Oakland Heights Senior Living.
Oakland Heights Senior Living is Ranked in the top 48% of California memory care with 13 CDSS citations on record; last inspected Apr 2026.




Large Memory Care Community in East Oakland's Fruitvale Area, reviewed on public record.

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Compared to 93 California facilities with a similar number of beds.
RCFE memory care · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
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.
FACILITY WATCH · BETA
Oakland Heights Senior Living has 13 citations on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
13 deficiencies on record. Each bar is a month with a citation.
Finding distribution
12 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 Oakland Heights Senior Living's record and state requirements.
State records show one Type A deficiency indicating actual harm to a resident — what was the nature of this citation, what corrective actions were taken, and what safeguards now prevent recurrence?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Sixty complaints have been filed with CDSS during the period on file — how many were substantiated, what were the primary concerns raised, and what operational changes resulted?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
With 197 licensed beds operated by Pacifica Oakland LLC, what is the staff-to-resident ratio on each shift, and how does staffing scale across the three building addresses on the campus?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every inspection visit, verbatim.
37 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-04-28Other VisitNo findings
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On 04/28/2026 at 10:30 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver an amended complaint dated 01/30/2026. LPA met with Executive Director Anthony Garcia and explained the purpose of the visit. Amended 9099. Created new 9099 with a Substantiated allegation. Exit interview conducted and a copy of this report provided.
2026-04-28Complaint InvestigationSubstantiatedType B · 1 finding
“Based on observation, the licensee did not comply with the section cited above by not having the supplied pendent functioning which posed a potential health and safety risk to persons in care.”
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Continued from LIC9099 When the pendant is pressed, an alert will prompt on three monitors spaced throughout the facility. The alert shows who is calling for help and where the resident is calling from. Staff respond to the alert and touch their ID badge to the pendent to clear the alert. S2 demonstrated to LPA how the pendants alert and operate. The pendent will flash yellow when pressed to indicate a low battery, and the resident is instructed to inform staff when the battery gets low. S3 informed LPA that residents in Independent Living are instructed and reminded to inform staff when the battery gets low so staff can change out the battery. S3 reported that R1 was given a pendent with instructions on how to operate and check the battery, however R1 had never informed staff of a low battery nor brought the pendent in for staff to look over. Although staff instructed in R1 how to operate and check the battery status of the provided pendent, it is still the responsibility of staff to monitor the pendent and ensure it is in working condition. As staff did not regularly inspect the pendent after giving it to R1, staff did ensure the pendent was functioning, therefore the allegation is SUBSTANTIATED. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . Deficiency is cited from Title 22 California Code of Regulations (see LIC9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in an additional civil penalty. Deficiency and plan and proof of correction were discussed with Executive Director Anthony Garcia f Exit interview conducted, Appeal Rights, and a copy of this report provided.
2026-04-06Other VisitType A · 2 findings
Plain-language summary
During a health and safety inspection on April 6, 2026, inspectors found that hot water temperatures in bathrooms exceeded safe levels, ranging from 100 to 120 degrees Fahrenheit. The facility had adequate food supplies, working carbon monoxide detectors, a complete first-aid kit, and current fire extinguishers, though the smoke and fire alarm system was undergoing repairs at the time of the visit. The facility was cited for the hot water temperature violations and given a deadline to correct these issues.
“Based on observations and record review, the licensee did not comply with the section cited above by having unlocked medications such as polyethylene glycol in R1’s room in memory care and unlocked bug spray in the common area which posed an immediate safety risk to persons in care.”
“Based on observation, the licensee did not comply with the section cited above by having the water temperature measured at 100.1 degrees Fahrenheit which poses a potential safety risk to persons in care.”
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On 04/06/2026 at 12:00 PM, Licensing Program Analyst (LPA) P. Manalo conducted a Health & Safety inspection as a result of a priority 2 complaint. LPA met with Executive Director, Anthony Garcia and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 100.1, 104, 106, and 120 degrees Fahrenheit in the hallway bathrooms and/or resident bathrooms. There are 7-days of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies twice a week. Carbon monoxide detectors were observed in operating condition. Smoke/ Fire Alarm is undergoing repairs and reinstallation by vendors Bay Alarm. First-aid kit was complete. Fire extinguisher was last serviced on 04/24/2025 and 04/01/2026 all around the facility. Liability Insurance is effective from 10/01/2025 to 10/01/2026. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Executive Director. Appeal Rights and a copy of this report provided.
2026-02-25Complaint InvestigationType B · 1 finding
Plain-language summary
State inspectors visited the facility on February 25, 2026, to follow up on a complaint about the admission agreement. They found that the facility's contract incorrectly required residents to pay for bed bug treatment and pest control costs, but California law makes the facility responsible for maintaining safe, clean living spaces—costs cannot be shifted to residents. The facility was cited for this violation and told to correct it or face financial penalties.
“This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by including bed bug appendix in the admission agreement which poses a personal rights violation to the persons in care.”
