California · Covina

Park View Place.

RCFE · Memory Care142 bedsDementia-trained staff
Park View Place
Park View Place — photo 2
Park View Place — photo 3
Park View Place — photo 4
© Google · Park View Place Senior Living
Facility · Covina
A 142-bed RCFE · Memory Care with 3 citations on file.
Licensed beds
142
Last inspection
Aug 2025
Last citation
Feb 2025
Operated by
Oakmont of Covina Llc;wellquest Living Llc
Snapshot

A large home, reviewed on public record.

Peer Comparison

Compared to 93 California facilities with a similar number of beds.

RCFE memory care · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.

Severity rank
59th%
Weighted citations per bed.
peer median
0
100
Repeat rank
Not enough repeat citations
among peers to rank.
Repeat deficiencies as share of total.
Frequency rank
50th%
Deficiencies per inspection.
peer median
0
100

Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.

FACILITY WATCH · BETA

Park View Place has 3 citations on record. Know the moment anything changes.

New findings, complaint investigations, or status changes — emailed to you free.

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The Rulebook

The rules that apply to this facility.

State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.

What dementia-care training must staff complete?22 CCR §87705 / HSC §1569.625
+
Plain language

Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.

Ask on tour

Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?

Tour Prep

Questions to ask before you visit.

A short pre-tour checklist tailored to Park View Place's record and state requirements.

01 /

The facility has 1 serious citation on file across all inspections — can you provide your corrective-action plan for the cited item, and show families any documentation of remediation steps taken?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

02 /

10 complaints are on file with CDSS — were any substantiated, and what remediation did the facility take in response to substantiated findings?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

03 /

The most recent inspection occurred on August 19, 2025 — can you provide families with a copy of the deficiency notice from that visit and walk through any corrective actions completed since then?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

Full Inspection Record

Every inspection visit, verbatim.

13 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.

13
reports on file
3
total deficiencies
1
severe (Type A)
2026-03-12
Complaint Investigation
Unsubstantiated
No findings
Inspector · Sanjay Vaid

Plain-language summary

A complaint investigation found no evidence of four allegations: that staff failed to notify residents of rate increases, did not meet dietary needs, did not provide timely incontinence care, or spoke inappropriately to residents. Staff, residents, and family members interviewed either denied the allegations or stated that services were provided as required, and the investigator determined there was insufficient evidence to substantiate any of the claims.

Read raw inspector notes

Regarding the allegation: Facility staff did not provide required notice of rate increase. It is alleged that the facility staff is not providing required notice of rate increase to residents. Five of five staff interviewed denied this allegation. According to staff the increase to the rate is delivered to self-responsible residents and residents’ Power of Attorney(POA) by the information on file. R1 and R2’s rate of increase is delivered to R1 and R2’s family. LPA Vaid’s conversation with R1’s POA confirmed delivery of notice of yearly rental increase for R1. W1 stated that R2 is not familiar with payment of the facility dues, W1 stated the family is given 60-day notice of the yearly rate increases for R1. Eight of ten residents could not corroborate this allegation, five of ten stated their family handles their finances and is communicated the rate increases, six of ten residents stated they are given 60 days’ notice for the yearly rate increase. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Facility staff did not meet dietary needs of residents. It is alleged that staff are not meeting residents’ dietary needs by not delivering breakfast on time to residents’ room and meal portions are small. Five of five staff deny this allegation; residents are encouraged to eat meals in the dining room to promote socialization amongst the residents. A delivery charge is assessed for meals deliveries to residents’ rooms; delivery charge is not assessed for residents with serious medical conditions who cannot attend dining room meals. Seven of ten residents could not corroborate this allegation, residents stated they have the correct meals served according to their health and dietary plans, meal sizes are reasonable. Three of ten residents stated they have requested and received extra portions of meals. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUED ON 9099C............................. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation: Facility staff did not meet incontinence care needs of resident. It is alleged that the staff is not meeting residents’ incontinent needs, staff left R1 in soiled diaper for 24-hours. Five of five staff deny this allegation, staff stated residents with incontinent needs are periodically checked throughout each shift by caregivers to ensure residents are dry and comfortable in their briefs. Seven of ten residents could not corroborate this allegation, residents interviewed don’t have incontinent needs. Two of ten residents stated staff checks on them periodically throughout the day. Their incontinent needs are met daily, two of ten residents stated being checked on very 2-hours due of over active health issue. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Facility staff spoke inappropriately to resident. It is alleged that staff spoke inappropriately to resident, and resident observed staff speaking rudely and making a resident cry. Five of five staff interviewed deny this allegation, staff stated they are respectful of the residents in memory care and assisted living and treat all residents with dignity and respect. Staff stated they do not speak about residents’ issues in public, rather meet in private and discuss issues with the residents and their families. R3 denied having a confrontation with S1 over past issue. Seven of ten residents could not corroborate this allegation; residents stated the staff does not speak to them in a rude or inappropriate manner and residents stated never having witnessed staff making residents feel sad. Residents stated staff is cheerful and helpful. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was held and copy of investigation report was provided to Administrator, LeeAnn Hefner.

