Westmont of Culver City.
A large home, reviewed on public record.
Compared to 160 California facilities with a similar number of beds.
RCFE · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
among peers to rank.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
Citation history, plotted month by month.
2 deficiencies on record. Each bar is a month with a citation.
Finding distribution
2 total · 36 monthsScope × Severity (CMS A–L)
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.
Plain language
Elopements, fires, epidemic outbreaks, and poisonings must be reported immediately. Abuse with serious bodily injury requires a 2-hour phone report + 2-hour written report to CDSS, Adult Protective Services, and law enforcement. Abuse without serious bodily injury must be reported within 24 hours. A resident death requires a phone call by the next working day and a written report within 7 days. Injuries requiring medical treatment beyond first aid, and bankruptcy/foreclosure/utility shutoff notices, must also be reported. Incidents not reported on time are a separate violation — families may file a complaint directly with CDSS.
Ask on tour
“When was the last incident report filed with CDSS, and may I see your incident log summary for the past 12 months?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Westmont of Culver City's record and state requirements.
The facility holds license number 198320402 with 160 licensed beds and zero deficiencies on file — can you provide the most recent CDSS inspection report and walk families through how the facility maintains compliance with Title 22 requirements?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
No complaints appear in CDSS records for this location — what internal quality-assurance process does the facility use to identify and address resident or family concerns before they escalate to formal complaints?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
The facility is licensed for 160 beds under operator Westmont Liv Inc — can you confirm current occupancy and provide documentation showing the facility has maintained its LICENSED status without citations or administrative actions?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every inspection visit, verbatim.
11 inspections in the public record, most recent first. Plain-language summaries open first — click into any row for the full citation text.
2026-08-06Other VisitNo findings
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On 08/06/26, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annually required inspection visit to Westmont of Culver City. LPA was met by Dawn Smith, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve 160 ambulatory residents aged 60 and over of which 160 may be non-ambulatory. The facility has an approved hospice waiver for 20 residents and approved for delayed egress. Currently the facility has (152) residents. The facility’s annual fees are current. The facility is a five-story structure located in a commercial neighborhood. The facility consists of (137) resident bedrooms. The 2nd through the 5th floor are assisted living units and independent living units consisting of studio, 1 bedroom and 2 bedroom units. All units have a refrigerator, stove, microwave, and personal washer and dryers located in the bathrooms. The 1st floor is comprised of Compass Rose Memory Care units. At 10:30am, LPA and staff toured the facility. There are no bodies of water or firearm/ammunition on the premises. LPA toured the following rooms: 154, 157, 164, 202, 221, 304, 314, 323, 402, 407, 430, 506, 508, 509, and 513. Beds and bedding were in good condition, adequate lighting provided, and adequate storage for resident personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there was adequate lighting, and sufficient toiletries were accessible to residents. The water temperature was within title 22 regulations in all bathrooms (range between 105-120f degrees). A comfortable temperature is maintained in the facility. Report Continued On LIC809-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 LPA observed the facility to be clean, sanitary, and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to residents in the Compass Rose Memory Care units. The kitchens were inspected and there is enough perishable and non-perishable food available for the residents. All food items were stored properly. The water temperature measured 118.9F degrees in the kitchen. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked with manuals in both medication rooms . The fire extinguishers were charged and last inspected on 06/09/2026. The smoke and carbon monoxide detectors were operable. The last fire/emergency drill was conducted on 07/01/2026. The last evacuation drill was conducted on 04/07/2026. The facility’s administrator’s certificate (7005885740) is pending renewal, application was received on 07/10/2026. The facility’s liability insurance was valid from 09/15/2025 through 09/15/2026. LPA conducted a review of (10) resident records, (10) staff records, and reviewed the facility disaster plan. LPA observed that residents had the required medical documents and other pertinent documents in their resident folders. Staff records were complete with required documents and training. The facility disaster plan was last updated on 07/24/2026 and in compliance with Title 22 regulations at the time of visit. LPA reviewed (4) resident medication administration records, and medication, and did not observe any discrepancies at the time of visit. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA advised the facility to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing ( www.cdss.ca.gov ) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues. No deficiencies were cited during this inspection visit. An exit interview was held, and a copy of this Facility Evaluation Report was provided to Dawn Smith, Administrator.