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On 2/25/2026 at 3:00PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a case management visit to follow up facility’s inclusion of a Bed Bug Addendum in resident’s admission agreement. LPAs met with Executive Director, Anthony Garcia and informed him the reason for the visit. LPAs reviewed the facility’s current admission agreement/contract dated 1/9/2026. This includes Appendix J Bed Bug Addendum which reads, “As such, you shall be responsible for any damages incurred by us as a result of such infestation, including but not limited to the cost of treatment for the Community and any surrounding units as recommended by a qualified and licensed pest control company…” Per regulation 87468.1(a)(2), resident shall be “...accorded safe, healthful and comfortable accommodations, furnishings and equipment.” Additionally, under regulation 87303(a), “the facility shall be clean, safe, sanitary and in good repair at all times.” Therefore, it is the facility’s responsibility to ensure residents are provided with safe, healthful, and comfortable accommodations which includes bed bug eradication. The cost cannot be transferred to the residents in care. An admission agreement shall not contain any written or oral agreements to waive facility responsibility for 'the provision of safe and healthful facilities, equipment and accommodations.' The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.
2026-02-09Other VisitNo findings
Plain-language summary
A licensing analyst visited the facility on February 9, 2026, to review an addendum added to residents' admission agreements that requires them to accept responsibility for bed bug issues or risk eviction. The facility provided a copy of the updated agreement, and no violations were found during this unannounced case management visit; the state said it will review the addendum further and conduct another visit.
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On 02/09/26 at 12:40PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Case Management visit to review the facility’s inclusion of a Bed Bug (Appendix N) Addendum on current and future residents’ admissions agreements dated 11/2024 and January 2025 as stated in the notification sent by ED dated 12/05/25 to all residents of the facility. This Addendum requires each resident to agree to the Lease and Bed Bug Addendum (Appendix N) terms and conditions or face potential eviction or termination of their lease agreement. LPA met with executive director (ED) and explained the purpose of the visit. At 12:55PM, LPA obtained a signed copy of resident's current admission agreement with Bed Bug Addendum (Appendix N) included. ED stated the new version of the residency admission agreement was approved by Licensing on 11/07/24 when there was a change in ownership and new management at the facility effective 01/10/2025 under Oakland Heights Senior Living. LPA advised ED the Department will review current residency admission agreement with Bed Bug Appendix N Addendum and follow-up with another case management visit. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.
2026-01-30Other VisitNo findings
Plain-language summary
This was an investigation into a complaint that staff did not respond timely to a resident's call for help after a fall. The investigation found that the resident's emergency pendant had a dead battery that the resident never reported to staff, so staff had no way of knowing it wasn't working; when another resident alerted staff to the fall, they responded immediately and called 911, and paramedics arrived promptly.
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Continued from LIC9099 When the pendant is pressed, an alert will prompt on three monitors spaced throughout the facility. The alert shows who is calling for help and where the resident is calling from. Staff respond to the alert and touch their ID badge to the pendent to clear the alert. S2 demonstrated to LPA how the pendants alert and operate. The pendent will flash yellow when pressed to indicate a low battery, and the resident is instructed to inform staff when the battery gets low. S3 informed LPA that although the signal system will show on the monitor if a battery is getting low, but it is not full proof, and residents in Independent Living are instructed and reminded to inform staff when the battery gets low so staff can change out the battery. S3 reported that R1 was given a pendent with instructions on how to operate and check the battery, however R1 had never informed staff of a low battery nor brought the pendent in for staff to look over. Residents in Assisted Living have their pendent batteries checked by care givers periodically. R2 informed LPA R2 does not like to wear the pendent and never checks it. R2 did tell LPA that R2 was shown how it operates and instructed to inform staff of a low battery or have staff look it over to ensure it is functioning. R2 is in Independent Living. Since R1 had not altered staff to the battery in the pendent being dead, nor did R1 ever have staff inspect the pendent since it was given to R1, staff had no way to ensure the pendent was functioning or not, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff did not answer resident's calls for assistance timely Investigation Findings: It was reported to the department that the facility did not answer the resident’s call for assistance timely. The facility had issued a wearable emergency fob to R1 that did not function resulting in another resident having to seek assistance for R1. LPA spoke with R3, the resident that sought help for R1. R3 heard R1 fall, walked into the kitchen and saw R1 on the floor. R1 told R3 that R1 pressed the pendent, but it did not light up to indicate it made the call. R1 then asked R3 to call for help. R3 walked out of the apartment and to the front desk of the facility and asked S3 to call 911. S3 called 911, EMTs responded promptly. S3 also informed caregivers in the facility that R1 had fallen, and caregivers went to the room to assist. R3 reported staff acted immediately when informed of the fall, therefore the allegation of Staff did not answer resident’s calls for assistance timely is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is 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 was provided.
2026-01-30Complaint InvestigationUnsubstantiatedNo findings
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Continued from LIC9099 Investigation Findings: It was reported to the department that the facility did not answer the resident’s call for assistance timely. The facility had issued a wearable emergency fob to R1 that did not function resulting in another resident having to seek assistance for R1. LPA spoke with R3, the resident that sought help for R1. R3 heard R1 fall, walked into the kitchen and saw R1 on the floor. R1 told R3 that R1 pressed the pendent, but it did not light up to indicate it made the call. R1 then asked R3 to call for help. R3 walked out of the apartment and to the front desk of the facility and asked S3 to call 911. S3 called 911, EMTs responded promptly. S3 also informed caregivers in the facility that R1 had fallen, and caregivers went to the room to assist. R3 reported staff acted immediately when informed of the fall, therefore the allegation of Staff did not answer resident’s calls for assistance timely is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is 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 was provided.
