Terraces of los Gatos, the
CCRC
A Continuing Care Retirement Community (CCRC) offers multiple levels of care on a single campus — typically independent living, assisted living, and skilled nursing. Residents often enter under a long-term contract and can transition between care levels as their needs change. CCRCs in California are regulated by the California Department of Social Services.
800 Blossom Hill Road · Los Gatos, 95032
Quick facts
Quality snapshot
Updated April 25, 2026Compared to 19 California CCRC facilities of similar size, over the last 36 months.
Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →
Quality grade· click to show how this was calculated
Severity17thWeighted citations per bed
Repeats100thRepeat deficiencies as share of total
Frequency28thDeficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Quality grade· click to show how this was calculated
Weighted citations per bed
Repeat deficiencies as share of total
Deficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Terraces of los Gatos, the scores C−. Better than 48% of comparable California RCFE-CONTINUING CARE RETIREMENT COMMUNITY facilities. Severity: bottom 17%. Repeats: top 0%. Frequency: 28th percentile.
Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / ccrc / xl beds (19 facilities).
Citation severity over time
stableWeighted severity score per month · 24 months
Weighted score (24mo)
0
Finding distribution
6 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility
California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.
What training are all staff required to complete?22 CCR §87411
All direct-care staff must complete:
- 10 hours initial training within the first four weeks of employment.
- 4 hours annual in-service every year thereafter.
- Administrator certificate from a CDSS-approved program — 80 hours for first-time, 40 hours renewal every 2 years.
Ask on tour: Ask when the last staff training was completed and how it's tracked.
How many staff must be on duty overnight?22 CCR §87415
Based on 458 licensed beds:
3 awake caregivers on duty overnight, one on-call caregiver physically on premises, and one additional on-call caregiver.
State law adds one awake caregiver for each 100 residents above 200.
Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.
Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.
What health conditions can this facility legally accept or refuse?22 CCR §87612–87615
Restricted — allowed with physician order + care plan
- Supplemental oxygen
- Insulin and injectable medications
- Indwelling or intermittent catheters
- Colostomy / ileostomy
- Stage 1 and Stage 2 pressure injuries
- Wound care (non-complex)
- Incontinence
- Contractures
Prohibited — facility must refuse or discharge
- Stage 3 or Stage 4 pressure injuries
- Feeding tubes (PEG, NG, or J-tube)
- Tracheostomies
- Active MRSA or communicable infections requiring isolation
- 24-hour skilled nursing needs
- Total ADL dependence with inability to communicate needs
A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.
Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.
What must this facility report to the state — and how fast?22 CCR §87211 / WIC §15630
- ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
- 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
- 24 hrsAbuse without serious bodily injuryWithin 24 hours
- Next dayDeath of a residentPhone by next working day; written within 7 days
- Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
- WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure
Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).
How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
- 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
- 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
- 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
- 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
- 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.
See how these rules have been applied to this specific facility:
View state inspection record and citationsState records
California Dept. of Social Services · Community Care Licensing- License number
- 430708817
- License type
- RCFE-CONTINUING CARE RETIREMENT COMMUNITY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 458
- Operator
- Humangood & Humangood Norcal
Inspections & citations
18
reports on file
7
total deficiencies
5
Type A (actual harm)
Other visitDecember 18, 2025No deficiencies
Plain-language summary
This was a routine annual inspection of the facility's assisted living, memory care, and independent living units. The inspector reviewed resident and staff files, toured all areas including the memory care unit and emergency exits, tested safety systems (the memory care exit door alarm sounded and two caregivers responded within 20 seconds), checked temperatures and food storage, and confirmed fire safety equipment was in place and functional. No violations were found.
