
Follow-Up
Census: 140
Capacity: 250
Deficiencies: 0
Date: Sep 10, 2021
Visit Reason
The inspection was an unannounced case management visit to follow up on multiple self-reported incident reports submitted to Community Care Licensing, including a resident death, missing money, and a fall with injury.
Findings
During the visit, Licensing Program Analyst Lopez reviewed documents and took statements related to the incidents. No deficiencies were cited during this inspection.
Report Facts
Capacity: 250
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noma Malik | Administrator | Met with Licensing Program Analyst during inspection and involved in incident investigations |
| Kayla Young | Assistant Director | Given consent to sign report during Administrator's absence |
| Karen Lopez | Licensing Program Analyst | Conducted the inspection and gathered records and statements |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 250
Deficiencies: 1
Date: Aug 23, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations received on 07/07/2021 regarding the quality of food and availability of hot water for residents at the facility.
Complaint Details
Two complaints were investigated: 1) Food quality alleged to be poor and difficult to chew for a resident; this was unsubstantiated. 2) Lack of hot water for residents over an extended period; this was substantiated based on statements, records, and resident council meeting notes.
Findings
The complaint regarding food quality was unsubstantiated after review of records, witness statements, and food sampling. However, the complaint about insufficient hot water was substantiated, with evidence showing residents experienced lack of hot water during May and June 2021, posing an immediate risk to health and welfare.
Deficiencies (1)
87303e(2) Maintenance and Operation. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Hot water not available to residents for periods during the months of May and June, 2021, posing an immediate risk to health and welfare.
Report Facts
Capacity: 250
Census: 145
Deficiency count: 1
Plan of Correction Due Date: Sep 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Named in relation to the licensing program management and oversight |
| James Hall | Administrator | Facility administrator named in the report |
| Noma Malik | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 250
Deficiencies: 2
Date: Aug 23, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/22/2021 regarding foul odor, improper food preparation, and untimely food service at the facility.
Complaint Details
The complaint investigation was unannounced and based on allegations of foul odor, improper food preparation, and untimely food service. The initial allegations were unsubstantiated. A separate complaint about insect infestation, facility disrepair, unlabeled food, and unclean food storage areas was substantiated.
Findings
The investigation found no evidence to substantiate the allegations of foul odor or improper food preparation and untimely food service, resulting in an unsubstantiated finding for those complaints. However, a separate complaint regarding insect infestation, facility disrepair, unlabeled food, and unclean food storage areas was substantiated with observed deficiencies in kitchen cleanliness and food storage practices.
Deficiencies (2)
Kitchen floor, food storage areas and carts were observed in a dirty state, posing an immediate risk to resident health.
Opened food observed stored without labels or dates, posing an immediate risk to resident health.
Report Facts
Capacity: 250
Census: 145
Deficiencies cited: 2
Plan of Correction Due Dates: Type A deficiency due date 08/23/2021, Type B deficiency due date 09/06/2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| James Hall | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 250
Deficiencies: 2
Date: Aug 10, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit following complaints received on 07/02/2021 regarding mold, lack of showers, urine odors, a stomach outbreak, insufficient administrator presence, pests, and inadequate incontinence care at the facility.
Complaint Details
The complaint investigation was triggered by multiple allegations including mold, lack of showers, urine odors, stomach illness outbreak, insufficient administrator presence, pests, and inadequate incontinence care. The mold, shower, urine odor, stomach illness, and administrator presence allegations were unsubstantiated. The pest and incontinence care allegations were substantiated.
Findings
The investigation found no evidence of mold, urine odors, or lack of showers, and the stomach outbreak was reported and source unknown, resulting in unsubstantiated allegations for those complaints. However, the allegations of pests and inadequate incontinence care were substantiated, with evidence of ongoing rodent problems and residents waiting up to two hours for incontinence assistance.
Deficiencies (2)
Managed Incontinence: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence was not met, as a resident reported waiting up to 2 hours for assistance.
General Food Service Requirements: Kitchen areas were not kept clean and free of litter, rodents, vermin, and insects, with ongoing rodent problems reported.