2026-01-26
Complaint Investigation
Unsubstantiated
No findings
Inspector · Sanjay Vaid

Plain-language summary

A complaint investigation looked into four allegations: that staff did not respond timely to resident calls for help, that families were not notified of fee increases, that staff did not treat residents with dignity and respect, and that resident rooms were not kept clean and sanitary. All four allegations were found to be unsubstantiated—staff and most residents interviewed either denied the allegations or could not confirm them, and records showed the facility's stated practices were documented in admission agreements. No violations were found.

Read raw inspector notes

Regarding the allegation: Staff do not respond to resident's calls for assistance in a timely manner . It is alleged that the staff is not responding to residents’ call for assistance with the residents’ needs in a timely manner. Six of six staff interviewed deny this. According to the staff interviewed, the staff responds to the residents’ call for assistance within twenty minutes and staff will notify and alert another staff members when one staff person is delayed assisting other residents that reside on the floor. Nine of ten residents interviewed could not corroborate the allegation. Six of ten residents stated the staff responds to their call for assistance within ten to fifteen minutes. Based on interviews and observations, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff did not provide resident's responsible party with required notice of fee increase. It is alleged that staff are not providing resident’s responsible party with notice of fee increase. Six of six staff interviewed deny this. According to the staff the yearly increases are in accordance with the residents’ admissions agreement and care service descriptions. The notifications are mailed from the corporate office to self responsible residents and the residents Power of Attorney via United States Postal Service and or preferred communications. Nine of ten residents interviewed could not corroborate this allegation. Six of ten residents stated they are aware of and are notified by the facility for increase in rent and services required for resident’s needs. According to records reviewed, R1 and R1’s financial Power of Attorney agreed to all the terms of the admissions agreement, including cost increase of needs and services, signed and dated on 07/08/2024. Based on interviews and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff do not ensure that resident is treated with dignity and respect. It is alleged that the staff are not treating residents with dignity and respect. Six of six staff interviewed deny this. Staff stated they treat each resident with respect and dignity. Staff are providing care and comfort to all residents. Staff stated they provide a safety and harmonious environment for all residents in memory care and assisted living. Seven of ten residents interviewed stated they feel safe and secure residing at the facility. Five of ten residents stated they are treated with kindness and dignity and stated they have never been ridiculed and made to feel embarrassed. Based on interviews and observations, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUED ON 9099C....... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation: Staff do not ensure resident's room is clean and sanitary. It is alleged that the staff are not ensuring residents’ room is clean and sanitary and trash is not collected frequently. Six of six staff interviewed deny this. Staff stated they clean each room according to the assigned schedules. Staff collect trash from the residents’ room, bathroom and trash placed by residents’ door. Staff performing housekeeping duties, cleaning and sanitizing the residents’ room and bathroom, and removing all the trash. Staff performing janitorial duties keep corridors clean and clear of trash. Based on interviews and observations, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted and copy of report provided to Executive Director LeeAnn Hefner.

2025-09-11
Complaint Investigation
Unsubstantiated
No findings

Plain-language summary

A complaint alleged that staff was isolating residents in their rooms because of body odor and making shaming remarks during meals, forcing some residents to eat alone. Investigators interviewed all staff and residents, reviewed records, and observed residents in common areas; none of the interviewed residents or staff could confirm these allegations, and the investigator found insufficient evidence to substantiate either claim. The facility's records showed that staff encourage residents to shower on scheduled days and assist with hygiene needs, though some residents refuse to shower.