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Health Service Administrator (HSA). The facility has 40 Assisted Living residents and 16 Memory Care residents. License, ADM certificate, and Personal rights posters were observed in the facility. LPA reviewed 7 resident files and 6 staff files. LPA toured the Memory Care Unit. LPA tested the delay exit door. The alarm sounded when the exit door was pushed; and the door was able to open after 30 seconds. Two caregivers came on site around 20 seconds after the alarm sounded. The memory care unit has 16 bedrooms. LPA randomly picked up one resident room to inspect. LPA toured the activity room and living room, and dining area in memory care unit. Room temperature was observed at 74 degree F. LPA toured the memory care unit patio area. LPA toured Assisted Living unit. The elevator was observed functional. LPA toured 2 resident rooms in Assisted Living Unit. LPA toured the activity rooms, dining room. Laundry room and chemical supplies room were observed locked. Evacuation chairs were observed in the stairs. LPA toured the Independent Living Unit and toured one resident room and fitness center. LPA toured the common area. Two days perishable foods and seven day nonperishable foods were observed sufficient. Room temperature was observed at 74 degree F, hot water temperature was observed at 118 degree F. The temperature of the freezer was observed at 0 degree F and the temperature of the refrigerator was observed at 37 degree F. Medication room, laundry room were observed locked. Continue on LIC809-C. page 1 of 2. 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 facility was equipped with fire alarm, smoke and carbon monoxide detectors. Carbon monoxide detector was tested, and was working. Fire extinguisher was serviced on 4/24/2025. The last the facility fire drill was last conducted on 12/08/2025. No citation issued today. This report was reviewed with HSA and a copy of this report was provided.
Other visitDecember 10, 2025No deficiencies
Plain-language summary
On December 5, 2025, the facility reported four incidents: one resident received the wrong medication on December 2nd (the correct medication was given afterward, the resident was assessed and reported feeling fine, and the two medications had no harmful interaction), one resident reported lost jewelry, another resident reported a lost diamond watch, and a third resident's fiduciary reported possible financial abuse—all incidents were reported to police and are under investigation by the Department. The facility provided staff training in response to the medication error and stated it was the first incident involving that staff member. The Department indicated it may conduct a follow-up visit depending on the investigation results.
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Director of Wellness (DW) Alexandra Matjunas. DW stated all these residents live in Independent Living unit.On 12/05/2025, the Department received 4 incident reports regarding resident R1, R2, R3 and another incident report regarding R1. On 12/02/2025, resident R1 was given wrong medication nurse (S1) found the mistake immediately. R1 was also given the correct medication. S1 wanted to assessed R1 to check if R1 was fine but R1 refused and stated he/she was fine upon incorrect administration. R1 allowed S1 to assess later. The facility notified R1' PCP, and follows PCP's instruction. The facility notified pharmacist who stated the medications that S1 gave to R1 had no interaction to each other. DW stated R1 is fine and still lives in independent living unit. After the incident, the facility provide the staff training to S1, nurses and Med Techs. DW stated this is the first time of the incident regarding S1 and R1. On 12/01/2025, resident R2 reported R2's jewelry was lost to staff. Around 2:00PM, R1 called police department and reported the incident. DW stated police officers came to the facility to interview staff and residents. On 12/03/2025, Housekeeper supervisor reported that resident R3 lost Diamond Omega Watch. DM stated police officers came to the facility to interview staff and residents. Continue on LIC809-C. Page 1 of 2.. 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 12/03/2025, resident R1's fiduciary reported that someone outside may financial abuse R1. DW stated police officers conducted interview on 12/09/25. LPA interviewed DW, Housekeeper Supervisor, 3 residents, and 1 staff. LPA toured resident rooms. LPA obtained the staff training material, copies of the updates of the incidents, and the statement of staff. At this time, these cases are under review and the Department will conduct a follow visit if warranted. Exit interview was conducted with DW. The report was provided to DW for review. A copy of the report was provided to DW. Page 2 of 2..
Other visitSeptember 16, 2025No deficiencies
Plain-language summary
A staff member at the facility noticed a resident had difficulty breathing and a change in lip color on August 12, 2025, and called 911 immediately; the resident was hospitalized and died that same day from heart disease. State inspectors conducted a follow-up visit in September 2025, reviewed the resident's medical records and death certificate, and found no indication of wrongdoing by the facility. No violations were cited.