2026-07-24Annual Compliance VisitNo findings
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On 07/24/2026, between the hours of 1:30pm – 2:30pm, the Department conducted a records review and observed the following: An Orkin inspection (dated 06/01/2026) (PC Standard – Every Two Weeks documented inspection of the interior and exterior building, kitchen area, front patio, dumpster room, break room, restrooms, garage/exterior rodent bait stations, and one resident unit for bed bug follow up. Live activity was found, with ten bed bugs located throughout the sheets of the primary bedroom. An Orkin Service Report (dated 06/19/2026) documented a canine inspection of three units and the third floor hallway, with no bed bug activity found. An LIC 624 Unusual Incident/Injury Report (dated 07/14/2026) documented that pest control inspected a resident’s apartment and noted one bed bug in the frame of the bed. A protectant cover was to be placed on the box spring, and Orkin was scheduled to perform treatment on 07/14/2026. An Orkin Service Report (dated 07/14/2026) documented a thorough inspection of the interior of R2’s and R12’s rooms, with live activity found; one adult bed bug was located underneath the mechanical bedframe (top left corner). A residual spray was applied to all walls of both rooms, and in R2’s room the mechanical bedframe, cover sheets, and bedframe were also treated. On 07/22/2026, Orkin also conducted a canine inspection between the hours of 5:00am– 5:30am in all common areas, including each floor sitting room, staff break room, library, living room, dining room, bistro, laundry room, housekeeping cart, activity room, fitness room, theater room, card room, and billiards room and no live or dead activity was discovered. Overall, records show that Orkin conducted ongoing pest control services, including PC Standard Every Two Weeks on 02/10/2026, 02/21/2026, 03/10/2026, 03/24/2026, 04/07/2026, 04/21/2026, 05/05/2026, 06/01/2026, and 06/30/2026, and Bed Bug Odd Job treatments on 05/22/2026, 05/29/2026, 06/16/2026, 06/19/2026, and 07/14/2026. These records demonstrate consistent pest control activity throughout the facility. Based on information gathered through interviews and record reviews, there is not enough evidence to support the 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. 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 Based on information gathered through interviews and record reviews, there is not enough evidence to support the 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 with Dawn Smith (Executive Director) 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 The investigation revealed the following: Allegation: Staff do not ensure the facility is free of bed bugs It was alleged that a resident reported ongoing bites, a worker reportedly located a bed bug in a resident’s bed, the room was sprayed, and the resident is concerned about whether the facility is maintaining a bed bug free environment. On 07/20/2026, between the hours of 1:22pm – 1:33pm, the Department interviewed the Administrator (A1) regarding the allegation. A1 confirmed the allegation and stated bed bugs were reported in R1's, R3's, and R2's room. A1 stated that Orkin found one live bed bug and one dead bed bug in R2's room. On 07/20/2026 & 07/24/2026, between the hours of 9:00am – 3:32pm, the Department interviewed 11 staff regarding the allegation. 1 out of 11 staff confirmed the allegation and stated Orkin found a bed bug in R2's room. 10 out of 11 staff denied the allegation and stated they had never witnessed any bed bugs in any resident room and only heard about bed bug concerns through general facility communication. On 07/20/2026, between the hours of 12:31pm – 3:34pm, and on 07/24/2026, between the hours of 9:20am – 9:32am, the Department interviewed 11 residents regarding the allegation. 1 out of 11 residents confirmed the allegation, with R1 stating the first sign of bed bugs in their room occurred in June 2026. 9 out of 11 residents denied the allegation and stated they had never seen bed bugs in their rooms nor anywhere else in the facility. 1 out of 11 residents did not confirm nor deny the allegation and stated seeing bed bugs in their room back in August 2025. On 07/24/2026, between the hours of 9:15am – 10:07am, the Department conducted a tour of five resident rooms and observed the following: A1 conducted a bed inspection by removing all bed linens from the rooms of R1, R2, R3, R11, and R12 . No live or dead bed bugs were observed. 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 Allegation: Resident sustained bug bites due to staff neglect It was alleged that a resident reported experiencing bites over a period of time and believes the bites occurred because staff did not adequately address the bed bug issue. On 07/20/2026, between the hours of 1:22pm – 1:33pm, the Department interviewed the Administrator (A1) regarding the allegation. A1 confirmed the allegation and stated R1 and R2 experienced bites. On 07/20/2026 & 07/24/2026, between the hours of 9:00am – 3:32pm, the Department interviewed 10 staff regarding the allegation. 