Greenhaven Estates.
A large home, reviewed on public record.
Compared to 160 California facilities with a similar number of beds.
RCFE · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
Citation history, plotted month by month.
30 deficiencies on record. Each bar is a month with a citation.
Finding distribution
29 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Elopements, fires, epidemic outbreaks, and poisonings must be reported immediately. Abuse with serious bodily injury requires a 2-hour phone report + 2-hour written report to CDSS, Adult Protective Services, and law enforcement. Abuse without serious bodily injury must be reported within 24 hours. A resident death requires a phone call by the next working day and a written report within 7 days. Injuries requiring medical treatment beyond first aid, and bankruptcy/foreclosure/utility shutoff notices, must also be reported. Incidents not reported on time are a separate violation — families may file a complaint directly with CDSS.
Ask on tour
“When was the last incident report filed with CDSS, and may I see your incident log summary for the past 12 months?”
Every inspection visit, verbatim.
31 inspections in the public record, most recent first. Plain-language summaries open first — click into any row for the full citation text.
2025-12-04Complaint InvestigationUnsubstantiatedNo findings
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LPA and administrator met and discussed the activities calendar posted in a cental area of the facility. LPA monitored and observed all calendar activities taking place at the facility. Per discussions with Administrator LPA advised some revision to the activities calendar as some activities do overlap with dining services times and want to encourage as many individuals attending activities. LPA reviewed activities and determined the activities are meeting the requirements of regulations identified for planned activities. LPA also provided suggestions on obtaining feedback from residents on activities and how to get information from residents about new activities they may prefer. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of personal rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
2025-11-20Other VisitType A · 5 findings
“med tech arrived to provide medications for residents in assisted living which resulted multiple residents not receiving their medications for the morning of 11/1/25 which poses an immediate health, safety and personal rights risk to residents in care.”
“reports and resident statements that there was no coverage available to ensure residents in assisted living received their morning medications which poses an immediate health, safety and personal rights risk to residents in care.”
“met as evidenced by incident reports and resident and staff statements corroborating there was no AM med tech to provide medications to residents in care which poses an immediate health, safety and personal rights risk to residents in care.”
“sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case...Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. this requirements was not met as evidenced by LPA receiving Incident reports 17 days after the reported incident occurred which poses a potential health, safety and personal rights risk to residents in care.”
“staff are not documenting medications administered to residents timely as LPA observed some medications documented administered up to 4 hours after the medication was to be provided to the resident which poses a potential health, safety and personal rights risk to residents in care.”
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In review of medication administration records for one resident, LPA observed the facility is not appropriately documenting medications administered to residents as they are administered and LPA observed multiple dates where staff members did not document a medication after administered an would document the medications several hours after administered to residents in care. department also observed that there is no weekly staff schedule posted in a place where staff may observe the weekly schedule. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of medications is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home. 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 Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
2025-11-20Complaint InvestigationSubstantiatedCitation on file
Substantiated — the state found a violation and issued a citation. Full citation details are on file with the state.
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of qualifications is substantiated. Per the California Code of Regulations, Title 22, the following deficiency is cited. Due the the violation reoccurring in a 12 month period an immediate civil penalty will be issued. Other violations observed have been addressed on another Complaint Inspection on 11/20/25. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
2025-10-02Complaint InvestigationType B · 1 finding
“met as evidenced by LPA observations of the floor being visibly dirty with accumulated dirt and grime which poses a potential health, safety and personal rights risk to residents in care.”
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On 10/2/25 at 1:30pm Licensing Program Analysts (LPAs) Kevin Gould and Noel Wolf-Petersen conducted an unannounced case management deficiencies inspection to address observations of the facility. LPAs conducted a walk through of the facility and observed the dining room floor to be dirty and was apparent to LPAs that the floor is not regularly cleaned. LPAs each observed the floors to be sticky, with observable grime and dirt. LPAs informed staff who quickly assigned a staff member to clean the floor of the dining room. Per the California Code of Regulations, Title 22, the following deficiency is cited. Exit interview conducted and a copy o this report and appeal rights were left at the facility.