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Director of Wellness (DW) Alexandra Matjunas. Today's visit is to follow up with the case management visit on 09/04/2025. . On 8/12/2025, resident R1's private companion (PC) noticed that R1 breathing changed and lip turned in blue color. PC notified the facility wellness center. The facility LVN went on site and 911 was called immediately. R1 was sent to hospital. On 08/12/2025, at 08:55AM, R1 passed away in the hospital. On 09/04/2025, LPA conducted an unannounced case management visit at the facility. LPA interviewed DW and Health Service Administrator (HSA). LPA requested R1's physician report, assessment, and progress notes. On 09/09/2025, LPA received R1's death certificate. Based on the review of R1's death certificate, R1's cause of death is heart disease, natural cause. Based on the interview and records reviewed, there is no suspicion of R1's death. No citation noted today. Exit interview was conducted with WD. The report was provided to WD for review and signature. A copy of the report was provide to WD.
Other visitSeptember 4, 2025No deficiencies
Plain-language summary
An unannounced case management visit was conducted on June 4, 2025, after the facility reported that three unauthorized transactions had been made on a resident's bank account; the bank reimbursed the full amount, and the resident stated staff were helpful and had no complaints. Investigators interviewed the resident, facility staff, and a companion, and found no evidence to support that facility staff or anyone at the facility had access to the resident's banking information or were involved in the transactions. No violations were found.
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Assisted Living Director Lady Anthonett Turman (ALD). On 6/4/2025, the department received an incident report regarding resident R1 from ALD. On 6/6/2025, LPA interviewed ALD. ALD stated on 6/4/2025, R1's old bank account was closed and a new bank account was opened. On 6/6/2025, R1's bank already reimbursed the full amount of money of the 3 unknown transactions to R1. ALD provided the police report case number. ALD stated R1 did not leave bank statement in the room and did not have any missing check. LPA toured R1's room in the assisted living unit and interviewed R1. R1 stated he/she does not have any complaint. R1 stated the facility staff are helpful. R1 confirmed he/she received the refund from the bank of the full amount of money of the 3 unknown transactions. On 9/4/2025, LPA interviewed 3 staff and a private companion of R1. 4 out of 4 stated they never saw R1's bank statement, checkbook or bank card. Based on the interview and records reviewed, The investigation finding for this case is UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No Citation noted today. Exit interview was conducted with ALD. The report was provided to ALD for review and signature. A copy of the report was provide to ALD.
Other visitSeptember 4, 2025No deficiencies
Plain-language summary
During an unannounced visit on August 13, 2025, inspectors learned that a resident had experienced a change in breathing and bluish discoloration of the lips on August 12, 2025, prompting immediate calls to 911 and hospitalization. The facility's licensed nurse responded promptly and emergency services were called right away. The department is conducting further investigation and requested medical records and the resident's death certificate.
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Director of Wellness (DW) Alexandra Matjunas. On 8/13/2025, the Department received a report from DW regarding resident R1. On 8/12/2025, R1's private companion (PC) noticed that R1 breathing changed and lip turned in blue color. PC notified the facility wellness center. The facility LVN went on site and 911 was called immediately. R1 was sent to hospital. LPA interviewed DW and Health Service Administrator (HSA) Bill Penrod. LPA requested R1's physician report, assessment, and progress notes. DW stated he/she will send R1's death certificate to CCL office when available. This case needs further investigation. Exit interview was conducted with DW. The report was provided to DW for review and signature. A copy of the report was provided to DW.
Other visitJune 17, 2025No deficiencies
Plain-language summary
During an unannounced visit, state regulators delivered an immediate exclusion letter prohibiting a privately hired caregiver from having any contact with residents or being present at the facility, as the department determined this person poses a threat to resident health and safety. The facility administrator acknowledged understanding the exclusion and agreed the caregiver cannot work, live, or volunteer there. The caregiver was hired by a resident through a home care agency, not employed by the facility itself.