Read raw inspector notes

Regarding the allegation: Staff isolates resident. It is alleged that the staff is isolating residents in their rooms and not allowing them to come out of their room due to mal body odor from the resident. (6) of (6) staff interviewed denied the allegation. (10) of (10) residents interviewed could not corroborate the allegation. Interviews with staff acknowledge a few residents with strong body odors. Staff assist residents with their Assisted daily living needs. Residents are encouraged by staff to shower on their scheduled days. Some residents refuse to shower as scheduled. Staff will attempt three times during their shift to convince the resident to shower and then change personnel and attempted to convince three times again. Records reviewed show R1's scheduled for shower twice weekly and refusing to shower. Staff communicates residents’ behaviors to next shift. Residents are never left alone; staff interact with residents when making their rounds. Family and physician are informed of residents’ behaviors. LPA observed the resident in the common area watching TV interacting with other residents. Based upon record review and interviews conducted the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff has inappropriate interaction with resident. It is alleged that the staff make shaming remarks about residents’ foul body odor during the mealtime and resident is forced to eat in their room. (6) of (6) staff interview denied this allegation. (10) of (10) residents interviewed could not corroborate this allegation. Interviews with staff acknowledged that a few residents have strong body odor. Staff encourages residents to keep up with their hygiene and are not shaming any of the residents for their body odor. Staff understands the behaviors that residents have and assists the residents with their needs and services. The residents are allowed to wander the facility freely. Staff acknowledge that some residents will make remarks towards residents with a foul odor. Staff interviewed stated they assist all residents with comfort and safety and treat residents with respect and dignity. Based upon record review and interviews conducted the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and copy of this report was given to Lee Ann Hefner- Executive Director.

2025-08-19
Other Visit
No findings

Plain-language summary

During an unannounced annual inspection, the facility was found to comply with all state requirements for a 142-bed memory care and assisted living home. The inspector checked staffing, training records, medication storage, food safety, fire safety equipment, resident rooms, and emergency preparedness, and observed no violations. Staff demonstrated proper infection control practices, residents had access to activities and outdoor space, and all required documentation was in place.

Read raw inspector notes

Licensing Program Analyst (LPA) S Vaid conducted the required annual inspection. LPA arrived unannounced and met with Claudella Farrow-receptionist who notified the administrator LeeAnn Hefner arrived shortly after and assisted with the assisted with the tour. The facility is licensed to serve 142 non-ambulatory residents ages 60 and over, of which eight (8) may be bedridden, approval for twelve (12) hospice. There is an approved delayed egress for memory care. The building is a three-story building which was consisted of the front lobby, the memory care unit, common areas, resident rooms and private bathrooms, public bathrooms, dining rooms, central restaurant style kitchen, offices, housekeeping closets, activity rooms, bar area, beauty salon, theater room, laundry and linen storage and supply rooms, and medication rooms. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, and facility maintains the required liability insurance. Con't 809C...... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Physical Plant & Environment Safety: LPA toured facility, ten (10) residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested daily throughout the facility resident private restrooms and measured within the required range of 105-120 degrees. There is a shaded patio and garden area for residents. Staffing: There is always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Staff have criminal record clearance, current First-Aid training along with training in postural supports, assisted living, memory care, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed. Administrator LeeAnn Hefner certificate expires on 3/29/25, renewal was sent and is awaiting. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 10 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman posted in the front lobby and common areas. Planned Activities: Facility provides scheduled activities with a monthly calendar. There is an outdoor activity area available for the residents. LPA observed residents participating in planned activity. Con't 809C................... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Dining staff uses approved menus and follow residents special diets. Walk-in fridge and freezers temperatures are measured and recorded daily. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a Medication Room and are in their original containers. LPA reviewed medications for six (6) assisted living residents and four (4) memory care residents. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Fire and disaster drills are conducted unannounced monthly by third party company during different shifts. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files. There are currently one (1) in bedridden resident in hospice at the facility. LPA observed rooms that have oxygen with the required signs posted. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to LeeAnn Hefner.