2025-08-27Annual Compliance VisitNo findings
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On 8/27/25 at 3:00pm LPA met with interim Administrator, Arlene Moreno (S1) to discuss the status of the appointment of a new administrator. LPA met with administrator and reminded staff that per title 22 regulations, The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator and the requirements for the facility to have a qualified and certified administrator. Per review of Administrator certifications records that an application for certification for R1 was received by the department on 6/9/25 and is in process of approval. The department will require the following documents to approve a new administrator when identified: LIC 200 (application) identifying new administrator and signed by the licensee LIC 500 (staff scheduled with all staff and new administrator) LIC 501 (Personnel Report) LIC 503 (Health Screening & TB clearance) Transcripts or diploma to meet education requirements of a facility with a capacity of over 50. Written statement or minutes from board of directors meeting appointing a new administrator.
2025-08-27Complaint InvestigationUnsubstantiatedNo findings
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LPA conducted interviews with three other residents who did not report any concerns with medications or call response times Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of medications and neglect/lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
2025-07-02Complaint InvestigationUnsubstantiatedNo findings
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
2025-05-15Complaint InvestigationType B · 2 findings
“Based on LPA observation, the licensee did not comply with the section cited above as LPA observed three outdoor maintenance storage areas that were lot locked or secured and contained materials which are required to be made inaccessible which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 05/23/2025 Plan of Correction 1 2 3 4 Licensee written Plan of correction including training provided to maintenance staff on securing items that may pose a danger to residents and a monthly checklist that certifies maintenance staff have ensured all items have been stored securely to be checked off daily. checklist will be completed for 6 months.”
“Based on LPA review of staff files , the licensee did not comply with the section cited above in 6 out of 6 files reviewed LPA could not verify annual training which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 05/23/2025 Plan of Correction 1 2 3 4 Licensee has agreed to provide an annual training plan that indicates the specific training topics, including dementia and medication training to be completed annually and the total 20 hour training to be completed each year.”
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On 5/15/25 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Greenhaven Estates for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Arlene Moreno and together conducted a tour of the facility. LPA and staff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed three outdoor maintenance storage areas were left unsecured and items that are required to be made inaccessible to residents were not secured. LPA reviewed staff files and was unable to verify all staff members have completed annual training of 20 hours with 8 hours of dementia care training. LPA measured the water temperature, temperature measured at 117 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
2025-04-24Complaint InvestigationUnsubstantiatedNo findings
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The staff member (S1) who responded and provided CPR to R1 provided statements that R1 was already cool to touch and had no pulse when they arrived to respond to R1's medical emergency. R1's partner, R2, does not believe R1's death was a result of any delay in medication administration. Local police have determined R1 passed of natural causes and is not investigating. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Questionable Death are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
2025-03-28Complaint InvestigationUnsubstantiatedNo findings
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Four of the residents interviewed stated the facility and dining rooms to be a comfortable temperature. LPA previously conducted an inspection to address the heath in the facility and LPA determined the heater is functioning properly and LPA observed the facility to meet the minimum heating requirements in previous inspections. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of physical plant are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
2025-03-14Complaint InvestigationUnsubstantiatedNo findings
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The facility recently purchased a new electronic door assist mechanism to ensure easy access for residents to access the designated smoking area and that it has already malfunctioned and is in the process of being returned. The facility has already obtained a quote for reinstalling a new electronic assist device for the door with push button access to automatically open the door for residents to ensure easy access the smoking area. LPAs also conducted a walk through of the common areas of the facility and observed several one area of the common space the thermostat was off and not blowing hot air. The temperature observed for this area still met regulations as LPAs observed a temperature of 68 degrees F. Administrator was able to access the thermostat and turn on the heat which did blow hot air. LPAs have determined that the heater is not in disrepair at the time of inspection. Administrator denied the have been any recent issues with the facility HVAC. LPAs also addressed concerns regarding the removal of garbage bins. LPAs met with administrator and facility chef. Both individuals interview denied ever witnessing any staff member transport garbage or human waste through the facility kitchen. Facility chef and administrator both confirmed only kitchen staff have access to the facility and administrator showed LPAs where staff are directed to remove garbage from the facility. The facility still has two large bins located in the front parking lot for disposing of waste for collection. Administrator provided statements the only bins that were removed were garbage bins from the common area laundry that staff members were dropping off waste/garbage from individual rooms and disposing in the common area laundry. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Physical Plant are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
2025-02-28Other VisitNo findings
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On 2/28/25 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced POC inspection to ensure previously cited deficiencies have been corrected as agreed upon by the department and facility representatives. LPA reviewed outstanding POCs and observed all corrections to have been made and all items identified are currently in compliance with title 22 regulations. POC letters generated and left at the facility. no deficiencies were observed or cited during today's inspection. Exit interview conducted and a copy of this report was left at the facility.