Report Facts
Resident census: 140
Total capacity: 250
Shower logs reviewed: 40
Bed bug cases: 3
Scabies cases: 2
Plan of Correction due date: Aug 13, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Oversaw the complaint investigation |
| James Hall | Administrator | Facility administrator mentioned in relation to allegations about presence and management |
| Kayla Young | Assistant Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Census: 135
Capacity: 250
Deficiencies: 0
Date: Aug 4, 2021
Visit Reason
The visit was an unannounced case management inspection to evaluate completed renovations at the facility, specifically the conversion of assisted living apartments to memory care support.
Findings
The inspection found that 8 of 26 rooms require additional time to complete but can be secured from resident access. Water temperatures and carbon monoxide detectors were within regulation and working order. The fire sprinkler system was undergoing its annual inspection, and the renovated section was approved for delayed egress and ready for resident use. No citations were issued.
Report Facts
Rooms requiring additional time to complete: 8
Water temperature range: 105
Water temperature range: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noma Malik | Executive Director | Met with Licensing Program Analyst during inspection |
| Christopher Arnhold | Licensing Program Analyst | Conducted the case management visit |
| Bethany Moellers | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 250
Deficiencies: 1
Date: Jul 29, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-06-11 regarding residents being locked in the facility and not treated with dignity and respect, as well as facility disrepair.
Complaint Details
The complaint investigation was triggered by allegations received on 2021-06-11 that residents were locked in the facility and not treated with dignity and respect. These allegations were unsubstantiated. A separate allegation that the facility was in disrepair was substantiated based on site visit observations.
Findings
The allegations that residents were locked in the facility and not treated with dignity and respect were found to be unsubstantiated due to lack of preponderance of evidence. However, the allegation that the facility is in disrepair was substantiated based on observations of dirty kitchen equipment, broken appliances, and other maintenance issues posing immediate risk to residents.
Deficiencies (1)
On or about July 07, 2021, the kitchen was observed to contain dirty cold and hot wells, grill with old food under grates, and inoperable and broken appliances posing an immediate risk to the health of residents.
Report Facts
Facility capacity: 250
Census: 140
Deficiency count: 1
Plan of Correction due date: Aug 2, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kayla Young | Assistant Director | Met with Licensing Program Analyst during investigation |
| James Hall | Administrator | Facility administrator named in the report |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 250
Deficiencies: 1
Date: May 3, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-04-14 regarding facility staff not responding to a resident's call for help.
Complaint Details
The complaint alleged that facility staff did not respond to a resident's call for help. The allegation was substantiated based on interviews, document reviews, and witness statements. Another allegation regarding insufficient front desk staffing was unsubstantiated.
Findings
The investigation substantiated that on or about April 13, 2021, a resident called the front desk following a fall but did not receive timely assistance for approximately 20 to 30 minutes. The front desk staff failed to respond promptly, posing an immediate risk to the resident's safety and health. Disciplinary action was taken against the staff involved, and a plan of correction was required.
Deficiencies (1)
Front desk staff did not respond to resident's call for help in a timely way following a fall, posing an immediate risk to safety and health of resident in care.
Report Facts
Capacity: 250
Census: 133
Deficiencies cited: 1
Plan of Correction Due Date: May 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kayla Young | Assistant Administrator | Met with Licensing Program Analyst during investigation and involved in findings |
| James Hall | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 250
Capacity: 250
Deficiencies: 1
Date: Nov 3, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not responding to residents' pendents in a timely manner and that staff were not showering residents.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not responding to residents' pendents in a timely manner, with evidence from call logs showing response times of 20-30 minutes 319 times, 30 or more minutes 241 times, and no response 281 times between March 25 and April 14, 2020. The allegation that staff were not showering residents was unsubstantiated.
Findings
The allegation regarding delayed response to residents' pendents was substantiated based on call log reviews showing numerous delayed or no responses, posing an immediate health and safety risk. The allegation regarding staff not showering residents was found to be unsubstantiated based on documentation and interviews.
Deficiencies (1)
Failure to follow program plan as shown by call button logs, posing an immediate health and safety risk for residents in care.
Report Facts
Response times 20-30 minutes: 319
Response times 30 or more minutes: 241
No response recorded: 281
Facility capacity: 250
Census: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Hall | Executive Director | Met with Licensing Program Analyst during investigation and named in findings delivery |
| Christopher Arnhold | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
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