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Licensing Program Analysts Steve Chang conducted an unannounced case management visit and met with Health Service Administrator Bill Penrod (BP). The purpose of today's visit is to deliver immediate exclusion letter for an individual (referred as PC1). LPA read and explain the immediate exclusion letter to BP that the Department determined that PC1 must not have continued or future contact with clients/residents or presence in the facility constitutes a threat to the health and safety of clients/residents in care. BP agreed and understood that PC1 is not allowed to work, resident or volunteer in the facility. PC1 is not an employee or employed by the facility; he/she was hired by resident as Private Caregiver through a Home Care Agency (HCA). Exit interview was conducted with BP. The report was provided to BP for review and signature. A copy of this report and the exclusion letter for PC1 were provided to BP.
Other visitJune 6, 2025No deficiencies
Plain-language summary
During an unannounced visit in June 2025, state licensing staff investigated an incident in which a resident discovered three unauthorized transactions on his bank account; the resident's bank reimbursed the full amount, and the resident reported no complaints about facility staff. The facility director immediately notified the resident's family and police, and helped the resident close the compromised account and open a new one. The state indicated this case requires further investigation.
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Assisted Living Director Lady Anthonett Turman (ALD). On 6/4/2025, the department received an incident report from ALD. On 6/3/2025 at 11:25AM, ALD received a notice from resident R1 that his/her bank account has been hacked. There were 3 transactions he/she cannot recognize. ALD spoke with R1 and R1's family member. ALD suggested R1's family member to report to police depart. On 6/6/2025, LPA interviewed ALD. ALD stated on 6/4/2025, R1's old bank account was closed and a new bank account was opened. On 6/6/2025, R1's bank already reimbursed the full amount of money of the 3 unknown transactions to R1. ALD provided the police report case number. ALD stated R1 did not leave bank statement in the room and did not have any missing check. LPA toured R1's room in the assisted living unit and interviewed R1. R1 stated he/she does not have any complaint. R1 stated the facility staff are helpful. R1 confirmed he/she received the full amount of money of the 3 unknown transactions. LPA requested R1's physician report and appraisal needs and service plan. This case needs further investigation. Exit interview was conducted with LAD. The report was provided to ALD for review and signature. A copy of the report was provided to ALD.
InspectionMay 15, 2025No deficiencies
Plain-language summary
A licensing analyst investigated a report from May 2025 that a private caregiver had abused a resident; the investigator interviewed facility staff and the resident's family but was unable to speak with the resident, who refused an interview. The investigator reviewed the resident's room and requested additional documentation including the resident's care plan and contract with the facility's operations company. The investigation was ongoing at the time of this report.
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Director of Wellness Alexandra Matjunas (DW). On 5/13/2025, the Department received a incident report regarding an private caregiver abuse a resident. On 5/14/2025, the Department interviewed a staff on the phone. On 5/15/2025, LPA interviewed DW, resident R1's family on the phone and NextGen Operation Supervisor on the phone. DW stated R1 is an independent living resident. LPA and DW went to tour resident R1's room and to interview R1, R1 refused to have an interview. LPA was unable to enter R1's room. LPA toured another room with similar layout as R1's room with DW. LPA requested R1's physician report, appraisal needs and service plan, and the contract between R1 and NextGeb. The case need further investigation. Exit interview was provided with DW. The report was provided to DW for review and signature. A copy of the report was provided to DW.
Other visitDecember 26, 2024No deficiencies
Inspector: Marcela Yanez
Plain-language summary
This was a routine annual inspection of the facility's assisted living, memory care, and independent living buildings. Inspectors found no violations, confirming that water temperatures, emergency exits, fire safety equipment, food supplies, resident records, and staff qualifications all met state requirements.