2025-01-31Complaint InvestigationUnsubstantiatedNo findings
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LPA reviewed facility loss prevention binder which appeared to be complete with documentation and no references to R1's property. Memory care staff interviewed admitted to R2 being a wanderer in memory care and will enter other resident's rooms but is easily redirected. Facility has documented ongoing efforts to manage R2's wandering with supervision and adjustments to medications. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Neglect/Lack of supervision and personal rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
2024-10-17Complaint InvestigationSubstantiatedType A · 3 findings
“resident sustained an injury as a result of vendors tools being accessible to resident who tripped on the tools resulting in an injury to their foot/toe that required medical attention which poses an immediate health, safety or personal rights risk to residents in care.”
“which poses an immediate health, safety and personal rights risk to residents in care.”
“attempted repair from a contracted vendor provided to LPA was 12 days after it was first reported to the facility which poses a potential health, safety and personal rights risk to residents in care.”
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LPA reviewed file for responding staff member and did not observe sufficient training to meet regulations of 20 hours of annual training, of which 8 should be dedicated dementia care. LPA observed only two hours of training in 2024 related to dementia and the initial training observed also did not meet regulations. LPA was also unable to review a first aid certificate for the responding staff member. Additionally, LPA has determined through communications with the reporting party and facility staff members the air conditioner was not operational from May 10, 2024 until it was repaired by an contracted vendor on 5/29/24. As the facility may have taken steeps to repair the A/C unit by facility maintenance staff, the initial contact with the contracted vendor as provided to LPA was 5/22/24 12 days after fist being reported. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of neglect/lack of supervision, physical plant and qualifications is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. As the injury to the resident was sustained as a result of a deficiency observed during the investigation, an immediate civil penalty is issued and may be evaluated for additional penalties by the department.. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility. 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 Department has investigated the complaint alleging Other. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed. There are no deficiencies cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff and a copy of this report was left at the facility.
2024-08-23Complaint InvestigationSubstantiatedType B · 1 finding
“of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by LPA testing hot water temperatures throughout the facility and no residential area recorded a hot water temperature to meet title 22 regulations as all waters tested were below title 22 regulations which poses a potential health, safety and personal rights risk to residents in care.”
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Physical Plant is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
2024-07-17Complaint InvestigationSubstantiatedType A · 2 findings
“members that facility has delays in response to calls for service which resulted in resident's needs not being met in a timely manner.”
“obtained from the facility indicating the state required elevator repairs in 2023 which were not completed in a timely manner resulting in the elevator being shut down in March 2024 by the state until repairs have been completed which poses a potential health, safety and personal rights risk to residents in care.”
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The adult family member interviewed also corroborated that call pendants were not responded to when family member had to use the restroom and could not locate any staff on the floor which resulted in resident soiling their briefs. In regards to the elevator not working or in disrepair, LPA conducted staff interview with former administrator who provided documentation that the elevator was inspected by state inspectors in 2023 and identified a phone system not working and required to be operational or the elevator would be deactivated. In March 2024, state inspectors returned and observed the phone system in the elevator to still not be operational and deactivated the elevator. The elevator was reactivated a few days later and the telephone was fully repaired and operational by March 26, 2024. LPA has determined the facility's delay in repairing the elevator phone was the cause of the elevator shut down in March 2024. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision and Physical Plant is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
2024-06-20Other VisitType A · 1 finding
“Based on LPA observations the licensee did not comply with the section cited above as LPA observed the kitchen storage to not be locked containing multiple drawers of sharp knives which poses an immediate health, safety or personal rights risk to persons in care.”
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On 6/20/24 at 12:45pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Plan of correction (POC) inspection to ensure past deficiencies cited have been corrected. LPA conducted a walk through of the facility and observed all light fixtures to be operating as designed. POC clearance letter generated. While conducting walk through, LPA inspected the kitchen storage closet and again observed the door to be unlocked and sharp knives were stored accessible to residents. Per California Code of regulations, Title 22 the following deficiency was cited. Due to the 2nd violation in a 12 month period, an immediate civil penalty was issued. A copy of this report and appeal rights were left at the facility.