2025-11-24Complaint InvestigationSubstantiatedType B · 1 finding
Plain-language summary
A complaint investigation found that the facility charged a resident for bed bug treatment costs, which is not allowed—facilities must cover pest control expenses to maintain safe living conditions. State law requires that residents receive safe and sanitary accommodations at no additional charge for basic facility maintenance like pest eradication. The facility has been cited for this violation.
“Based on record review the licensee did not comply with the section cited above. Licensee added a bed bug addendum to the admissions agreement requiring residents to pay for bed bug eradication, which poses a potential health, safety or personal rights risk to persons in care.”
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The Bed Bug Addendum stipulates that residents are responsible for paying for any bed bug treatment. Per statute and regulation, residents have a right to be accorded safe, healthful, and comfortable accommodations under HSC Code §1569.269(a)(5) and 22 CCR §87468.1(a)(2). Facilities must be maintained in clean, safe, sanitary conditions under 22 CCR 87303(a). Therefore, it is the facility’s responsibility to ensure that residents are provided with safe, healthful, and comfortable accommodations. This includes maintaining the facility in a clean, safe, and sanitary condition, which encompasses pest control and bed bug eradication. This cost cannot be transferred to the residents in care. This agency has investigated the complaint that the facility is charging the resident for cost of pest treatment. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided.
2025-08-06Other VisitNo findings
Plain-language summary
Inspectors made an unannounced visit on August 6, 2025, to request documentation from the facility's pest control company covering the previous six months. No violations were found during this visit, and the facility was asked to provide records showing the scope of pest control work and treatment locations.
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On 8/06/25 at 2:30 p.m., Licensing Program Analyst (LPAs) Greg Clark and Luisa Fontanilla arrived unannounced to conduct a case management visit on this date to request documents. LPAs meet with Anthony Garcia, Administrator (ADM) and explained the purpose of the visit. LPAs requested that ADM send LPA documents from the past 6 months from the pest control company that indicate the scope of work, what treatment is being done, where it is being done by 8/07/25. No deficiencies cited. Exit interview conducted conducted and a copy of the report provided.
2025-08-06Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
An investigator looked into a complaint about pests not being properly addressed at the facility. After interviewing residents and reviewing documentation of an outbreak report made to public health in July 2025, the investigator found the complaint to be unsubstantiated, meaning there was not enough evidence to prove the allegation occurred.
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S2 stated that she reported the outbreak to public health on 7/11/25 via phone and followed up with an email on 7/15/25. LPA reviewed the email documentation 7/15/25. Interviews with residents revealed that 4 of the 5 affected residents live in the independent side of the facility and as such do not receive any care. All 4 reported that when they started feeling symptoms they sought care from their physicians and once diagnosed they reported it to the facility. LPAs attempted to interview R5’s conservator but was unable to reach her. This agency has investigated the complaint alleging facility staff are not properly addressing pests in the facility. We have found that the complaint was unsubstantiated. 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, a copy of this report provided.
2025-07-24Annual Compliance VisitNo findings
Plain-language summary
An unannounced inspection visit was conducted on July 24, 2025 to review case management practices. The inspector requested documentation of all pest control treatment invoices for 2025 to be provided by July 30, 2025. No violations were identified during this visit.
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On 7/24/25 at 2:50 PM Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit. LPA met with Anthony Garcia, Administrator(ADM) and explained the purpose of the visit. LPA requested that ADM send LPA all invoices related bug bed treatment for the year 2025 by 7/30/25. Exit interview conducted, a copy of this report provided
2025-07-24Complaint InvestigationSubstantiatedCitation on file
Substantiated — the state found a violation and issued a citation. Full citation details are on file with the state.
2025-07-02Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that the facility failed to keep the home free from pests. An investigation found no violation—the facility has a weekly pest management contract with a professional service and maintenance staff available daily, and when bed bugs were reported in one resident's apartment, the pest control company inspected and treated it on July 2, 2025, clearing the issue.
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*** report continues from LIC9099*** S1 stated that the facility has a contract for routine pest management with Orkin who come out to the facility weekly. The facility also has maintenance staff on duty to treat issues as they arise on a daily basis. As soon as S1 is made aware of bed bugs in R1’s apartment he calls Orkin to come out to access and treat the apartment. The apartment was checked on 7/2/25 by Orkin and is clear of bed bugs. This agency has investigated the complaint alleging staff did not keep the facility free from pest. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED .
2025-06-25Other VisitNo findings
Plain-language summary
This was a routine annual inspection on June 25, 2025, in which the inspector toured the facility, checked resident apartments and common areas, reviewed resident and staff records, and examined safety systems including fire detectors, emergency plans, and medication storage. The inspector found adequate lighting, appropriate temperatures, functioning safety equipment, proper food supplies, and complete records with no violations or deficiencies. All areas inspected—including bathrooms, kitchen, and emergency preparedness—met requirements.
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On 6/25/25, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Anthony Garcia and explained the purpose of the visit. LPA toured the facility including but not limited to 3 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a hallway bathroom was measured at 111.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 4/25/25. Emergency Disaster Plan was last signed on 7/29/24. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/24/25. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
2025-06-05Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
State investigators looked into a complaint that staff were not keeping the facility free of rodents. During their inspection, investigators did not observe any rodents in the resident's apartment, and found no evidence to support the complaint.