4 out of 10 staff confirmed the allegation and stated they observed bites and/or red marks on R2, which R2 also reported. 4 out of 10 staff denied the allegation and stated they had not observed any bug bites on residents. 2 out of 10 staff did not confirm nor deny the allegation and acknowledged that residents reported itchiness, which staff could not attribute to bed bugs. On 07/20/2026, between the hours of 12:31pm – 3:34pm, and on 07/24/2026, between the hours of 9:20am – 9:32am, the Department interviewed 11 residents regarding the allegation. 2 out of 11 residents confirmed the allegation and stated R1 had bites on their chest and arms, while R2 had one bite on their arm. 8 out of 11 residents denied the allegation and stated they had never experienced any bites nor skin concerns related to bed bugs. 1 out of 11 residents did not confirm nor deny the allegation and stated they did not know whether they had been bitten nor was aware of any marks. On 07/24/2026, between the hours of 12:00pm– 1:30pm, the Department conducted a records review and observed the following: An LIC 624 Unusual Incident/Injury Report (dated 07/14/2026) documented that on 07/08/2026, a resident was noted to have small red spots on the right side of their neck, right side of their chest, and the back of their upper arm. The resident reported the areas were itchy and believed the spots may have been mosquito bites from sitting on the patio. The resident’s family was notified, and staff monitored the areas while investigating the possible cause of the skin lesions. On 07/20/2026, the Department observed a photo visible skin lesions on R1’s arm and back. Also as of 07/24/2026, the department did not observe any new reports of residents sustaining any bed bug bites.
2026-07-24Complaint InvestigationUnsubstantiatedNo findings
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The investigation revealed the following Allegation: Facility fire alarm system is in disrepair It was alleged that repeated false alarm activations occurred throughout the facility directing residents to exit the building by using stairwells including up to five (5) flights despite the reporting party stating this was not the correct emergency procedure and placed residents at risk. On 06/09/2026, between the hours of 11:50am -12:00pm, the Department interviewed A1 in regards to the allegation. A1 denied the allegation and stated the last documented fire alarm testing occurred on September 9, 2025. A1 explained the system entered a scheduled test beginning at 10:20am, the fire panel was placed “On Test” at 11:01am - 7:00pm, and maintenance checked smoke detectors and electrical loops during that time. A1 stated the alarms recorded that day were part of scheduled testing, not emergencies, and the facility’s automated system announces alarm events over the intercom with lights and sound. On 06/09/2026, between the hours of 9:15am - 9:22am, the Department interviewed 8 staff in regards to the allegation. 4 out of 8 staff confirmed the allegation and stated they were aware of false alarms occurring at the facility or had personally responded to false alarm activations. 2 out of 8 staff denied the allegation stated they had not experienced repeated false alarms or had not personally responded to an alarm activation. 2 out of 8 staff did not confirm nor deny the allegation and stated they had heard residents mention false alarms but had not personally responded to an alarm activation. On 06/09/2026, between the hours of 10:15am - 11:18am, the Department interviewed 9 residents in regards to the allegation. 8 out of 9 residents confirmed the allegation and stated the alarm activates frequently, is loud, occurs during both day and night, and staff do not consistently notify residents when the alarm event has ended. 1 out of 9 residents was aware of the allegation and stated knowing of the alarm activations but did not provide details regarding frequency or staff response. 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 On 07/16/2026, between the hours of 2:00pm - 3:00pm the Department conducted a records review and observed the following: the facility’s fire alarm system logs dated September 9, 2025. At 10:20:53 AM, the fire alarm panel recorded a system trouble diagnostic during a scheduled testing window. Automated notifications were generated to facility contacts between 10:21am - 10:50am, including several live confirmations. At 11:01:47 AM, the fire panel was placed “On Test” through 7:00 PM, and additional diagnostic activity occurred between 11:36am - 11:41am, followed by device loop verification between 3:56pm - 3:58pm. The records reviewed showed the trouble signals documented on September 9, 2025 were generated during scheduled diagnostic testing performed by maintenance personnel. The Department did not observe documentation indicating that the fire alarm system was in disrepair. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the 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 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 Allegation: Staff leave residents unsupervised during emergency evacuations. It was alleged that residents were not informed when alarm events ended, and that at least three alarm activations occurred at night when no staff were present at the front desk. It was further alleged that alarms sounded simultaneously in resident rooms, hallways, and the Memory Care unit. On 06/09/2026, between the hours of 11:50am -12:00pm, the Department interviewed A1 in regards to the allegation. A1 denied the allegation and stated the facility uses a shelter-in-place protocol, evacuation only occurs for a confirmed fire, and staff supervise residents including overnight med-techs and caregivers. The administrator stated she was not aware of any alarm activation where residents were left unsupervised and stated the fire department leads evacuation during a true fire. On 06/09/2026, between the hours of 9:15am - 9:22am, the Department interviewed 8 staff in regards to the allegation. 7 out of 8 staff denied the allegation and stated residents are only instructed to use stairwells when evacuation is ordered and that staff remain available during alarm events. 1 out of 8 staff did not confirm nor deny the allegation and stated they had not worked night shifts during an alarm activation. On 06/09/2026, between the hours of 10:15am - 11:18am, the Department interviewed 9 residents in regards to the allegation. 7 out of 9 residents confirmed the allegation and stated staff provided inconsistent instructions, some residents received no direction, and during nighttime alarms no staff were visible in hallways or at the front desk. 2 out of 9 residents did not confirm nor deny the allegation and stated they were aware of alarm activations but did not provide details regarding staff supervision. On 07/16/2026, between the hours of 2:00pm - 3:00pm the Department conducted a records review and observed the following: reviewed available incident reports, staff logs, and facility documentation and did not observe any entries indicating that residents were left unsupervised during emergency evacuations or fire alarm events. No records were found documenting resident evacuation, lack of staff presence, or staff failing to supervise residents during an alarm. Based on information gathered through interviews and record reviews, there is not enough evidence to support the 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 with Dawn Smith (Executive Director) and a copy of this report was provided.
2026-06-17Other VisitType A · 1 finding
“Based on observation and interview, S3 Pricilla Tejeda, S5 Mallory Hutcherson, and S7 Jovana Mendez were not associated to the facility as the time of unannounced complaint investigation which poses an immediate health, safety or personal rights risk to persons in care.”
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On 06/17/2026 at 2:00pm, the Department conducted an unannounced case management deficiencies at the facility listed above. Licensing Program Analyst (LPA) Zina Brown met with Dawn Smith (Executive Director) and explained the purpose of the visit. During the complaint investigation for 11-AS-20260609153600 , the Department observed 3 employees: Staff 3 (S3), Staff 5 (S5) and Staff 7 (S7) were not associated to the facility at the time of unannounced complaint investigation. As a result, civil penalties are being assessed and a deficiency is being cited under California Code of Regulation Title 22, Division 6, Chapter 8 are being cited on the LIC 809-D. Exit interview conducted with Dawn Smith (Executive Director) and a copy of this report was provided with appeal rights.
2026-02-25Other VisitNo findings
Plain-language summary
During a case management visit on this incident from February 10, 2026, inspectors found that a resident missed eight different medications over 4 to 8 days because the facility ran out of stock; the resident had been managing their own medications according to a physician's assessment, and the facility had no system to track whether doses were actually taken. The facility sent the resident to the hospital for reassessment and moved them to a new medication management plan where facility staff now handle all medication administration. The inspector noted the facility's incident report was incomplete but cited no violation and advised the director on proper reporting requirements.
