Landmark Villa.
140-Bed Memory Care RCFE in Hayward's Mission Boulevard Corridor, reviewed on public record.
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Compared to 84 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.
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.
5 deficiencies on record. Each bar is a month with a citation.
Finding distribution
5 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
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?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Landmark Villa's record and state requirements.
State records show one Type A deficiency (actual harm) — what was the nature of this citation, what corrective action was taken, and what systems are now in place to prevent recurrence?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
CDSS investigated three complaints during the period on file — can you describe what those complaints concerned and whether any were substantiated?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
The facility has been cited under §87705 or §87706 for dementia care — what specific changes to staff training or care protocols resulted from that citation?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every inspection visit, verbatim.
22 inspections in the public record, most recent first. Plain-language summaries open first — click into any row for the full citation text.
2026-09-15Complaint InvestigationNo findings
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On 9/15/2026 at 12:00pm, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo arrived unannounced to conduct a health and safety inspection. LPAs met with Assistance Director, Heather Helton. LPAs then spoke with Interim Administrator Geraldine Tayo via phone and obtained verbal authorization for Helton to sign the report. LPAs toured facility with including but not limited to dining room, activity area, library, kitchen, common areas, and common bathrooms. During tour LPAs observed several residents in the dining room having lunch, in common areas, and staff on each floor. LPAs selected 2 apartments on 1 st floor, 3 on 2 nd floor, and 3 on the 3 rd floor to inspect. LPAs observed the evacuation chair on the 3rd floor. LPAs tested the hot water temperature in the common bathrooms on first floor. LPAs observed facility has a 7-day supply of non-perishable and 2-day of perishable foods. LPA reviewed and obtained the facility roster, personnel report (LIC500), the face sheet and medical assessment for 19 residents. LPAs review of the Annual Fire Sprinkler System dated 02/25/2026. The facility is noted to be clean, in good repair, and residents in care appear to be safe. There are no imminent health or safety concerns on today's date. No deficiencies cited on today's date. Exit interview conducted and a copy of this report provided.
2026-09-10Other VisitNo findings
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On 9/10/2026, at 11:00am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a health and safety inspection. LPA met with Business Office Director, Elizabeth Velega. LPA then met with Interim Administrator, Geraldine Tayo and explained the reason for the visit. LPA toured facility with Interim Administrator including but not limited to dining room, activity area, library, kitchen, common areas, and common bathrooms. During tour LPA observed several residents in the dining room having lunch, in common areas, and staff on each floor. LPA selected one (1) apartment on each floor to inspect. Apartments were #107, #220, and #314. LPA tested the hot water temperature in the common bathrooms on each floor. All three bathrooms met required hot water temperature. LPA observed facility has a 7-day supply of non-perishable and 2-day of perishable foods. LPA also observed there was a variety of foods. S3 assisted LPA with tour of kitchen while staff was prepping for dinner. S3 stated there are two (2) deliveries per week Tuesday and Saturday. LPA reviewed and obtained the facility roster, personnel report (LIC500), the face sheet and medical assessment for 19 residents. Before concluding the visit LPA observed residents participating in activities. The facility is noted to be clean, in good repair, and residents in care appear to be safe. There are no imminent health or safety concerns on today's date. No deficiencies cited on today's date. Exit interview conducted and a copy of this report provided.
2026-09-04Complaint InvestigationType B · 1 finding
“-Based on review of records, the licensee did not comply with the section above in Residents R2, R3 and R6's medical assessments more than a year old which pose a potential health, safety and/or personal rights risks to person in care.”