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***continues from LIC9099*** LPA's toured R1's apartment and observed that the sliding glass door is very difficult to operate. LPA's did not observe any rodents. This agency has investigated the complaint alleging staff do not keep the facility free of rodents . We have found that the complaint was unsubstantiated. 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, a copy of this report provided.
2025-05-19Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that staff were allowing a resident to smoke in his room. During the investigation, inspectors found no evidence of smoking in the resident's room, interviewed both the resident and staff, and confirmed the facility had placed the resident on a smoking cessation program with nicotine replacement therapy and issued a written warning about the facility's no-smoking policy—the complaint was not substantiated.
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LPA interviewed S1 who stated that there has been an issue with R1 smoking in his room that he and the corporate management of the facility have been dealing with the issue for several months. S1 also stated that R1 is currently on a smoking cessation program. R1 has nicotine gum and is on a nicotine patch. The facility has also issued R1 a later dated 5/14/25 that references that section of the admission agreement that R1 is in violation of and that if there is another incident of him smoking in his room he will be evicted. LPA reviewed the letter during the visit. LPA interviewed R1 in his room at the facility. LPA did not observe any cigarettes, ash trays or any other items that would indicate R1 was smoking in his room. R1 stated that he knows he must follow the rules or face eviction. R1 also stated that he like living at the facility and does not want to get “kicked out.” This agency has investigated the complaint alleging staff are allowing residents to smoke in the facility. We have found that the complaint was unsubstantiated. 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, a copy of this report provided.
2025-05-01Annual Compliance VisitNo findings
Plain-language summary
During an unannounced visit on May 1, 2025, the state investigated whether staff had received incorrect guidance about reporting resident information to the state. The inspector reviewed the relevant regulation with staff and found no violations. No deficiencies were issued.
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On 5/1/2025, at 3:30pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Anthony Garcia, Executive Director and explained the reason for the visit. While LPA L. Hall was conducting a complaint investigation 15-AS-20250318163614 information was ascertained that on March 17, 2025, S1 inquired with the Oakland Regional Office regarding Provider Information Notice Summary 24-13 (PIN) and was given the incorrect information. LPA reviewed regulation 87464, specifically section (e), with S1, to provide information regarding residents that receive SSI after being admitted to the facility. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.
2025-05-01Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
This was a complaint investigation into a resident's finances and potential eviction at a facility that only accepts private-pay residents. The investigator reviewed email communications between staff and the resident's guardian from February through April 2025 and found no violation of regulations.
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Continued from LIC9099. hadn't been any additional communication with any one at the facility regarding R1's financial change. S1 stated during initial interview the facility is a private pay facility only and do not accept SSI recipients. The rates for residents are set by corporate. During S1 interview on May 1, 2025, S1 stated he had heard that R1 was receiving SSI, and inquired with R1's guardian. LPA obtained email communication between S1 and R1's guardian dated February 4, 2025, regarding resources for R1, March 17, 2025, April 7, 2025, and April 17, 2025. S1 also stated there have not been any additional notices sent for the eviction process. S1 stated he has left messages with R1's family member, guardian, and ombudsman to meet and develop a plan to guide R1. On March 17, 2025, S1 inquired with the Oakland Regional Office regarding Provider Information Notice Summary 24-13 (PIN) and was given the incorrect information. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.
2025-03-27Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint investigation found no evidence that the facility failed to maintain a comfortable temperature, retaliated against a resident, or unlawfully evicted anyone. The investigator observed the memory care unit at an appropriate temperature with residents appearing comfortable, and found no record of complaints or retaliation. All allegations were unsubstantiated.
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Allegation: Facility did not provide comfortable temperature S1 stated that from time to time the thermostats in the Memory Care Unit need maintenance to operate properly. Upon notice of an issue S1 calls a HVAC company and they come out with-in a day or two to address the issue. LPA toured the memory care unit and found that the temperature in the unit was at a proper level and the residents all looked comfortable. Allegation: Facility staff is retaliating against the resident LPA found that there is no evidence to support this allegation. LPA observed R1 to be comfortable in the Memory Care Unit dressed in sweats and a black hoodie. LPA also could not find any evidence of any complaints filed regarding R1. This agency has investigated the complaint alleging: Unlawful eviction , facility did not provide comfortable temperature and facility staff is retaliating against the resident . We have found that the complaints were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.
2024-11-21Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that the facility failed to prevent smoking indoors and maintain a smoke-free environment. Investigators interviewed multiple staff members and residents; some recalled seeing a resident smoking near the building entrance as he left the property, while others stated they had never observed smoking inside the building or detected smoke odor. The complaint was found to be unsubstantiated due to insufficient evidence to prove the allegation.