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Licensing Program Analyst (LPA) Sparkle Day conducted this Case Management regarding an incident dated 2/10/26. Licensee Reported that R#1 missed several medications due to the facility ran out of the medications. It was reported that Resident #1 (R#1) missed eight (8) different medications from 4 to 8 days. During today's visit Licensing Program Analyst spoke with Dawn Smith, Executive Director and Rosetta Hines, Resident Service Director who were consistent in their statements that R#1 was managing their own medication according to physician report dated 5/15/2024. LPA reviewed the file of R#1 and observed an physician report indicating R#1 was able to manage and administer their own medication without assistance. The facility did have a list of the medications of R#1 upon admission but had no way of knowing if medications were missed. Due to this incident the facility has sent R#1 to the hospital for re assessment and R#1 is now on the medication management plan with the facility where ALL medications are now handled and administered by a Medication Tech at the facility. Licensing Day found that the incident report was not complete with ALL necessary information required. LPA Advised Executive Director of the Reporting Requirements per Title 22 No deficiency was cited today Exit interview conducted with Executive Director, Dawn Smith
2025-11-10Other VisitNo findings
Plain-language summary
On November 10, 2025, inspectors investigated an incident from November 4 in which a staff member shoved a resident into a wheelchair and threw soiled gloves and wipes at them; the staff member was removed from the schedule and police were called. During interviews, five of six other staff members said they had not observed this employee being physically aggressive, the resident reported feeling safe at the facility, and inspectors found no violations of state regulations. The facility provided training records on reporting obligations and safety practices.
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On 11/10/2025 at 9:15am, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced Case Management- Incident visit to the facility listed above. LPA met with Marielena Cardenas, Business Office Director, and the purpose of today’s visit was explained. LPA was granted entry into the facility. On 11/05/2025, the Regional Office received an Unusual Incident/Injury Report stating that on 11/04/2025 Staff (S1) was observed by facility Staff (S2) shoving Resident (R1) into their wheelchair by pushing their left shoulder downward. Once Resident R1 was in their wheelchair, S1 proceeded to remove their soiled gloves and throw the soiled gloves and soiled wipes at Resident R1. During today’s visit, LPA received a Resident Roster, Staff Roster, Incident Report, SOC341, Resident Notes, In-Service Logs, interviewed Staff S2-S7, interviewed Witnesses W1-W2, and interviewed Resident R1. During interviews with Staff S2-S7 were asked if they observed S1 being physically aggressive with residents, five (5) out of six (6) stated no, they have not observed S1 be physically aggressive with residents. During an interview with Resident R1 was asked if they feel safe here at the facility, R1 stated yes. During Record Review, LPA observed Staff S1 was sent home and removed from the schedule following the incident. Additionally, Culver City Police Department were called out to investigate and provided case # 25-5668. LPA received and reviewed In-Service training logs (dated 11/08/2025) regarding Mandated Reporters, and Safety while providing ADLs. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted with Marielena Cardenas, Business Office Director, and a copy of this report was conducted.
2025-10-27Other VisitType B · 1 finding
Plain-language summary
A licensing analyst visited the facility on October 27, 2025, following an unusual incident report about an event that occurred on September 30, 2025. The facility failed to report the incident to the licensing agency within the seven-day requirement set by state regulations. The facility was cited for this delay and told it will face daily fines until it submits proof that it has corrected the problem.
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“Based on observation and record review, the licensee failed to ensure the incident report faxed on 10/9/25 was not sent within 7 days of the incident on 9/30/25. This poses a potential health and safety risk to residents in care.”