2025-07-08
Complaint Investigation
Unsubstantiated
No findings

Plain-language summary

A complaint was investigated about air conditioning problems at the facility. The facility experienced A/C malfunctions affecting some rooms starting in late April 2025, which staff repaired over several weeks while providing portable fans and air conditioning units to residents; residents and staff confirmed the cooling issue but stated it was resolved with these accommodations, and room temperatures were measured between 78-85 degrees Fahrenheit. The complaint could not be substantiated as a violation.

Read raw inspector notes

Five (5) out of five (5) staff could not corroborate this allegation, according to the staff the facility did have Air Conditioner issues with a A/C units that affected thirteen (13) occupied rooms and two (2) unoccupied rooms and common areas. On 04/29/25 the facility A/C units had issues and HVAC company was called out to repair. On 05/02/25 compressor parts for the malfunctioned A/C units were ordered. On 05/30/25 the parts were delivered, and A/C unit was partially repaired, the circuit board to the A/C unit was damaged and needed replacement and was ordered. On 06/06/25 the compressor was replaced but A/C systems still had issues. Portable fans and portable A/C units were and provided to the residents affected. Additional portable A/C units and fans were purchased on 06/19/25 and 6/23/25. 06/27/25, HVAC company ordered new parts, new parts arrived 7/5/25 and the A/C system was now under repair. The HVAC company and Maintenance Director are checking cooling in the affected residents’ rooms. Unusual incident report was faxed to the licensing department on 07/02/25 by the Executive Director regarding the A/C repairs. Nine (9) out of nine (9) residents interviewed were not able to corroborate the allegation, according to the residents the A/C was out for couple of weeks but only some areas and rooms were affected. Review of resident medical records by LPA Vaid did not corroborate this allegation. According to one resident the A/C breakdown does not cause their health conditions to become worsen in hot weather. Residents’ claim the A/C breaking down is hassle, but the facility staff were able to accommodate them by providing fans and portable A/C units. Residents interviewed confirm the facility staff provided portable fans and A/C units placed in the residents' rooms. The air temperature was measured in nine (9) residents’ rooms affected by the A/C malfunction. During tour of facility, the temperature in the residents’ rooms were measured by LPA using State issued thermometer and the range is within of 78-85 deg F, which is within the regulations. Residents' R1-R9 stated that they are comfortable with the air temperature, they are able to control the temperature in their room via thermostat. Based on records reviewed, interviews conducted, and observations made the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and copy of this report was given to Leeann Hefner, Executive Director.

2025-04-26
Complaint Investigation
Unsubstantiated
No findings

Plain-language summary

This was a complaint investigation into allegations that a resident sustained a fracture due to staff neglect, that staff failed to prevent a physical altercation between residents, and that staff did not meet the resident's incontinence needs or provide clean linen. Investigators interviewed staff and reviewed resident records but found no evidence to support any of these allegations, and no violations were cited.

Read raw inspector notes

The investigation revealed the following: regarding the allegation(s)- Resident sustained a fracture due to staff neglect. It is alleged that R1 sustained a fracture due to staff neglect on 12/16/2024. Interviews conducted by Community Care Licensing-Investigations Branch did not corroborate this allegation. Review of R1’s resident records by Community Care Licensing-Investigations Branch did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Staff did not prevent physical altercation between residents. It is alleged that facility staff did not prevent physical altercation between R1 and R2 on 12/16/2024. Interviews conducted by Community Care Licensing-Investigations Branch did not corroborate this allegation. Review of R1’s resident records by Community Care Licensing-Investigations Branch did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Staff did not meet resident's incontinence needs. It is alleged that staff did not meet R1’s incontinence needs. Five (5) out of the five (5) staff interviewed by LPA Ramirez did not corroborate this allegation. LPA Ramirez attempted to interview R1 but, R1 was unavailable for an interview. LPA Ramirez attempted to contact R1’s responsible party but, R1’s responsible party was not available for an interview. Review of R1’s resident record by LPA Ramirez did not corroborate this allegation. During tour of facility, LPA Ramirez observed residents to be well groomed and not malodorous. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Staff did not provide resident with clean linen. It is alleged that facility staff did not provide R1 with clean linen. Five (5) out of the five (5) staff interviewed by LPA Ramirez did not corroborate this allegation. LPA Ramirez attempted to interview R1 but, R1 was unavailable for an interview. LPA Ramirez attempted to contact R1’s responsible party but, R1’s responsible party was not available for an interview. Review of R1’s resident record by LPA Ramirez did not corroborate this allegation. During tour of facility, LPA Ramirez observed resident rooms to be free from malodorous and observed sufficient supply of extra clean linen in laundry room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No violations were cited for this complaint investigation. Exit interview was conducted. A copy of this report was provided via email.