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**REPORT CONTINUES FROM LIC 9099** LPAs reviewed the letter dated 11/08/2024 that serves as a reminder to smoke off site. S1 stated that every residents received the letter on their doors. LPAs interviewed S2 who stated that she suspects a resident on the first floor of the independent living building is lighting his cigarette as he is living the building which is a violation of the rule as he is not off site. LPAs interviewed S3 who stated that she has never seen anybody smoking in the independent living building and she has never smelled smoke. LPAs also interviewed R1 who stated that she has seen a resident who uses a scooter lighting up his cigarette as he finds his way off of the site. R1 further stated that she has never seen anybody smoking in the building. This agency has investigated the complaint alleging staff did not keep the facility free from cigarette odor". We have found that the complaint was unsubstantiated. 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, a copy of this report provided
2024-11-08Other VisitType B · 2 findings
Plain-language summary
This was a complaint investigation into pest control and admission practices. Inspectors found that one resident's apartment had bed bugs return repeatedly despite pest control treatments, and that the facility required residents to sign an agreement making them financially responsible for bed bug treatments and threatening lease termination if they refused to sign. The facility confirmed this addendum has been part of their standard admission agreement since 2020 and is mandatory for all residents.
“This requirement is not met as evidenced by the facility did not ensure the R1’s apartment was kept free of bed bugs.”
“This requirement is not met as evidenced by the facility threatening R1 with eviction if they did not sign the addendum to the admission agreement.”
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Allegation: Staff did not keep the facility free from pest infestation The RP stated that for the third time in a year R1’s apartment at the facility is infested with bed bugs. LPA interviewed S1 who confirmed that the apartment in question had in fact been infested with bed bugs numerous times over the past year and that treatments from the pest control company work for a time, but the bed bugs return. R1 also confirmed that the bed bugs continue to be an issue. Allegation: Staff threatened the residents with eviction RP reported that residents at the facility were forced to sign an admission agreement addendum stating that all treatments for bed bugs would be paid for by the residents and that if the residents did not sign the addendum their lease would be terminated. S1 confirmed that the bed bug addendum to the admissions agreement started getting rolled out in 2020 and is now part of the facility’s standard admissions agreement. S1 further stated that residents were required to sign the addendum or face eviction. R1 stated that she signed the bed bug addendum because she was getting too stressed out by facing possible eviction. An email sent to the RP from S1 stated, "…the addendum we are asking to have signed has been a part of our leases since 2020. We are requiring all resident (sic) to sign it. It is a condition of R1 staying in the community .” Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided.
2024-11-08Complaint InvestigationSubstantiatedType B · 2 findings
Plain-language summary
A complaint investigation found that one resident's apartment experienced repeated bed bug infestations over a year despite pest control treatments, and that the facility required residents to sign an agreement making them financially responsible for bed bug treatments or face eviction. The facility confirmed this bed bug addendum has been standard since 2020 and is a condition of residency. Both allegations in the complaint were substantiated.
“This requirement is not met as evidenced by the facility did not ensure the R1’s apartment was kept free of bed bugs.”
“This requirement is not met as evidenced by the facility threatening R1 with eviction if they did not sign the addendum to the admission agreement.”
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Allegation: Staff did not keep the facility free from pest infestation The RP stated that for the third time in a year R1’s apartment at the facility is infested with bed bugs. LPA interviewed S1 who confirmed that the apartment in question had in fact been infested with bed bugs numerous times over the past year and that treatments from the pest control company work for a time, but the bed bugs return. R1 also confirmed that the bed bugs continue to be an issue. Allegation: Staff threatened the residents with eviction RP reported that residents at the facility were forced to sign an admission agreement addendum stating that all treatments for bed bugs would be paid for by the residents and that if the residents did not sign the addendum their lease would be terminated. S1 confirmed that the bed bug addendum to the admissions agreement started getting rolled out in 2020 and is now part of the facility’s standard admissions agreement. S1 further stated that residents were required to sign the addendum or face eviction. R1 stated that she signed the bed bug addendum because she was getting too stressed out by facing possible eviction. An email sent to the RP from S1 stated, "…the addendum we are asking to have signed has been a part of our leases since 2020. We are requiring all resident (sic) to sign it. It is a condition of R1 staying in the community .” Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided.
2024-10-24Other VisitType B · 1 finding
Plain-language summary
On October 24, 2024, licensing staff conducted a case management visit after the facility notified the state of plans to convert part of the building to independent housing for people 55 and older while keeping the licensed memory care section open. The facility was already advertising for these independent renters and mixing them with memory care residents without getting state approval for this change, and staff found the facility had not provided adequate details about how it would manage the two different resident populations safely. The facility was cited for making this operational change without state permission, and was warned that failure to correct this could result in penalties.
“Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety, or personal rights risk to persons in care.”
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On 10/24/24 at 1:15 pm, Licensing Program Analyst (LPA) Greg Clark conducted a case management visit pertaining to a letter received by the Oakland CCL ASC Regional Office from the facility. LPA met with Executive Director(ED), Anthony Garcia and explained the purpose of the visit. On July 9, 2024, the Oakland CCL ASC Regional Office received from the facility a letter of intent to de-license the third floor of the physical plant and convert those units for Independent Individuals who are 55 years of age and older. The letter did not specifically request approval from CCL and had insufficient detail pertaining to how the co-mingling of Independent aged 55+ renters, and licensed RCFE Assisted Living residents, would be managed to ensure the Health & Safety of the Assisted Living residents. LPA interviewed the ED who stated that the facility currently has seven(7) 55+ independent living residents at this time. On 10/16/24 LPM Jeremy Fong and on 10/24/24 LPA Greg Clark and ED confirmed that the facility’s website is advertising for independent renters aged 55 and older, which constitutes a change to the Plan of Operation without having obtained approval from Community Care Licensing. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.