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On this day, 9/04/26, at 3:30 pm Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection. LPA met with Wellness Coordinator (WC) Rhea Medrano and informed the reason for visit. LPA toured facility with WC. LPA inspected including but not limited to dining room, activity area, library, kitchen, common areas, common toilets. LPA selected 2 residents apartments each on first, second and 3rd floors. LPA observed facility has 7-day of non-perishable and 2-day of perishable food supplies. LPA observed kitchen staff preparing dinner which consists of salad, chicken a la king, clam chowder soup and banana cream pie for dessert. Facility has running water and electricity. LPA interviewed 3 residents. LPA obtained copy of current resident. LPA checked 17 resident records and obtained copies of Face Sheet/ LIC601 Identification and Emergency Contact Information and LIC602A Physician Reports.s LPA observed the following: from 4:40 pm to 5:50 pm, Residents R2, R3 and R6's medical assessments more than a year old. LPA also observed Residents R1, R9, R17 current medical assessments (LIC602As) indicated ambulatory, however, R1's LIC602A indicated major neurocognitive disease and R9 and R17 use mechanical aid/equipment to ambulate. CONTINUED ON 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 Deficiency is cited from Title 22 California Code of Regulation and listed on 809D . Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Rhea Medrano. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
2026-08-27Complaint InvestigationNo findings
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On this day, 8/27/26, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection. LPA met with Executive Director (ED) Geraldine Tayo and informed the reason for visit. LPA also met with Assistant Administrator Heather Helton and Assisted Living Director (ALD) Leonora Ramos. LPA toured facility with ED and inspected including but not limited to dining room, activity area, library, kitchen, common areas, courtyards and common toilets. LPA selected 2 residents apartments each on first, second and 3rd floors. LPA observed facility has 7-day of non-perishable and 2-day of perishable food supplies. Facility has running water and electricity. LPA obtained copies of current resident roster and LIC500 Personnel Report. LPA checked 17 resident records and obtained copies of LIC601 Identification and Emergency Contact Information and LIC602A Physician Reports. At 2:00 pm, LPA observed Resident R6's medical assessment (LIC602A Physician's Report) indicated R6 is bedridden but R6 can reposition by self. Exit interview conducted and copy of this report provided to Geraldine Tayo.
2026-08-07Other VisitType B · 1 finding
“-Based on interview and observation, the licensee did not comply with the section in heavily soiled and dilapidated carpet on stairwells which pose a potential health, safety and/or personal rights risks to persons in care.”
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During investigation, LPA obtained copy of LIC500 Personnel Report and interviewed the Maintenance Director (MD). LPA inspected the 5 stairwells and the stair going to the parking garage with Assisted Living Director (ALD) and MD. All 5 stairwells and stair were observed with heavily soiled carpets. LPA also observed dried leaves on one of the stairwells and some of the edges of the stairs with black tape.Two of the 5 stairwells were also observed with dilapidated carpet. Therefore, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 California Code of Regulation and listed on 9099D . Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed over the phone with Executive Director (ED) Geraldine Tayo in the presence of the MD and ALD . The ED authorized ALD to sign and receive this report. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
2026-08-04Other VisitType A · 1 finding
“-Based on observation, the licensee did not comply with the section above in unlocked and unattended laundry and housekeeping rooms which pose an immediate risks to persons in care.”
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On this day, 8/04/26, at 11:40 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct inspection to ensure the health and safety of residents. LPA met with Assistant Administrator (AADM) Heather Helton, and informed the reason for visit. LPA later met with Executive Director Geraldine Tayo. LPA toured the facility inside out with AADM. LPA inspected including but not limited to the dining room, kitchen, activity room, library, courtyard. Food supplies were observed adequate. LPA randomly selected 2 apartments each on first, 2nd and 3rd floors for inspection. Five stairwells checked. Facility has running water and electricity. Hot water in the one of the bathrooms was tested and measured at 109.7 degrees Fahrenheit. LPA interviewed 3 staff and 1 resident. LPA obtained copies of current LIC500 Personnel Report and resident roster. .....continued on 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 observed the following: at 12:15 pm, unlocked and unattended laundry room on the first floor. at 12:16 pm, unlocked and unattended housekeeping room on the first floor where cleaning supplies are stored. at 12:24 pm, unlocked and unattended laundry room on the second floor. from 12:40 pm to 12:55 pm, 1 out of 5 stairwells has no evacuation chair. Deficiencies are cited from Title 22 California Code of Regulations and Health and Safety Code and listed on 809D. Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with the Executive Director. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
2026-07-27Other VisitNo findings
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At 3:00 p.m. on this day, July 27, 2026, a virtual meeting was called. The meeting was arranged to review the Decision and Order with Prema Thekkek, licensee, Ms. Thekkek was not able to attend. The meeting was attended by the following: Regional Manager Isaac Taggart Licensing Program Manager Jeremy Fong Acting Licensing Program Manager Grace Luk Licensing Program Analyst Alicia Delmundo Vinod Nichani, Legal Counsel for Prema Thekkek and Anthony Thekkek Attorney Vinod Nichani was informed that the meeting was originally scheduled to review a Decision and Order excluding Prema Thekkek. The Regional Office (RO) was informed by the attorney that the licensees would like to surrender the license. ....continued on 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 Regional Manager Taggart informed Mr. Nichani that two statues are involved, depending on whether a licensee forfeits the license, or sells the business with a prospective buyer submitting an application. The requirements of the two statutes (Health and Safety Codes) were reviewed with Mr. Nichani, who was also informed that the Decision and Order to remove Prema Thekkek from the current license must be done on this date, July 27, 2026. Mr. Nichani stated that he will begin immediately working with the Licensees for removal of Ms. Thekkek and a change of ownership. Mr. Nichani indicated that a prospective buyer has been identified and that he will work with licensees to finalize this arrangement. Mr. Nichani was also informed that if a license application is submitted by the prospective buyer, the current licensees will remain responsible until the new license is issued. Copy of this report provided via email along with copies of Decision and Order and H&S Codes 1569.191 1569.682 to Mr. Nichani on this same day.