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On October 27, 2025, at approximately 2:30 pm, Licensing Program Analyst- LPA Alfonso Iniguez conducted an unannounced Case Management/Incident visit at the facility. LPA Iniguez met with Marielena Cardenas /Business Office Director and explained the purpose of the visit. On October 9, 2025, the Regional Office received an Unusual Incident Report (UIR) describing an incident that happened on 9/30/25. Based on Title 22 regulations, a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. LPA Iniguez observed that more than seven days had passed after the (UIR) was faxed to the Regional Office. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -Facility failed to report an incident within the time stipulated by Title 22. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Marielena Cardenas / Business Office Director.
2025-10-27Annual Compliance VisitNo findings
Plain-language summary
On October 27, 2025, the state investigated an allegation that a staff member had struck a resident's hand. The investigator interviewed the staff member, the resident, and reviewed the facility's internal investigation, and found no evidence that any physical contact occurred—the resident stated they had never been struck and described staff as friendly and caring. No violations were found.
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On October 27, 2025, at approximately 12:00 pm, Licensing Program Analyst- LPA Alfonso Iniguez conducted an unannounced Case Management/Incident visit at the facility. LPA Iniguez met with Marielena Cardenas, Business Office Director, and explained the purpose of the visit. On August 21, 2025, the Regional Office received a Report of Suspected Dependent Adult/Elder Abuse or SOC 341 stating that a former facility staff (S#2) had observed another facility staff (S#1) strike a resident’s (R#1) hand. After the incident was reported, the facility conducted an internal investigation, which revealed that (S#1) did not struck (R#1). On 10/27/25, LPA Iniguez spoke with (S#1), (S#1) stated that they did not strike (R#1) on their hand. Also, (S#1) said that they have never physically abused another resident in care. On 10/27/2025, LPA Iniguez spoke with (R#1), (R#1) stated that they have never been struck by (S#1) or any other facility staff. On the other hand, (R#1) noted that the facility workers here are “friendly and nice, and they are concerned about”. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Marielena Cardenas / Business Office Director.
2025-07-24Other VisitNo findings
Plain-language summary
This was the facility's annual one-year inspection, conducted without advance notice. The inspector reviewed resident records, medication records, staff files, and toured all five floors of the building, checking bedrooms, bathrooms, common areas, the kitchen, and grounds, and found no deficiencies.
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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Marielena Cardenas , Business Office Director and the purpose of the visit was discussed. The facility is licensed to serve 160 ambulatory residents age 60 and over of which 160 may be non ambulatory. The facility has an approved hospice waiver for 20 residents. There is also an approved delayed egress. Currently the facility serves 60 Assisted Living residents and 66 residents are in Independent living. Currently there is (1) residents receiving hospice services and (11) residents are receiving home health services. The facility does not handle any of the residents’ money. LPA Day reviewed 10 resident records, 10 resident medication records and 8 staff files. LPA found All records to be in order and complete according to Title 22. This is a 5 floor building consisting of: (137) resident bedrooms. The 2nd to 5th floor is Assisted Living Units and Independent living Units consisting of studio, 1 bedroom and 2 bedroom units. All units have personal washer and dryers located in the bathrooms. The 1st floor is Compass Rose Memory Care Units. LPA and Maintenance Director, Mario Carrillo toured the facility from the 1st floor to the 5th floor. and outside grounds. LPA toured the following rooms #512, #510, #522, #416, #411, #415, #313, #217, #228, #210 and The Memory Care unit. All bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 112 degrees - 116 degrees. . Common areas were clean and clear of hazards; doorways were free of obstructions. There are game 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 rooms on the 3rd and 4th floor. There is a doggy area on the 2nd floor and medication room. The 1st floor consists of entrance, Concierge desk, Dining room, Lobby, Meeting area, outside Courtyard and grill, Kitchen, Mail room, Activity room, Wellness room, Theater, Public restrooms for men and women, Bistro and staff offices. All mandated inspection posters were displayed throughout the facility. Facility Annual Fess are current. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. Last Fire drill inspection was June 2025. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. Residents wear pendants and Wander guard watches for emergencies while in apartments. There are also pull stations in every room. During todays visit LPA did not observe any deficiencies. Exit interview conducted with Business Office Director, Marielena Cardenas and copy of this report was provided at time of visit.