2025-02-13
Complaint Investigation
Mixed
Type A · 1 finding

Plain-language summary

This was a complaint investigation that looked into five allegations about care and supervision, including claims of multiple falls, an unexplained burn injury, failure to assist with eating, delayed provision of records, and lack of communication about care changes. None of the allegations were substantiated—staff and other residents could not corroborate the claims, and facility records and observations did not support that violations occurred. The facility provided requested records within two days and maintained current care documentation.

Type A22 CCR §87465(a)(4)
Verbatim citation text · 22 CCR §87465(a)(4)

This requirement was not met as evidenced by: R1 was not assisted with their Depakote medication between 9/1-9/2/24 which poses an immediate health and safety risk to residents in care.

Read raw inspector notes

In regards to the allegation "Staff did not provide adequate supervision, resulting in a resident sustaining multiple falls" it is alleged that R1 has had multiple falls in the facility in the last year due to lack of supervision. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff only showed knowledge of one fall where R1 slipped from their wheelchair. Staff were present and able to assess R1. 911 was also called but no injuries were noted. File review shows an SIR dated 6/2/24 on the incident provided to licensing. There were no other recordings of falls R1 may have had in the facility. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff neglect resulted in resident sustaining an unexplained injury" it is alleged that due to staff neglect of supervision R1 received a unknown burn on their hand. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews stated that blisters were observed on R1's hand on 10/8/24. Staff interviewed denied any knowledge of what caused the blisters. Interviews added that the blisters were initially observed by R1's relative while they were in private. Once staff became aware, they assessed R1 and called paramedics. There was no knowledge of the blister prior to the family visit. File review shows there is an incident report on file for this day. Staff stated there are no chemicals in the open near R1's bed and R1 receives total assistance with mobility around the facility. This means staff are present and near R1 when moving anywhere in the facility. Interview with R1's home health agency stated the blisters classify as a burn but the cause remains unknown. The blister was in between the finger and more resembled friction burn rather than a chemical burn. LPA observed R1's room to be free of any items that pose a danger. LPA observed staff supervision to be sufficient. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continued on LIC 9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 In regards to the allegation "Staff did not assist resident with eating" it is alleged that staff did not assist R1 with eating their meals after their left hand was bandaged. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews stated that R1 had a bandaged left hand but eats with their right hand. Staff interviewed stated that R1's care plan requires cut up food and encouragement but not to be fed directly. Staff stated they however do make sure R1 finishes their meals and will assist if R1 needs it. LPA observed R1 eating in the facility on their own during the initial visit. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff did not provide resident’s records to authorized representative in a timely manner" it is alleged that R1's family requested resident records but the facility would not provide them. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interview with staff stated that R1's responsible party requested, in writing, for a list of documents from R1's file on 10/29/24. Staff stated the documents have been gathered as of 10/31/24 and R1's responsible party was notified they can be picked up. File review confirms the date of the request and the date the documents were provided. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff did not communicate with resident's authorized representative regarding care in a timely manner" it is alleged that the facility has not communicated any changes in R1's care plan since R1 moved in. (7) of (7) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated R1 moved in on 11/24/23 and there have been no changes since the finalized care plan completed on 1/26/24. This plan was communicated with R1's responsible party. File review showed last service plan on file for R1 was created on 1/26/24. Staff stated the plan is still current and there have been no changes. LPA was not informed of what changed were done that needed to be communicated. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Interviews showed that there were medication errors on 9/1/24 and 9/2/24 for R1 regarding their Depakote medication. On 9/4/24, Staff observed the medication still in the bubble pack for those two days meaning that R1 did not receive it. Review of R1's file shows that R1 requires assistance with medication from staff. File review also showed an incident report was created to report the missing medications to licensing and in service training was scheduled with staff. This shows that the facility failed to dispense R1's medication as prescribed. Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has continue therefore the above allegations are found SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D. Exit interview conducted. Appeal rights discussed. A copy of this report and the appeal rights were provided.