2026-07-27Complaint InvestigationNo findings
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At 3:00 p.m. on this day, July 27, 2026, a virtual meeting was called. The meeting was arranged to review the Decision and Order with Prema Thekkek, licensee, Ms. Thekkek was not able to attend. The meeting was attended by the following: Regional Manager Isaac Taggart Licensing Program Manager Jeremy Fong Acting Licensing Program Manager Grace Luk Licensing Program Analyst Alicia Delmundo Vinod Nichani, Legal Counsel for Prema Thekkek and Anthony Thekkek Attorney Vinod Nichani was informed that the meeting was originally scheduled to review a Decision and Order excluding Prema Thekkek. The Regional Office (RO) was informed by the attorney that the licensees would like to surrender the license. ....continued on 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 Regional Manager Taggart informed Mr. Nichani that two statues are involved, depending on whether a licensee forfeits the license, or sells the business with a prospective buyer submitting an application. The requirements of the two statutes (Health and Safety Codes) were reviewed with Mr. Nichani, who was also informed that the Decision and Order to remove Prema Thekkek from the current license must be done on this date, July 27, 2026. Mr. Nichani stated that he will begin immediately working with the Licensees for removal of Ms. Thekkek and a change of ownership. Mr. Nichani indicated that a prospective buyer has been identified and that he will work with licensees to finalize this arrangement. Mr. Nichani was also informed that if a license application is submitted by the prospective buyer, the current licensees will remain responsible until the new license is issued. Copy of this report provided via email along with copies of Decision and Order and H&S Codes 1569.191 1569.682 to Mr. Nichani on this same day.
2026-07-02Other VisitNo findings
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On this day, July 2, 2026, at 10:40 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit in regard to the licensee transferring the operation and license of the facility. LPA met with Executive Director (ED) Geraldine Tayo and explained the purpose of the visit. LPA called and spoke over the phone with Prema Thekkek, licensee/corporate officer of HCRC, Inc. On January 1, 2026, Prema Thekkek submitted to the Department a copy of notification to the residents and residents family members dated January 1, 2026 pertaining to change of ownership, of which LPA received on January 2, 2026. The notification indicated that effective January 1, 2026, the facility was transitioning to new ownership, and that the new licensed operator will be Integral Community Care, LLC (DBA: Mission Community). Integral Community Care, LLC did not submit new application for license. LPA conducted case management visit on January 6, 2026 and the Department conducted an Office Meeting with Prema Thekkek and Executive Director at that time on January 13, 2026. Deficiency is cited from Title 22 Health and Safety Code and listed on 809D. Deficiency was discussed with Prema Thekkek over the phone in the presence of Geraldine Tayo. Exit interview conducted. Appeal Rights and copy of this report provided.