2024-06-20Annual Compliance VisitNo findings
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On 6/0/24 at 12:45pm Licensing Program Analyst (LPA) Kevin Gould arrived at Greenhaven Estates for the purpose of conducting a continuation of the required 1 year annual inspection begun on 5/24/24. LPA met with Administrator, Debra Duval and together conducted a tour of the facility. LPA Gould completed file review of resident files. LPA observed most files to be complete with one resident requiring an updated LIC 602 as it was over a year old and is in need of renewal. Advisory note issued. Per California Code of regulations title 22, there were no deficiencies cited during today's inspection. Exit interview conducted and a copy of the report was left at the facility.
2024-05-24Other VisitType A · 9 findings
“Based on LPA observations, the licensee did not comply with the section cited above as LPA observed cleaning supplies and sharp object accessible to residents in the activity room, laundry room and kitchen storage area which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 05/28/2024 Plan of Correction 1 2 3 4 Facility will conduct training with all staff members to inform staff where items to be secured from residents may be stored and ensuring the doors are always locked. facility will provide documentation of training of all staff members to the department.”
“Based on LPA observations the licensee did not comply with the section cited above as LPA observed the kitchen storage to not be locked containing multiple drawers of sharp knives which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 05/28/2024 Plan of Correction 1 2 3 4 Facility will conduct training with all staff members to inform staff where items to be secured from residents may be stored and ensuring the doors are always locked. facility will provide documentation of training of all staff members to the department.”
“Based on record review, the licensee did not comply with the section cited above in 5 out of 6 staff files reviewed which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 05/28/2024 Plan of Correction 1 2 3 4 Facility will conduct training from an outside provider and renew first aid certificates for all staff members. All certificates will be placed in staff files for department review.”
“Based on LPA observations, the licensee did not comply with the section cited above as LPA observed several gloves disposed of in common area drawers and furniture which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 06/12/2024 Plan of Correction 1 2 3 4 Facility will conduct infection control training for all staff regarding the proper disposal, downing and doffing of PPE.”
“Based on LPA observations the licensee did not comply with the section cited above as LPA observed several common area hallway lights out and not working as designed which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 05/31/2024 Plan of Correction 1 2 3 4 Facility will ensure lighting in all common areas and resident bedroom are working and operating as intended.”
“Based on observations of memory care showers the licensee did not comply with the section cited above in two out of for bathroom showers which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 06/28/2024 Plan of Correction 1 2 3 4 facility will install non slip matt or strips an all bathrooms and showers.”
“Based on record review, the licensee did not comply with the section cited above as LPA was unable to review all staff files as the staff present did not have access to all staff file the department is required to review which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 05/31/2024 Plan of Correction 1 2 3 4 Written plan of correction to ensure administrator and their designee have access to all resident and staff records and be made available for department review.”
“Based on record review, the licensee did not comply with the section cited above in 4 out of 6 staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 06/28/2024 Plan of Correction 1 2 3 4 Facility has agreed to evaluate and inventory all staff and have ha health screening conducted and TB test completed for all staff who do not have a completed LIC 503 and do not have a TB test and all staff members who's TB test was conducted in house and not conducted by a licensed physician.”
“Based on record review, the licensee did not comply with the section cited above as there was no documentation for hands on training for any of the staff files reviewed by LPA which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 06/28/2024 Plan of Correction 1 2 3 4 Facility will review staff training records and will provide the department a written plan of correcting indicating the steps the facility will take to ensure staff receive and document 16 hours of hands on training.”
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On 5/24/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Greenhaven Estates for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Debra Duval and together conducted a tour of the facility. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture. LPA observed several lights out in common areas and hallways. LPA measured the water temperature, temperature measured at 114 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed cleaning supplies and sharp objects not secured from residents in the activity room, laundry room and kitchen storage room. LPA observed gloves not disposed of in a manner consistent with department infection control, LPA observed gloves in common area drawers. LPA observed two showers in Memory care without non-slip mats or strips on the floors. During staff file review LPA observed several staff files without health screening, tb test and first aid certificates. LPA was unable to verify staff training's meet requirements as staff present did not have access to all resident files at the time of inspection. 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 Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility. An annual continuation will be required to complete the annual inspection.