2025-03-13Other VisitNo findings
Plain-language summary
A community care licensing investigator visited the facility on March 13, 2025, to gather information about a fall that occurred on February 9, 2025, when a resident tripped on a blanket in the memory care activity area while staff were trying to help prevent an accident as the resident walked around carrying the blanket. The resident was taken to the hospital and had hip surgery, and is now in rehabilitation. The resident's fall risk assessment indicated standard fall prevention measures should be in place, and the facility notified the regional office of the incident.
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On 03/13/25 Community Care Licensing division (CCLD) Staff, conducted a case management -other visit at the above facility. CCLD Staff met with Executive Director, Dawn Smith and Memory Care Director, Larianna Logan(S1) and explained the purpose of the visit was to gather information surrounding the fall of Resident #1(R1) The Regional office received a Unusual Incident Report from the facility who reported the fall. It was reported the fall occurred on 02/09/25 in the common area of the Memory Care Unit's activity area. Interview with (S1) indicated that staff (S2) and (S3) informed (S1) that (R1) had fallen on the floor of the activity area and complained of hip pain. (S2)and (S3) indicated that they were attempting to assist (R1) due to (R1) walking around in the common area carrying /dragging a blanket, in an effort to prevent an accident from occurring. (R1) became agitated which prompted (S2 and (S3) to give (R1) space and time to calm down. (R1) subsequently tripped on the blanket and fell to the floor. (R1) was taken to St. John's Providence Hospital, where surgery was performed on the hip. (R1) is currently in rehabilitation at Berkeley West, Santa Monica. (S1) indicated she has phoned family and left messages to check on resident but has not received any return calls as of today. LPA unable to interview (S2) and (S3) due to work schedule is 10 PM - 6 AM. Record review indicated (R1) on the Morse Fall Scale (MFS) indicates score of 25 - Level 2- Implement standard fall prevention interventions. No medications taken. Elopement Risk Evaluation indicates (R1) , yes - for wandering and Yes- for wandering around looking for a spouse or family member. An exit interview was conducted and a copy of this report was provided to the Executive Director, Dawn Smith.
2024-07-19Other VisitNo findings
Plain-language summary
This was a pre-licensing inspection on July 19, 2024, for a facility designed to serve 160 elderly residents, with approval for up to 20 residents in hospice care. Inspectors toured all five floors and found the facility met all requirements: the building was clean and safe, medications were properly stored, bathrooms and bedrooms had adequate space and supplies, the kitchen had proper food storage and equipment, emergency systems were in place, and required postings were visible. No corrections were needed before the facility could be licensed.
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On 7/19/24 Licensing Program Analysts (LPA’s) Deborah Lee, Yolanda Rosser and Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized administrator: Tracy Flaherty. The licensee has applied for a license to serve (160) elderly residents age range 60 and over. The fire clearance is approved for (160) non-ambulatory only. Approved hospice waiver for (20). A tour of the entire facility was conducted: 1 st , 2 nd , 3 rd , 4 th , and 5 th floors, kitchen, common areas, outside of facility, medication rooms, records room, bathrooms, activity room, fitness center, and cinema room. The following was observed during this visit: MEDICATIONS There are locked storage areas for Resident medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly. Report continues 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 BEDROOMS There is a space for client’s own furniture that will accommodate a bed, a chair, a nightstand, a lamp, reading lights and a chest of drawers. BATHROOMS There is at least (137) toilet and washbasin per six (6) clients, family, and personnel. There is at least (137) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is between 105F°. and 120F°. Bathrooms are located inside clients’ bedrooms. There are nightlights in the hallways outside non-private bathrooms. SUPPLIES There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. Report continues 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 RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. DELAY EGGRESS and SECURE PERIMETER Delay egresses are located on the 1 st floor memory care entry. MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for commercial laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. Copy of liability insurance was email to LPA during this visit. Report continues 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 During this pre-licensing inspection, LPAs did not find corrections were needed. LPA Iniguez conducted the Component III Orientation with the administrator and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst. Exit interview conducted with Tracey Flaherty/Administrator
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