2026-04-22Other VisitNo findings
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LPA obtained copy of current LIC500 Personnel Report which showed Geraldine Tayo as administrator. LPA interviewed Geraldine Tayo (IADM) and staff, S1 and S2. IADM stated she is still the interim administrator and works 5 days a week and off on 2 days but available on the phone and on-call 24/7. She further stated that when she learned S2 took administrator certification, she encouraged S2 to be the administrator but she (IADM) is still in-charge of the operations of the facility. S1 confirmed Geraldine Tayo is the interim administrator and that S2 never said she is the administrator. S2 stated Geraldine Tayo is the administrator and that she never introduced herself to the residents nor staff that she is the administrator. Based on information gathered, the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiency cited. Exit interview conducted and copy of this report provided.
2026-04-03Other VisitNo findings
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...Continued from 9099 On the allegation: Facility does not have active liability insurance Based on LPA’s record review, the facility does have current and active liability insurance. S1 stated they have no intention of letting it lapse when the renewal is due. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.
2026-04-03Complaint InvestigationUnsubstantiatedNo findings
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...Continued from 9099 On the allegation: Facility does not have active liability insurance Based on LPA’s record review, the facility does have current and active liability insurance. S1 stated they have no intention of letting it lapse when the renewal is due. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.
2026-03-19Other VisitNo findings
Plain-language summary
On March 19, 2026, the licensing program responded to an unusual incident report from the facility regarding a resident who fell on February 28, 2026, and was found on the floor with bruises and confusion; the resident was hospitalized and diagnosed with a fracture in the lower back. The resident was placed on hospice care on March 4, 2026, and died on March 7, 2026. No violations were found.
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On this day, March 19, 2026, at 11:20 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) submitted by the facility on March 2, 2026. LPA met with Geraldine Tayo, interim administrator (IADM), and informed the reason for visit. UIR indicated that on February 28, 2026, at around 2:35 pm, resident (R1) was found on the floor in his living room by care staff during safety check. R1 presented with confusion and bruises on the back and face. R1 was sent out and came back the same day. R1 was diagnosed with a transverse process fracture on lower back which will heal on his own time. LPA reviewed R1's file and obtained copies of including but not limited to LIC602A Physician's Reports before and after fall incident; Notification of Hospice Initiation; Death Report; Appraisal; LIC625 Appraisal/Needs and Services Plan; hospital After Visit Summary LPA conducted interview. IADM stated R1 was placed on hospice care on March 4, 2026 and passed away after few days. Death Report showed R1 passed away on March 7, 2026. No deficiency cited. Exit interview conducted and copy of this report provided.
2026-02-10Other VisitNo findings
Plain-language summary
On February 10, 2026, state inspectors conducted a surprise health and safety check and found no violations. The facility was clean and well-stocked, residents appeared safe, and all staff on duty had passed background clearances. No concerns were identified during the inspection.
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On 02/10/2026 at 9:35 AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted an unannounced Case Management Health and Safety check. LPA met with Administrator, Geraldine Tayo and explained the purpose of the visit. During the health and safety check, LPA observed a total of nine (9) Staff throughout the facility. Residents were gathered in the front common areas preparing for the social activity of Bingo. LPA conducted a tour of the facility, including but not limited to residents' bedrooms, bathrooms, common areas, kitchen, and outdoor areas. LPA observed that the kitchen was clean and the food supply was sufficient. Refrigerator temperature was observed at 33 degrees Fahrenheit and the walk-in freezer at negative 10 degrees Fahrenheit. Clients in care appear to be safe and there are no imminent health/safety concerns on today's date. LPA checked four resident files and four staff files, and 4 of 4 were fingerprint cleared and associated to the facility. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
2026-02-02Other VisitType B · 2 findings
Plain-language summary
During an unannounced visit on February 2, 2026, inspectors found that the facility did not have an adequate supply of hygiene products and was missing a former staff member's personnel file. These violations were documented and the facility was notified that failure to correct them may result in penalties.
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“Based on observation, the licensee did not comply with the section cited above by not having adiquate hygiene supplies avaliable for residents in care which poses a potential health and safety risk to persons in care.”
“Based on record review, the licensee did not comply with the section cited above by not having former staff file avaliable which poses a potential health and safety risk to persons in care.”
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On 02/02/2026 at 3:15PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a case management visit. LPA met with Administrator, Geraldine Tayo. While LPA Carol Fowler was at the facility for a complaint investigation (#15-AS-20260130110921), the following deficiencies were observed. During the complaint investigation, LPA observed that the facility didn't have an adequate supply of hygiene supplies. While LPA was conducting a record review and the Administrator informed LPA that the former staff file was missing from the facility. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, and appeal rights provided.