2024-04-11Other VisitType B · 1 finding
“to maintain the above temperatures This requirement was not met as evidenced by LPAs observations and logs of recorded fridge temperatures in excess of 40 degrees and observed to be as high as 45 degrees which poses a potential health, safety and personal rights risk to residents in care.”
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On 4/11/24 while conducting an unrelated complaint investigation. LPA Kevin Gould inspected the kitchen and observed refrigerator temperature's and temperature logs for refrigerators to be in excess of 40 degrees. LPA observed several logs for refrigerators with temperatures recorded over 40 degrees F. on several dates and some recordings of 45 degrees. Per title 22 regulations the maximum temperature allowed is 40 degrees F. Per California Code of Regulations, Title 22, the following deficiencies are cited. Exit interview conducted and a copy of this report and appeal rights were left at the facility.
2024-03-08Other VisitNo findings
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On 3/8/24 at 12:45pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to gather additional information regarding control of property and change of administrator. LPA met with executive director Melissa Del Dosso (S1) and together discussed recent changes at the facility, transition to a new management group and to obtain required documents to confirm appointment of new administrator. LPA, through discussions with the appointed administrator and the corporate representatives was able to confirm the submission of requested documents to confirm the appointment of a new administrator. Exit interview conducted and a copy of this report was left at the facility.
2024-02-08Other VisitNo findings
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On 2/8/24 at 1:00pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to gather additional information regarding control of property and facility name change. LPA met with executive director Melissa Del Dosso (S1) and together discussed recent changes at the facility and transition to a new management group. LPA provided S1 with required documents needed to make a name change including signatures and approval from the licensee. LPA discussed control of property and the next steps department and management company will take to ensure the licensee retains control of property to meet regulations. LPA has agreed to reach out to CPMB to expedite administrator certificate so the newly appointed ED can take over the position with department approval. S1 states that control of property information and name change request documents will be submitted to the department by 2/16/24. Exit interview was conducted and a copy of this report was left at the facility.
2024-01-05Other VisitNo findings
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On 1/5/24 at 8:30am, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced case management visit to address concerns with facility change of ownership. Upon arrival, LPA observed the business front signage was changed to Spanish Vines. LPA met with Business Director Alexandria Noel and explained the purpose of today’s visit. LPA Truong conducted a walk through of the facility to ensure the health and safety of residents in care. LPA discussed the transfer of property requirement with the business director. It was learned that a new management company (TARANTINO SR LVG) was added to the license and not a change of ownership. The Department had received no notification of the sale of property or change of ownership. LPA spoke with management company's Regional Director of Operation, Peggy Oneil, and was advised that they had purchased the property from a foreclosure sale. At this time, the Application Bureau has not received an application for change of ownership. Licensee and prospective applicant will be consulting their attorneys regarding additional issues. Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were left at the facility.
2023-12-20Complaint InvestigationNo findings
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Continued... In addition, LPA was informed that during the time of receiving this complaint, everyone (staff and residents) were upset because of layoffs due to having a low census. LPA was also informed during an interview today that the residents were fine. Based on interviews and observation, the allegation is deemed UNFOUNDED. The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint. Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.
2023-12-14Other VisitType A · 1 finding
“Based on observation and interviews which confirmed the absence of an Administrator of record on file with CCL or a designee. This violation poses an immediate health, and safety risk to residents in care.”
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/14/23 at 9am on a subsequent visit. Upon arrival LPA received information that the previous Administrator Benji Doctolero is no longer working for the facility. Alexandria Noel, was interim but is now on leave of absence. These two were designated on the LIC308. During this visit, LPA met with Bradley Boyer, Executive Chef/Culinary Director and Adriana Vue (LVN) Interim Assisted Living Director (ALD). LPA stated the purpose of the visit. LPA obtained additional information that Arlene Moreno Assisted Living Director is on leave of absence and Tyler Brown Residential Care Coordinator is not in office today. LPA observed Lindsey Palmer Director of Sales & Marketing showing facility to potential new resident. The facility was provided the pertinent information below regarding submission for change in Administrators and/or Executive Directors. -Ensure the person is fingerprint cleared and associated to the facility through your Guardian account -Submit all documents mentioned below: Administrator Certificate, Personnel Record (LIC501), Health Screening with TB (LIC503), CPR/First Aid, Designation (LIC308), A letter from the Licensee appointing the person to be able to speak on behalf of the Licensee, Updated Personnel Report (LIC500) showing the Administrator on schedule in the facility 40hrs per week. These documents are to be submitted as well as notification to the Department any time there is a change or intended change in the Administrator and/or Executive Director. Based on information obtained and a review of the posted LIC308, the preponderance of evidence standards has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The facility representative was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
2023-12-14Complaint InvestigationNo findings
2023-11-03Complaint InvestigationMixedType A · 1 finding
“Based on interviews confirming staff were sleeping during their shift. This poses an immediate health and safety risk to residents in care.”