2024-08-23Complaint InvestigationUnsubstantiatedNo findings
2024-07-16Other VisitType A · 2 findings
Plain-language summary
During an unannounced annual inspection on July 16, 2024, inspectors found the facility generally well-maintained with adequate lighting, temperature control, locked medications, and working safety equipment, but identified two issues: medications were pre-poured and left in a drawer for several days rather than stored securely, and hot water in a hallway bathroom measured 147.2 degrees, which is too hot. The facility was required to correct these deficiencies by a specified deadline.
“Based on observation, the licensee did not comply with the section cited above. Hot water in the hallway bathroom was measured at 147.2 degrees F which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/17/2024 Plan of Correction 1 2 3 4 Administrator will submit a photo of the hot water temperture in the hallway bathroom within regulation by POC date.”
“Based on observation the licensee did not comply with the section cited above. LPA observed several days of pre-poured medication s in the med room which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/19/2024 Plan of Correction 1 2 3 4 Administrator will submit training records for all staff who pass medications in the proper storage and management of meds by POC date.”
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On 7/16/24 at 10:30 AM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit. LPA toured the facility including but not limited to residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 5/01/24. Emergency Disaster Plan was last posted on 6/01/23. First aid kit was observed to be complete. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. ***report continues on LIC809C*** 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 ***report continues from LIC809*** THE FOLLOWING DEFICIENCIES WERE OBSERVED: · LPA observed several days of medications pre-poured in a drawer in the med room. Hot water temperature in the hallway bathroom was measured at 147.2 degrees f. The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
2024-06-19Complaint InvestigationNo findings
Plain-language summary
An investigation found that a complaint about an unlawful eviction was unfounded — the facility properly followed legal procedures when initiating eviction after non-payment of fees, including sending a compliant notice to the person legally responsible. The facility had received initial payment but no further payments were made before starting the eviction process on March 1, 2024.
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Continues from LIC 9099 S1 stated that the facility received the initial payment for the care, but no further payments were made. S1 started the eviction process on 03/01/2024. Eviction letter was sent to the person legally responsible via registered mail and a copy provided to the resident.LPAs reviewed the letter and found it to be compliant with the regulation. This agency has investigated the complaint alleging staff unlawfully evicted a resident. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this report provided.
2024-04-30Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint about neglect of physical care was investigated following a resident's self-initiated call to 911 and subsequent hospitalization for mental health evaluation. Investigators found no violation—the resident was taking prescribed medication regularly, staff reported he was sometimes non-compliant with care and doctor visits but manageable, and there was insufficient evidence that physical care was neglected. The family expressed satisfaction with how staff handled the resident's care.
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Review of R1’s file revealed that R1 has a diagnosis of schizophrenia. Review of R1’s medication administration record reveled that R1 is compliant with taking his medication on a daily basis. On 4/20/24 R1 called 911 on himself and was transported to Kaiser Hospital. R1 was subsequently moved to St. Helena Hospital for further evaluation of his mental health condition where he remains as of today. There is no discharge date at this point. Interview with W1 revealed that he is happy with the care R1 receives at the facility and is hopeful that he can return to the assisted living side of the facility. W1 stating that R1 can be difficult, at times, to deal with and he feels facility staff do a good job dealing with R1. W1 also stated that facility staff keep him information of any issues regarding R1’s care or medical condition. Interviews with S1, S2 and S3 revealed that R1 is sometimes non-compliant but staff can usually gain his compliance. Interviews also revealed that R1 would refuse housekeeping services for months at a time and also refuse to see his doctors. All three staff stated that although R1 had his issues, they feel they can work with him to keep him safe and healthy. This agency has investigated the complaint alleging neglect of physical care. We have found that the complaint was unsubstantiated. 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, a copy of this report provided.
2024-04-04Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
This complaint investigation looked into allegations of abuse, neglect from dehydration, lack of supervision causing fractures, and failure to monitor a resident's decline in condition. The facility's staff reported they saw no bruises or signs of abuse during care, that the resident refused food for two days after learning of a family member's absence, and that staff documented the resident's declining condition and attempted to contact the family; an X-ray during hospitalization showed some fractures of unclear age, with one possible recent fracture that may have resulted from a fall in the facility. The state found the complaint unsubstantiated, meaning there was not enough evidence to prove the allegations occurred.