2026-01-13Other VisitNo findings
Plain-language summary
On January 13, 2026, state licensing staff held a virtual meeting with the facility's leadership to address several administrative issues, including an improper subletting arrangement that was to be withdrawn, unpaid annual licensing fees that the licensee committed to paying immediately, and a letter sent to residents and families that needed to be rescinded. The facility is in the process of changing ownership, and the state outlined requirements for the prospective new management company, including fingerprint clearance and other documentation that must be submitted to state licensing. No violations related to resident care were identified during this meeting.
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At 2:00 p.m. on this day, January 13, 2026, a virtual meeting was called. The meeting was attended by the following: Licensing Program Manager Jeremy Fong Licensing Program Analyst Alicia Delmundo Licensee/Corporate Officer Prema Thekkek Executive Director Diane Pederson The following were discussed: 1. Subletting of Lease Agreement - shall be withdrawn within 24 hours and submit proof by January 14, 2026. 2. Non-transferability of license (Title 22 section 87109). 3. Letter dated January 1, 2026 sent to the residents and residents' families to be rescinded and proof to be provided to LPA by January 20, 2026. 4. Outstanding annual fee due and late fee charge - Prema Thekkek indicated she is going to pay on this day. Proof to be submitted by tomorrow, January 14, 2026. 5. Process in having the prospective buyer of the property being brought in as management company and abbreviated application and documents to be submitted to Sacramento. Fingerprint clearance and association requirements for the 2 individuals who are/will be in the facility while application is in the process. A copy of this report provided via email to Prema Thekkek and Diane Pederson.
2026-01-06Annual Compliance VisitNo findings
Plain-language summary
During a routine visit, the facility's leadership discussed a recent change of ownership with the state inspector. The inspector reviewed the notification that was sent to residents and families on January 1, 2026, and provided guidance on regulatory requirements and the process for obtaining a new license under the new ownership.
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While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo discussed with Executive Director (ED) Diane Pederson the copy of notification to the residents and residents family members dated January 1, 2026 pertaining to change of ownership. The copy was received by LPA on January 2, 2026. LPA discussed the process with the ED and refer the ED to Title 22 Regulations 87109 and Health and Safety Code 1569.191. LPA also discussed the submission of application for new license. LPA requested ED to have LPA updated. Exit interview conducted and copy of this report provided.
2025-09-11Other VisitNo findings
Plain-language summary
This was a routine annual inspection conducted on September 11, 2025, which included a full tour of the facility, review of eight resident apartments, medication records, and interviews with residents and staff. No violations were found. The facility maintained proper food storage, working safety equipment, appropriate hot water temperatures, and current emergency plans and insurance documentation.
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On this day, September 11, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA toured the facility inside out with ED. Facility is a 3 story building. LPA inspected the common areas, library, kitchen, dining room, yard, common bathroom and laundry room on the second floor. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Freezers and refrigerators temperatures are checked by kitchen staff and recorded daily, and records showed temperatures were within Regulations range. LPA randomly selected 8 residents apartments for inspection - 2 on the first floor, 3 on the second floor and 3 on the third floor. Hot water temperature in one of the resident's apartments was tested and measured at 110.6 degrees Fahrenheit. The 2 in 1 carbon monoxide and smoke detectors in another resident's apartment was tested and observed in working condition . Facility has evacuation chairs on stairwells . Facility conducts disaster drills at least every quarter, and records showed last conducted August 16, 2025 LPA reviewed 5 staff and 5 resident's files, and interviewed 4 residents. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Record. Facility does not handle resident's cash resources/P&I. .....continued on 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 received the following updated/current documents on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate No deficiency cited during today inspection. Exit interview conducted, and copy of this report provided.
2025-05-14Other VisitNo findings
Plain-language summary
An inspector made a follow-up visit on May 14, 2025 to continue gathering information from a case management review that began in January. The inspector met with the executive director and conducted interviews, and found no violations.