2024-10-29
Annual Compliance Visit
No findings
Inspector · Bonnie Tao

Plain-language summary

An investigator conducted an unannounced visit on October 5, 2024, in response to an incident report that a staff member grabbed a resident by the neck and did not use proper lifting equipment during care. The facility immediately suspended the staff member upon learning of the incident on October 4th, reported it to licensing and police, and the employee was voluntarily terminated three days later; the resident was not injured, did not recall the incident, and the investigator found no violations.

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Licensing Program Analyst (LPA) Tao conducted an unannounced Case Management- Incident visit in response to resident#1 (R1) Incident Report, dated 10/05/24. The facility has a capacity of 142 residents, licensed to serve elderly residents age 60 and above, approved for 142 non-ambulatory residents and has dementia program in place. LPA explained the purpose of today's visit to LeeAnn Hefner, administrator who assisted with this visit. During today's visit, LPA conducted physical plant, conducted interviews including Administrator, staff#2-staff#3, resident#1 (R1) and family member (FM), reviewed R1's file and staff file. LPA attempted but unable to reach staff#4 (S4) and the agency caregiver (S5) for interview. The incident report stated an agency caregiver (S5) reported to administrator that staff#4 (S4) was rough with resident#1 (R1) while providing care. The agency caregiver reported S4 did not use the Hoyer Lift to transfer resident, grabbed resident by resident’ neck and did not provide proper pericare to resident. LPA interviewed Administrator/staff revealed that the facility investigated the incident, put the alleged staff (S4) on an immediate suspension on 10/04/24, and reported the incident to Licensing/ ombudsman / responsible party/ police on 10/05/24. The staff interviews revealed it was a single incident and resident#1 (R1) was not injured nor physically abused. Staff S4 was a new hired and had completed training on providing care to dementia residents. S4 was voluntarily terminated on 10/07/24 after the incident. After the incident, the administrator hosted a brief meeting with caregivers regarding the proper procedures on providing cares to residents with dementia and using Hoyer Lift. Per interview of R1, resident seemed unable to recall the incident and did not observe injury on resident’s neck or back. R1 was on a daily monitor by staff for a week. FM interview revealed R1 was doing fine and did not complain any pain after the incident. Police case#24-22261. (-continued on LIC 809C-) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA obtained copies of the following documents: · Staff roster · Resident roster · R1’s Identification/Emergency Contact Information (facesheet) · Unusual Incident Report · Physician Report · Staff #4 staff files/document · In-service training LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. No deficiencies were observed and cited during this visit. Exit interview was held with administrator and this report LIC 809 was provided to administrator.

2024-07-30
Annual Compliance Visit
No findings
Inspector · Bonnie Tao

Plain-language summary

This was a routine annual inspection of the facility. No deficiencies were found—the building, safety systems, food supply, medications, resident rooms, bathrooms, and staff and resident records all met state requirements.

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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit to the facility. LPA met Lee Ann Hefner, administrator and the purpose of today's inspection was explained. The facility is licensed to serve age range 60 and over, approved for (142) non-ambulatory, including eight (8) may be bedridden. Delayed egress was approved. The facility had approved hospice waiver for twelve (12) for residents residing in bedrooms# 101,102,103,104,121,122,123, and 124. LPA conducted staff/resident interviews, used CARE inspection tool, conducted physical plant, reviewed food supply/medications and records/ staff/residents’ records. Facility fees were current. Administrator certificate was current until 3/29/25. The building was a three-story building which was consisted of a front lobby, memory care unit, common areas, resident rooms and private bathrooms, public bathrooms, dining rooms, central restaurant style kitchen, offices, housekeeping closets, activity rooms, bar area, beauty salon, theater room, laundry and linen storage and supply rooms, and medication rooms. The memory care unit was located on the first floor. A delayed egress door system and alarm system were operational. The signal system were tested and staff arrived within 8 mins. Physical plant was conducted in room 114, 117, 135, 230, 224, and 327. Residents’ bedrooms and bathrooms were in compliance. Hot water temperature was measured in a range of 114.2 to 115.1 degrees Fahrenheit which was within Title 22 Regulation guidelines. Landline telephone systems were operational and available for resident use. Smoke/carbon monoxide detectors were monitored by a fire alarm company and last service was on 5/10/24. Fire extinguishes were fully charged. (-continued on LIC 809 C-) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Sufficient supply of perishable and non-perishable foods was observed. A comfortable temperature of 75 degrees Fahrenheit maintained throughout the entire facility. No bodies of water observed. Staff and resident files will be kept in the director's office on the second floor. Elevators for residents' use were operational. Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview was held. A copy of the report was provided.