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On 7/02/23 R1 was observed to be below baseline behavior and was noted to have not eaten anything for 2 days. Facility staff called 911 and R1 was taken to San Leandro Hospital where he remained until returning to the facility on 7/08/23. Allegation: Resident sustained unexplained bruises from suspected abuse. Interviews with memory care staff revealed that while giving R1 his “bed baths” none of the staff observed any bruises, marks, or burns on R1. Staff also stated that R1 did not show any signs of pain from any type of fracture. Allegation: Facility staff neglected resulting in resident being severely dehydrated . Based on interviews and records R1 became depressed when W1 told him that he would be going out of town. Memory care staff attempted to feed R1 for 2 days (6/30 and 7/01/23) but he refused. On 7/02/23 R1 appeared weak and lethargic and refused to get up out of bed. 911 was called and R1 was sent out to the hospital. R1 was discharged back to the facility on 7/08/23. Allegation: Lack of supervision resulting in resident sustaining multiple fractures. At the time of admission R1 refused to let Pacifica staff perform a body check. Several small scratches were noted on R1’s elbow. W1 stated that he thought R1 was abused at his previous facility but didn’t provide any further details. While R1 was hospitalized (July 2-8, 2023) an x-ray was done. The x-ray revealed several fractures: a recent to semi-recent fracture on the right side of R1’s pelvis. This could have been caused by an incident at the facility where R1 slid down out of his wheelchair and ended up on the floor in a seated position. No hospital visit was made on that date, so the injuries are unknown. The x-ray also revealed that there was an old fracture to R1’s left collarbone and an older fracture to his lower back (T12 vertebra). The fractures were noted as “age indeterminate” meaning it was unclear how old these fractures were. ***report continues on LIC9099C*** 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 ***report continues from LIC9099C*** Allegation: Staff did not observe change of condition in resident Staff notes from R1’s file indicate that staff were documenting R1’s declining condition in late June and early July 2023. Staff also attempted to reach W1 to inform him but staff reported that W1 was difficult, at times, to get in touch with. The Department has investigated the complaint alleging resident sustained unexplained bruises from suspected abuse, facility staff neglected resulting in resident being severely dehydrated, lack of supervision resulting in resident sustaining multiple fractures and staff did not observe change of condition in resident. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.
2023-12-20Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint investigation found that the facility has both maintenance staff and a monthly pest control service available to treat residents' rooms for pests, and the person who filed the complaint could not provide information about whether the resident in question ever requested pest treatment. The allegations about pests and an elevator issue could not be substantiated due to insufficient evidence.
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LPA interviewed S1 who stated that the facility has a maintenance staff person on duty available to spray rooms upon request. There is also a monthly service contract with a pest control company also available to treat residents’ apartments for pests. The reporting party was not able to provide LPA with information if R1 ever requested treatment for pests. This agency has investigated the complaints alleging f acility elevator is in and staff did not keep facility free from pests. We have found that the complaints were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.
2023-09-08Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
An inspector investigated a complaint about lack of supervision and resident-on-resident altercations in the dining room. The inspector observed a lunch service with about 50 residents, 4 servers, and 1 staff member present, saw no incidents during the observation, and interviewed 4 residents—three reported never witnessing altercations, and one reported occasionally hearing raised voices but no physical fights. The complaint was found to be unsubstantiated due to insufficient evidence.
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LPA observed the lunch service with about 50 residents having lunch, 4 servers and 1 care staff. There were no incidents during the observation. LPA interviewed 4 residents. Three of residents (R1, R2 and R3) interviewed reported that they have never seen or heard any altercations in the dining room. All 4 residents eat lunch in the Assisted Living dining room on a daily basis. R4 reported that he has on occasion heard voiced raised and some arguments happening. He has never seen anything escalate to a physical altercation. This agency has investigated the complaint alleging lack of supervision resulting in resident-on-resident altercations. We have found that the complaint was unsubstantiated. 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, a copy of this report provided.
2023-08-29Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A resident reported suspected bed bug bites on her arms in August 2023, and the facility promptly had the unit inspected and treated by a pest control company, which found and removed bed bug residue from wall decorations. The facility notified families, arranged for deep cleaning and heat treatment, and this complaint investigation found no violation of the facility's duty to prevent bed bugs in resident rooms. The investigation determined there was insufficient evidence to prove whether the alleged violation occurred.
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On August 21, 2023, R1 reported to facility staff that she felt that she had new bites on her arms. Facility nurse applied hydrocortisone to the bites and informed the ADM. ADM emailed the family of the occupants of the Unit to inform them that he would be formulating a plan. ADM then called Orkin to return and inspect the Unit. Orkin returned on August 25, 2023, and treated the Unit with a chemical dusting. Upon closer inspection Orkin discovered there were felt banners on the wall of the Unit that had been removed during the heat treatment with bed bug residue on them. On August 29,2023, Orkin the ADM met with the family of the occupants of the Unit. The Unit will be deep cleaned and then heat-treated next week. LPA toured Unit 115 and observed Orkin technicians cleaning the Unit. This agency has investigated the complaint alleging staff does not prevent residents room from bed bugs we have found that the complaint was unsubstantiated. 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, a copy of this report provided.
2023-08-25Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that the facility was in disrepair, residents were left in soiled diapers for extended periods, and rooms were not being cleaned. During the investigation, inspectors found the plumbing working properly, interviewed staff who reported changing diapers at least three times per shift, and observed clean flooring in resident rooms despite some personal items on the floor. The complaint was closed as unsubstantiated, meaning there was not enough evidence to prove the violations occurred.