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Licensing Program Analysts (LPAs) Marcela Yanez and Manuel Monter conducted an unannounced Required 1 Year visit and met with Sandra Mirasol, Residential Living Director (RLD). LPAs stated the purpose of the visit. LPAs toured Assisted Living building with RLD inside and out, which include upstairs and downstairs. LPAs randomly inspected the following, but not limited to resident bedrooms: 45,47, 60, 66,70,and 72 LPAs randomly tested 4 resident bedrooms water with thermometer and measured range from 116.0 to 118.0 degrees F. LPAs also inspected the dining area and kitchen of the Assisted Living building . LPAs observed the kitchen area LPAs observed perishable food supply of at least two days and a non-perishable food supply of at least seven days . No obstructions were noted during tour. LPAs toured the Memory Care building inside and out. LPAs randomly inspected the following, but not limited to resident bedrooms: 1,2,3,4,5 and 9. LPAs randomly tested 6 bedrooms water temperature with thermometer and measured to range from 110.0 to 115 degrees F. LPA tested delayed egress doors which activated auditory sound when pressed. LPAs toured the Independent Living with RLD inside and out which included 3 floors and multiple different buildings. LPAs randomly toured the following, but not limited to, resident bedrooms: M151, M153, M154,M155, Q66,M355, and P397. LPA observed fire extinguisher was last serviced on 04/16/2024. LPA reviewed Fire and Earthquake log. the last Drill was last conducted on 12/06/2024. Facilities Sprinkler system was last inspected on 09/06/2024 Page 1 Out of 2. 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 reviewed resident records for 10 residents.. LPA reviewed 5 staff records and found them to be complete. LPAs interviewed 13 residents and 3 staff. LPA provided RLD with a flyer "Important updates to Dementia Care & Miscellaneous Changes, Effective January 1, 2025." LPA requested a copy of the following documents: 1.LIC 500, Personnel Summary 2. LIC 308, Designation of Administrative Responsibility 3.LIC400, Affidavit Regarding Client/Resident Cash Resources 4. Liability Insurance 5. Qualifications of Administrator (Certificate) 6. Please review your facility program for updates (incorporating new laws and/or regulations) No deficiency were cited as per California Code of Regulations Title 22. This report was reviewed with Residential Living Director Sandra Mirasol and a copy of this report and appeal rights were provided. Page 2 Out of 2. END OF REPORT.
ComplaintOctober 4, 2024No deficiencies
Inspector: Manuel Monter
Plain-language summary
A complaint investigation found that allegations of sexual abuse made by a resident during a temporary stay at a skilled nursing facility in September 2024 were unfounded—meaning the allegations were false or could not have happened. The resident was not at the facility operated by this home during the alleged incident; the resident had been transferred to the skilled nursing facility for rehabilitation following a fall. No violations were found.
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Staff S1 provided a detailed information of each 3 residents who were from their Assisted, Independent and Memory Care. 1 Out 3 residents (referred as R1) were transferred to Skilled Nursing Facility on September 2024, because of a fall while others need higher level of care and/or rehabilitation. S1 stated that R1 has never been back to his/her independent residence since he/she was admitted to SNF. S1 stated R1 will be returning to his/her independent living unit on September 28, 2024. S1 is the director of independent living unit wherein S1 was informed about the alleged sexual abuse by R1 that happened on September 19, 2024, and the investigation conducted by law enforcement agency at SNF. S1 stated that the alleged sexual abuse did not occur within the premises of the Assisted, Independent and Memory Units. S1 stated that they don't have staff working at SNF. Based on record review and interviews, R1 has neurocognitive disorder. On October 4, 2024, LPA Monter and Tarin interviewed Skilled Nursing Health Services Administrator (HSA). HSA stated resident R1 was located at the SNF from September 10 - September 28, 2024. HSA stated he/she is aware of the allegations that R1 has made during his/her stay at the SNF and reported it. HSA stated local law enforcement did come to the SNF and took a report. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, an exit interview conducted with Residential Living Director Sandy Mirasol and a copy of the report was provided. Page 2 Out of 2. END OF REPORT.