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On this day, May 14, 2025, at 11:35 am, Licensing Program Analyst arrived unannounced to continue the case management visit that was started on January 23, 2025 to obtain additional information. LPA met with Executive Director (ED) Diane Pederson, and informed the purpose of visit. LPA conducted interviews. No deficiency cited. Exit interview conducted and copy of this report provided.
2025-05-14Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
This was a complaint investigation into five allegations about care for a resident, including pressure injuries, diaper changes, hygiene, staff responsiveness, and respectful treatment. Investigators interviewed staff members, the resident's family, other residents, and reviewed home health records, but could not obtain information directly from the resident in question or from certain staff and home health personnel. Based on their investigation, all five allegations were found to be unsubstantiated.
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Page 2 LPA conducted inspection with ED on 2/07/22. LPA interviewed the following: staff (ED, S1, S2, S4, S5, S6) on 2/07/22, 9/28/23, 9/05/24, 9/13/24 and 4/30/25; R1’s family member (FM1) on 9/13/24; residents (R2, R3, R4, R6, R7, R8) on 2/07/22, 9/28/23 and 4/30/25. LPA tried to reach staff (S3) and home health nurse (HH1), but they did not return LPA’s calls. Allegation: Resident (R1) sustained pressure injuries while in care. S1 stated she does not remember if R1 had pressure injury but thinks R1 had some redness which is usual when one is staying long on the chair and R1 was attended by home health. S2 stated she was not assigned to R1 but observed caregivers attended to R1. S4 stated she does not remember R1 because residents come and go but if she observes skin issue, she reports to the med-tech and she repositions resident every 2 hours. S5 and S6 stated R1 had pressure injury. S6 also stated that that was also the reason R1 was visited by home health which was also stated by FM1. S5 and S6 stated R1 was a difficult resident. S5 further stated when R1 was repositioned, R1 returned to her original position. R1 was provided wedge; however, R1 asked the staff remove it. Review of home health records showed R1 was certified and re-certified for home health care from 2021 to 2022 and at some point, during these periods, R1 was visited by home health due to pressure injury. On 3/08/22 document indicated R1 was discharged from Home Health. It was noted on the document that R1 has no unhealed or stage 2 or higher pressure injury and had no stasis ulcer. Based on interviews and records review, and LPA unable to obtain information from R1, S3 and HH1, the allegation is unsubstantiated. Allegation: Resident's diapering needs are not being met. It was reported that when HH1 asked R1 to stand up so HH1 can see R1’s buttock wound, R1 said, “Let me first pee in my diaper” and when R1 was done, HH1 helped remove the diaper and amount of urine was weighing 2-3x of urine episode and that was causing the stage 2 pressure injury in the buttock. ..............................continued on 9099C (page 3) 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 Page 3 FM1 stated once or twice R1 called her and told her she was not changed but FM1 said it was something she was not aware of. Although FM1 stated that she run a couple of times when she visited and saw used diaper in a plastic bag in R1's bed, she never observed R1 soaked in urine nor not changed. S1 stated when R1 does not come down to the dining room, S1 goes to R1's room to give R1 medications and S1 observed caregiver changing R1's diaper. There were times when R1 will call for assistance and S1 hears the front desk calling for caregiver to attend to R1. S2 stated she never visually observed R1 soaked in urine or soiled and not being attended. S2 also stated she saw caregivers come and go to R1's room to attend to R1. S4 stated she changes residents’ diapers 3x during her shift and as needed. S5 stated residents who need assistance in changing diaper are changed regularly and as needed. S6 stated she changed residents' diapers every 2 to 3 hours and more often if resident is a frequent wetter. S6 further stated that R1 was a frequent wetter and a lot of time, R1 refused to be changed. Six of the residents interviewed stated the staff assist them when they need help. One of this 6 residents has been living in the facility for 8 years and stated that she needs assistance in changing diaper and staff change her 4 to 5 times and as needed. This resident further stated she never had rashes, UTI and/or pressure injury. Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated. Allegation: Resident's hygiene needs are not being met. It was reported that HH1 observed feces between R1’s buttock and some part at R1’s back which showed that the feces had been sitting there and that when staff wiped off, R1 was not cleaned entirely . .......continued on 9099C (page 4) 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 Page 4 FM1 stated R1 complained about the water being cold and would not want to take a bath, but FM1 tested the water and the temperature was okay. FM1 also stated that when FM1 started coming to the facility, R1 started taking a bath. All 6 residents interviewed stated the staff assist them when they need help. When LPA conducted inspection during the 10-day visit, when LPA and the ED entered one of the residents’ apartment, LPA observed a caregiver present and assisting the resident in that apartment. Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated. Allegation: Staff does not assist resident when requested. All 6 residents interviewed stated the staff assist them when they need help. When LPA conducted inspection during the 10-day visit, when LPA and the ED entered one of the residents’ apartment, LPA observed a caregiver present and assisting the resident in that apartment. Based on information gathered, and LPA unable to obtain information from HH1 and R1, the allegation is unsubstantiated. Allegation: Staff does not treat resident with dignity and respect. It was reported that HH1 observed the staff being disrespectful to R1. All staff interviewed denied being abusive to any residents. They stated they never observed other staff not treating residents with dignity and respect. ..............continued on 9099C (page 5) 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 Page 5 FM1 stated she never heard any staff being disrespectful to R1 or other residents. All 6 residents interviewed stated staff were never abusive to them and other residents. LPA reviewed Home Health records and documentation and didn’t observe any notes indicating HH1 observed abuse by facility staff. Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated. Based on interviews, observations and records review, there’s not a preponderance of evidence standard to prove that violations occurred, therefore, the 5 allegations are closed as unsubstantiated. Exit interview conducted and copy of this report provided.
2025-01-23Annual Compliance VisitNo findings
Plain-language summary
On January 23, 2025, the state inspected this facility in response to an unusual incident report about rough physical and verbal handling of a resident by a caregiver on January 19, 2025. The caregiver was immediately removed from the schedule and later terminated, and the resident's family and ombudsman were notified. No violations were found.
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At 12:30 pm on this day, 1/23/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) submitted by the facility on 1/20/25. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA also met with Resident Care Director Geraldine Tayo. UIR indicated that on 1/19/25 at approximately 5:00 am, staff (S2) stated she witnessed the caregiver (S1) physically and verbally handling resident (R1) roughly. S1 was removed from schedule and the ED notified R1's daughter, Ombudsman and Community Care Licensing. Investigation was conducted and S1 was terminated. LPA reviewed R1's file and conducted interviews. LPA obtained copies of resident roster, staff schedule, facility staff's statements, and including but not limited to the following R1's documents: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Appraisal and Re-appraisal No deficiency cited on this day. Exit interview conducted and copy of this report provided.
2024-09-05Annual Compliance VisitNo findings
Plain-language summary
On September 5, 2024, state inspectors conducted a routine annual inspection of the facility and found no violations. Inspectors reviewed resident and staff files, checked medication records against doctor's orders, tested safety equipment including fire extinguishers and smoke detectors, inspected 12 resident apartments across all three floors, and verified food storage and kitchen practices were adequate. The facility's infection control plan, emergency procedures, and insurance documentation were all current.
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On this day, September 5, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Executive Director (ED) Diane Pederson, and informed the reason for visit. LPA also met with Resident Services Director Geraldine Tayo. ED submitted an updated Infection Control Plan on September 28, 2023. LPA toured the facility inside out with ED. Facility is a 3 story building. LPA inspected the common areas, activity room, library, kitchen, dining room. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Freezers and refrigerators temperatures are checked by kitchen staff and recorded daily. Medication room was observed attended by staff. LPA randomly selected 12 residents apartments for inspection - 4 on the first floor, 4 on the second floor and 4 on the third floor. Hot water temperature in one of the common bathrooms was tested and measured at 113.6 degrees Fahrenheit. Facility has carbon monoxide and smoke detectors that were observed in working condition. Fire extinguisher in the kitchen checked, observed fully charge with tag showed serviced January 11, 2024. Facility has evacuation chairs on stairwells . Facility conducts disaster drills at least every quarter, and records showed last conducted June 11, 2024. LPA reviewed 5 staff and 5 resident's files. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Record. Facility does not handle resident's cash resources/P&I. .....continued on n809C 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 Page 2 LPA received the following updated/current documents on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate No deficiency cited during today inspection. Exit interview conducted, and copy of this report provided.
6 older inspections from 2021 are not shown above.
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