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Page 2 During inspection, LPA turned on the faucets and flushed the toilets in residents rooms in Assisted Living and Memory Care Units, and didn't observe any clogging and water in the sink was observed draining properly. Executive Director stated that no pipe broke or have issue where water backed-up. If residents flushed paper towel in the toilet, the toilet clogged and they fix the problem right away. One out of six (6) staff interviewed stated that residents may at times use the sink in the toilet to clean cups, and food scraps may cause draining problem but they take care of the problem immediately. Four out of 5 residents interviewed stated didn't have clogging issue, and 1 was not able to provide information. Allegation: R esidents left in soiled diapers for an extended period of time. Four staff interviewed who had or still have direct contact and/or provided/providing care to the residents stated residents' diapers are changed at least 3x during shift. The other 2 staff indicated they have not observed any residents in soiled diapers. Five residents interviewed indicated either not using diaper, can toilet on their own or use diaper and being assisted or changed by staff. Allegation: Facility staff are not cleaning residents room. It was alleged that residents rooms were not cleaned, and their garbage not removed. Staff interviewed stated that rooms in Memory Care Unit are cleaned and trash taken out everyday while the the Assisted Living rooms are cleaned once a week. One out of 5 residents interviewed was not able to provide information on the cleaning of the room. LPA conducted inspection and although observed 2 rooms in Assisted Living unit with residents' belongings on the floor, the flooring was observed clean. ....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 Based on information gathered, the allegations of facility in disrepair, residents left in soiled diapers for an extended period of time, and facility staff are not cleaning residents room are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted, and copy of this report provided.
2023-08-10Other VisitNo findings
Plain-language summary
An unannounced annual inspection was conducted on August 10, 2023, and found the facility in compliance with no violations. The inspector reviewed the building and grounds, checked lighting, temperature, hot water safety, bathroom safety features, food supplies, and medication storage, and interviewed residents and staff. All areas met standards for resident comfort and safety.
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On 8/10/23 at 1:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to complete annual inspection. LPA met with Administrator, Anthony Garcia and explained the purpose of the visit. LPA toured the facility including but not limited to 4 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 110.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA interviewed 5 residents and 5 staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
2023-08-10Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint investigation looked into allegations that staff failed to change residents' diapers promptly, did not reposition a resident, the resident experienced unexplained weight loss, the elevator was broken, and the resident fell and was bruised. The investigator found no violation—the facility's explanation that incontinent residents are checked every 2-3 hours and changed as needed, that the weight loss was within normal range for her age, that the elevator was repaired within 6-8 weeks, and that the resident bruises easily due to her medications could not be contradicted by available evidence. No preponderance of evidence supported the allegations.
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Staff failed to change residents’ diapers in a timely manner. RSD stated that residents in memory care that are incontinent are checked every 2 -3 hours and changed as needed. This is not documented as it is part of the daily schedule for care givers. Staff not repositioning resident R2 is wheelchair bound and spends most of her day in her wheelchair. When R2 needs to be changed R2 is taken by staff to her bedroom and placed in her bed to be changed. RSD stated there is no record of R2 having any pressure sores. Resident had unexplained weight loss. R2 weighed 134.8 lbs. on 3/3/22 and 127 lbs. on 3/01/23 for a weight loss of 7.8 lbs. which is 5.7 percent. This is with-in the normal range of a person in their late 80’s. R2 also takes Ensure daily to help with weight maintenance. Facility elevator is inoperable. ADM reported that the memory care elevator was out of service for a period of 6 – 8 weeks while the elevator was getting an upgrade. The elevator was back in service on 4/04/23. Resident fell resulting in a bruise. RSD reported that R2 bruises easily due to the medications she takes. R2 is a fall risk but hasn’t had a fall in over 1 year. This agency has investigated the complaints alleging staff failed to change residents’ diapers in a timely manner, staff not repositioning resident, resident had unexplained weight loss, facility elevator is inoperable, and resident fell resulting in a bruise. We have found that the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.
2023-08-02Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged the facility had bed bugs. The facility contacted pest control companies immediately when notified of the issue in July 2023, scheduled treatment with Orkin for July 31, 2023, and the resident reported no longer being bitten after treatment; inspectors found no evidence of bed bugs during their visit.
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ADM stated that as soon as he was made of the situation (7/24/23) he and the facility maintenance director called Bay Area Bed Bugs, Orkin and several other companies. Orkin inspected the unit on 7/25/23 and responded with a proposal. ADM agreed to the proposal and the service was scheduled for 7/31/23. LPA received a copy of the Orkin invoice dated 7/31/23. LPA interviewed R1 who stated that she is no longer being bitten. R1 sated “they killed them all.” LPA toured Unit 115 and observed no evidence of bed bugs. This agency has investigated the complaint alleging facility has pests we have found that the complaint was unsubstantiated. 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, a copy of this report provided.
2023-07-13Other VisitNo findings
Plain-language summary
A routine annual inspection was conducted on July 13, 2023. The inspector reviewed staff and resident records and found no deficiencies during the portions of the inspection completed that day, though the inspector planned to return later to finish the full review.
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On 7/13/23 at 12:46 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Anthony Garcia and explained the purpose of the visit. The facility’s fire clearance was approved for a total of 197 residents of which 166 can be non-ambulatory and 10 bedridden. At 1:00 p.m., LPA reviewed 5 staff records and 5 of 5 are associated to the facility. At 1:40 p.m., LPA reviewed 5 residents records. LPA will return at a later date to complete the inspection. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
2023-07-13Annual Compliance VisitNo findings
Plain-language summary
This facility was inspected on July 13, 2023, following a priority complaint, and the inspector found no violations. The facility met health and safety standards, including proper water temperature, adequate food supplies, secure medication storage, working fire safety equipment, and unobstructed pathways.
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On 7/13/23 at 3:10 p.m., Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Administrator, Anthony Garcia and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 118.5 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 38 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observed. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/26/23. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
13 older inspections from 2022 are not shown in the free view.
13 older inspections from 2022 are not shown in the free view.
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