Other visitOctober 2, 2024No deficiencies
Inspector: David Marrufo
Plain-language summary
This was a follow-up visit on May 20, 2024, when a resident was found deceased in their bed; the resident had reported neck pain, vomiting, and a headache early that morning and refused an offer to call 911. Emergency services were called when the resident was discovered, and no facility violations were found during the investigation. The facility has not yet received a coroner's report on the cause of death.
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Peter Morris. The purpose of the visit was to follow up on a Death Report submitted to the Department on 05/21/2024. The Death Report stated that resident R1 was found deceased on 05/20/2024 at approximately 08:00 AM. The Death Report stated that R1 had complained of neck pain as well as having experienced vomiting and a headache at 12:01 AM on 05/20/2024. The Death Report states R1 was offered to call 911 but R1 refused. R1 was observed deceased in R1's bed at around 08:00 AM. During today's visit, LPA Marrufo interviewed staff S1 and S2. S1 stated to have received a call from R1's spouse on 05/20/2024 stating that R1 appeared deceased. S1 stated to have entered R1's living unit and observed R1 to be laying on R1's bed with R1's feet touching the floor and R1's back resting on pillows and blankets. S1 stated 911 was called and firemen, paramedics, and police arrived. S1 stated police approved of the removal of R1's body from the facility. S2 stated during interview that the facility has not received a coroner's report. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Peter Morris and a copy of this report was provided.
Other visitJanuary 24, 2024No deficiencies
Inspector: Manuel Monter
Plain-language summary
The state visited the facility to correct an error from a previous complaint investigation report issued in January 2024, where an incorrect violation had been cited. No new violations were found during this visit, and the facility was provided with an amended report reflecting the correction.
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Licensing Program Analyst Manuel Monter conducted an unannounced case management to amend a complaint investigation deficiency page, LIC9099-D issued on January, 22, 2024.( 26-AS-20230404163203) LPA met with Residential Living Director Sandy Mirasol. The deficiency page is being amended due to citing the incorrect deficiency. LPA printed out a copy of the amended report. LPA requested Residential Living Director resend POC, with updated code section. No deficiencies cited during todays visit. A copy of the report was provided to Residential Living Director Sandy Mirasol.
ComplaintJanuary 22, 2024· SubstantiatedCitation on file
Inspector: Manuel Monter
Substantiated — CDSS found a violation and issued a citation. Full citation details are on file with the state.
Plain-language summary
A complaint investigation found that two private caregivers engaged in financial misconduct, including misuse of resident money and property and failure to provide proper care. The facility was cited for violations related to these findings. The administrator was notified and provided with the full report and information about appeal rights.
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page 2 of 2 Continuation from page 1 Based on investigation, document reviews, and interviews, private caregiver 1(PC1) & private caregiver 2 (PC2) engaged in conduct that is inimical to the health and morals, welfare or safety of either an individual in or receiving services. PC1 & PC 2 engaged in acts of financial malfeasance concerning the operation of a facility, including, but not limited to, improper use or embezzlement of client moneys and property or fraudulent appropriation for personal gain of facility moneys and property, or willful or negligent failure to provide services for the care of clients. Based on documentation, interviews and observation, the preponderance of evidence standard has been met therefore the above allegations are found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights was provided.
Other visitDecember 22, 2023No deficiencies
Inspector: Maria Partoza
Plain-language summary
On December 22, 2023, state licensing inspectors conducted an unannounced case management visit and delivered exclusion letters for two private caregivers, meaning these individuals are no longer permitted to provide care at the facility. No violations were found during the visit.
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On 12/22/2023 at 3:30 p.m. Licensing Program Analysts (LPAs) Steve Chang and Maria (Mita) Partoza conducted an unannounced Case Management visit and met with Health Services Administrator (HSA) Bill Penrod and explained that the purpose of the visit was to hand deliver a letter of exclusion for 2 individuals private care giver 1 (PC 1) and private care giver 2 (PC 2) from the facility. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Health Services Administrator Bill Penrod and a copy of the report was provided.