2024-07-09
Complaint Investigation
Unsubstantiated
No findings

Plain-language summary

A complaint alleged the facility illegally evicted a resident by refusing to accept her back after a hospital stay, but investigators found no evidence to support this claim. The facility provided documentation showing staff conducted a reassessment, informed the family of changed care needs and costs, and expected the resident to return; the family instead moved the resident out over the weekend without notifying staff. The complaint was determined to be unsubstantiated.

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R-1 was sent out to the hospital and when ready for discharge, R-1’s daughter moved resident back to own home with the one-on-one caregiver. Per the Executive Director and Wellness Director, they denied telling the hospital staff they were not accepting the resident back as alleged. LPA reviewed the facility documents which showed that the Wellness Director conducted a reassessment of R-1 on 6/5/24 at R-1’s private home. The Wellness Director also stated that R-1’s daughter was informed of the change in level of care and understood the cost will increase. Staff was told that R-1 was coming back to the facility after the weekend. However, the family came on the weekend to move out all of the belongings without informing any staff. LPA interviewed R-1’s family member, who heard from a hospital personnel that the facility was not accepting resident back but did not confirm with the Executive Director if information was true. Based on the information gathered, there is insufficient evidence to support this allegation of the illegal eviction. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with the Executive Director. A copy of this report along with the appeal rights were provided.

2023-08-28
Other Visit
No findings
Inspector · Bonnie Tao

Plain-language summary

An unannounced annual inspection was conducted at the facility, which is licensed to serve 142 non-ambulatory residents including up to eight bedridden residents. The inspector reviewed staff and resident records, toured the building including resident rooms and bathrooms, checked safety systems including fire suppression and alarm systems, inspected food storage and preparation areas, and verified medications and medical records—and found no deficiencies.

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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit to the facility. LPA met with Staff#1, who assisted with the visit. LPA spoke with Staff#2 over the phone. The reason for the inspection was explained. During the visit, LPA conducted staff/resident interviews, used CARE inspection tool, toured the facility, reviewed food supply, reviewed medications and records, and reviewed staff/residents’ records. Facility fees were current. Interim administrator's administrator certificate was current and had the expiration date on 6/22/24. The facility is licensed to serve age range 60 and over, approved for (142) non-ambulatory, including eight (8) may be bedridden. Delayed egress was approved. The facility had approved hospice waiver for twelve (12) for residents residing in bedrooms# 101,102,103,104,121,122,123, and 124. The building is a three-story building which was consisted of the front lobby, the memory care unit, common areas, resident rooms and private bathrooms, public bathrooms, dining rooms, central restaurant style kitchen, offices, housekeeping closets, activity rooms, bar area, beauty salon, theater room, laundry and linen storage and supply rooms, and medication rooms. The memory care unit is located on the first floor. A delayed egress door system was operational. Alarm system was tested and operational. Signal system was tested and staff arrived within 5 mins. (-continued in LIC 809C-) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA toured the resident rooms #111, 115, 123, 136, 229, 233, and 301. Residents’ bedrooms were observed to have all the required furniture with plenty of personal storage space, linen/supplies, and in compliance. Bathrooms were furnished with grab bars, nonskid surfaces and in compliance. Hot water temperature was measured in a range of 115.9 to 116.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. The facility had a landline telephone system which was operational and available for resident use. Several fire extinguishers were located and mounted on the walls down each hallway. They were observed to have recent inspections and be fully charged. Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens, and counter tops were observed to be clean. There were refrigerators located in the assisted living resident bedrooms, and one in the central kitchen. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility. Smoke detectors, carbon monoxide detectors and fire extinguishers were located throughout each building. The grounds were properly maintained and there were no hazards observed. No bodies of water observed. The facility also had an electrical and connected fire system that was tested and operational. Last fire drill was conducted on 7/6/23. All poisons, toxins, and cleaning supplies were locked in the housekeeping closets and were inaccessible to residents in care. First aid kits were inspected and observed the have the required supplies and first aid manual to meet Title 22 Regulations. Staff and resident files will be kept in the director's office on the second floor. Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview was held. A copy of the report was provided.