InspectionSeptember 22, 2023No deficiencies
Inspector: Chihhsien Chang
Plain-language summary
During a death investigation visit, the Department reviewed the case of a resident who was found unresponsive in the bathroom on July 1, 2023, and was pronounced dead by paramedics. The resident's physician records showed the cause of death was heart disease. No violations were identified at the facility.
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Licensing Program Analyst (LPA) Steve Chang conducted a Case Management - Incident investigation visit to deliver the investigation finding and met with Executive Director Jud Severns (ED). On 07/05/2023, the Department received a death report of resident R1 from the facility that R1 was found dead at R1's bathroom on 07/01/2023. On 7/6/2023, R1's physician report and appraisal Needs and Service Plan were obtained. On the same day, LPA interviewed Resident Service Director (RSD). RSD stated on 07/01/2023, R1 was found on the floor of the bathroom and was unresponsive. 911 was called immediately. Paramedics came and announced R1 passed away. During 7/6/2023 and 9/12/2023, investigation was conducted. Based on the reviews of R1's medical records, the cause of the death of R1 was heart attack disease. Based on the interviews conducted and documents reviewed, R1's direct cause of death was heart disease. No deficiency or citation were issued today. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.
ComplaintJuly 11, 2023No deficiencies
Inspector: Simranjit Rai
Plain-language summary
A family member complained that the facility failed to provide a resident's medical records as requested. The facility did not follow its own procedure for handling medical records requests by not involving the appropriate management team, though it eventually provided most of the records about a month after the initial request; however, the state investigator found the core complaint allegation to be unfounded.
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On 06/16/20, LPA interviewed staff at the facility and subsequently requested for documents of the facility’s correspondence with R1’s responsible party (RP). On 06/17/20, the facility provided the department with correspondence information they have provided to R1's RP. Between 10/02/20 and 11/23/20, the department obtained from RP, records of correspondence information between RP and the facility. Based on records review, RP signed a request form to access resident’s medical records on 04/25/20 and re-submitted a copy to the facility on 05/12/2020 as RP has not received R1's medical records from the facility. The request was dated from the resident’s admission date of 01/15/20 up to 12/31/20 (present). RP also provided a signed authorization form from R1’s doctor, for use or disclosure of resident’s health information. The form authorizes the facility to release all health information to RP pertaining to R1’s medical history, mental or physical condition and treatment received. As of the date of the complaint (05/12/20), the facility has only provided RP with resident’s medical records between 04/24/20 until 05/02/20. Based on a review of the facility's policy on medical records request, the facility has to notify their Legal/Risk Management Team wherein the facility did not refer this request which should have been handled accordingly hence the documents being released were incomplete and/or incorrect documents. The Garden Grove Director and the Resident Services Director had ongoing communication with the RP in various emails with ED and management team. ED stated, "... that any delays were certainly not intentional, as our fullest attention was providing direct care for the resident .." After a month from the date it was requested, R1's medical records were provided to R1's RP on 05/15/2020. This agency has investigated the complaint allegation listed. Based on interviews, review of records, and observations, the Department has found that the complaint allegation is unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. This report was reviewed with and signed by Charmaine Verador and Sandy Mirasol. A copy of the report was provided.
InspectionJuly 11, 2023Type A6 deficiencies
Inspector: Simranjit Rai
Plain-language summary
A state inspector conducted a follow-up visit regarding a previous complaint and found that three staff members worked at the facility without required criminal background clearances. The facility was cited for this violation and assessed a total civil penalty of $1,500, and must obtain criminal record clearances and additional paperwork for private caregivers working with residents.