2023-08-28
Complaint Investigation
Substantiated
Type B · 1 finding

Plain-language summary

A complaint investigation found that the facility's administrator did not have a current certificate—it had expired in June 2023—which meant the facility did not have a qualified administrator on staff as required. Residents, visitors, and staff confirmed that the administrator was present at the facility enough hours and that staff knew how to care for residents, and training records were current. The facility placed an interim certified administrator in the role while hiring a new administrator to start in early September 2023.

Type B22 CCR §87405(a)
Verbatim citation text · 22 CCR §87405(a)

Based on interviews and observation, the Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

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***This report serves as an amendment and supersedes the original complaint investigation report created on 07/18/2023. The finding remains the same as Substantiated. *** The investigation revealed that regarding allegation, “administrator is not fulfilling administrative duties and qualification,” it was alleged that administrator did not present enough hours to operate the facility, did not provide the required training to staff, and administrator’s certificate was not current. The investigation revealed the following: interviewed with residents from R1 to R5, all five (5) out of five (5) residents interviewed revealed that administrator had present enough hours at the facility and staff had the knowledge on taking care of residents. Interviewed with visitors from V1 to V3, all visitors interviewed revealed that administrator had present enough hours at the facility and staff knew how to take care of the residents. Four (4) out of four (4) staff interviewed were denied the allegation. LPA conducted a file review. File review revealed that administrator had present at least 40 hours/ week at the facility and staff’s in-services training were current. However, administrator certificate was not current and was expired on 6/8/23. During the visit on 07/13/23, Administrator stated the certificate renewal was in process and the expected completion day would be the end of August 2023. The interim certified administrator was Sahar Mosalla. Sahar's administrator certificate is current with expiration date on 6/22/24. Therefore, facility did not have a qualified and currently certified administrator. During today’s visit on 8/28/23, Karen Turnour, Business office director, stated Patricia Gustin was no longer working with the company and her last day was 08/16/23. Sahar will be the interim certified administrator. The new administrator will report to work in early September 2023. Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has continue therefore the above allegations are found SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D. An exit interview was conducted with Karen Turnour, Business office director . A hard copy of this report and appeal right were provided.

2023-07-18
Complaint Investigation
Substantiated
Citation on file

Plain-language summary

A complaint investigation found that while the administrator was present at the facility enough hours and staff had current training, the administrator's certificate had expired in June 2023 and had not been renewed, meaning the facility did not have a currently licensed administrator as required. Residents, visitors, and staff all reported the administrator was present and staff were knowledgeable in resident care. The state cited the facility for this licensing violation.

Substantiated — the state found a violation and issued a citation. Full citation details are on file with the state.

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The investigation revealed the following: interviewed with residents from R1 to R5, all five (5) out of five (5) residents interviewed revealed that administrator had present enough hours at the facility and staff had the knowledge on taking care of residents. Interviewed with visitors from V1 to V3, all visitors interviewed revealed that administrator had present enough hours at the facility and staff knew how to take care of the residents. Four (4) out of four (4) staff interviewed and denied the allegation. LPA conducted a file review. File review revealed that administrator had present at least 40 hours/ week at the facility and staff’s in-services training were current. However, administrator certificate was not current and expired on 6/8/23. Administrator stated the certificate renewal was in process and the expected completion day would be the end of August 2023. Therefore, facility did not have a qualified and currently certified administrator. Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D. An exit interview was conducted with Administrator. A hard copy of this report and appeal right were provided.

3 older inspections from 2022 are not shown in the free view.

3 older inspections from 2022 are not shown in the free view.

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