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Licensing Program Analyst (LPA) Simi Rai and Licensing Program Manager (LPM) Romeo Manzano conducted a case management visit due to additional information received regarding a complaint the Department received 4/4/2023. During today's visit, LPA and LPMs met with R1 at his/her apartment in the Independent Living Unit. R1 was interviewed and also observed. R1 is dependent on all aspects of his/her daily living except making decision and still able to fed himself/herself. R1 has mild neurocognitve disorder. LPA and LPM obtained R1's records to include Physician Reports, Appraisal/ Needs and Services Plan. LPA and LPM obtained PC 1 and PC2's records available at the facility. R1 hired a private caregivers 24/7 who provide bath, prepare his/her breakfast, laundry and housekeeping. R1 is not conserved but his/her son has a power of attorney when R1s become incapacitated. Facility will obtain criminal record clearance and additional paperwork for private caregivers working with R1. Deficiencies are being cited. See LIC 809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for staff (S1), $500 ($100 per day x 5 days = $500) for staff (S2), $500 ($100 per day x 5 days = $500) for staff (S3) working at the facility without criminal record clearance, for a total of $1500. Please see LIC 421BG. Exit interview conducted with Director of Resident Services, Sandra Mirasol. This report was reviewed with and a signed copy was provided. Appeal Rights was provided.
Regulation
(b)The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by:
Inspector finding
Based on interview with Wellness Director and Independent Living Director of Resident Services failed to do any detailed followup on the financial abuse and completed an assessment on R1 which poses an immediate Health, Safety, or Personal Rights risk to persons in care
Regulation
87606 Care of Bedridden Residents: (c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
Inspector finding
Based on interview, observation and record review, R1 is bedridden per physician's report and the room in whcih resident currently resides in does not have a bedridden clearance from Fire Department poses an immediate Health, Safety, or Personal Rights risk to persons in care
Regulation
Observation of the resident: The licensee shall ensure that residents are regularly observed for changes ...and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by: Based on record review and interview,
Inspector finding
R1 is bedridden with contractures, incontinent (bowel and bladder), unabe to care for self including medication management due to neurocognitve disorder which requiring needs care and supervision which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
Regulation
Exception for Health Conditions: (a) ...the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement is not met as evidenced by:
Inspector finding
Based on observation and record review, the IL director did not submit an exception request for R1’s suprapubic catheter which poses a potential Health, Safety, or Personal Rights risk to persons in care
Regulation
(D) A third-party contractor or other business professional retained by the client and at the facility at the request or by the permission of that client. These individuals may not be left alone with other clients. This requirement is not met as evidenced by:
Inspector finding
Based on record review and interview, R1's private caregivers S1, S2, S3 were left alone in R1's room and had access to the facility and left unattended which poses a potential Health, Safety, or Personal Rights risk to persons in care.
Regulation
87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility. (1) Obtain a California clearance or a criminal record exception.... This requirement is not met as evidenced by:
Inspector finding
Based on interview and observation, S1, S2, and S3 worked for R1 and reside at R1's apartment without a criminal background clearance which poses a potential Health, Safety, or Personal Rights risk to persons in care.
ComplaintDecember 28, 2021No deficiencies
Inspector: Marybeth Donovan
Plain-language summary
This was the facility's required annual inspection, which included a review of infection control practices. The inspector toured the building, reviewed policies, and checked that staff are properly trained and equipped—finding no violations in areas like screening procedures, hygiene supplies, fire safety, and personal protective equipment.
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Sandra Mirasol Resident Services Director and Martin Knoll Resident Services Manager. LPA toured the facility inside and out to include entrance, Galleria area, dining area, mail room, activity rooms, bathrooms, salon, and exterior. All fire exit routes were free and clear of obstructions. Facility observed to have designated entry point for COVID 19 symptom screening with questionnaire. Bathrooms observed to be supplied with hygiene products and hand washing signs. Hand sanitizer available to residents and visitors throughout the facility. LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, supplies, PPE usage, and Fit Testing. All staff are Fit Tested. No citations issued per the California Code of Regulations Tittle 22. LPA reviewed report with Sandra Mirasol Resident Services Director and Martin Knoll Resident Services Manager and a copy of this report emailed due to technical issues.
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
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