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Regarding allegation, “Staff inappropriately handle residents roughly causing bruising”, during interviews with S1-S6, of which 2 stated they heard that skin tears occurred and 1 stated bruising occurred from assisting with the dementia diagnosed residents none of which was a result of abuse or rough handling. LPA did not obtain a preponderance of evidence. Regarding allegation, “Staff inappropriately use children to care for residents”, LPA did not observe a preponderance of evidence based on interviews of staff (S1-S6). LPA obtained information through interviews that children were allowed to be present during special events and only in those areas and not allowed to assist residents. Regarding allegation, “Staff maintain expired medications”, LPA requested and observed a random amount of Medication Destruction Record of medications for resident #1(R1-R5) which had the most recent disposal dates of 5/27/23, 6/20/23, 6/22/23, 6/24/23, 5/14/22. LPA obtained a photo which indicates medications were in a white plastic bag. However, it is unclear where the items were located. LPA obtained information through interviews that expired medications are held in a medication container and are stored in a locked area of which there is 1 key only available to Medication Technicians, and Resident Care Coordinator. When caregivers need anything from that area, someone would get it for them. LPA observed the area where medications are discarded and they are in the red hazardous material containers. LPA did not observe medications in plastic bags in neither Memory Care, Assisted Living, supply room, nor housekeeping area. LPA did not obtain a preponderance of evidence. Based on interviews and lack of evidence the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided.
2023-10-06Complaint InvestigationNo findings
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By 6am, the staff took vitals, the responsible parties were notified of R1s health condition and medical attention was needed. R1 was sent to the hospital for low oxygen, phlegm, swallowing, and to ensure medications for 8am pass would be tolerated. This would be the 2nd time R1 was sent to the hospital for the same issues. As R1, was diagnosed this time with Pneumonia, R1 deceased at the hospital. Based on interviews and observation, the allegation is deemed UNFOUNDED. The preponderance of evidence standards has not been met. “This agency has investigated the complaint alleging, the above-mentioned allegation(s). 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. We have therefore dismissed the complaint.” Per the California Code of Regulations, Title 22, Div 6, Ch 8, no violations cited during this visit. Exit interview conducted copy given.
2023-09-08Other VisitType A · 2 findings
“Medication was not administered as prescribed to R1 Based on documentation and interviews which confirmed the medication error occurred This violation poses an immediate health, and safety risk to residents in care.”
“R1 advised S1 of feeling overmedicated Based on interviews, R1 did not receive medical attention after receiving an additional dose of prescribed medication This violation poses an immediate health, and safety risk to residents in care.”
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/8/23 at 9:30am to obtain information regarding an Incident Report (SIR) received by Community Care Licensing (CCL) which indicated a medication error occurred. LPA conducted interviews of staff during this visit. In reviewing the incident report, the medication error occurred on 9/3/23 and was reported to the Administrator via email from the Responsible Party on 9/5/23. This medication error involved resident #1 (R1) receiving a double dose of medication in the morning instead of 1 dose in the morning and 1 dose in the evening as prescribed. The incident report also indicates that all staff working with medication participated in an in-service for medication pass on 9/7/23. The interviews revealed that staff #1 (S1) was told by R1 that there was too many medications. S1 administered the medication without re-checking. Later, R1 was not feeling well and told that to S1. R1's notification to S1 was ignored, not documented, and medical attention was not provided. In addition, during the next shift R1 was provided with the correct dose as prescribed which indicates that R1 received the dose 3 times that day (total of 6 pills: 4 in am and 2 in pm). When the facility staff was notified by the responsible party, an investigation began by S2. S1, confirmed the medication error occurred and medical attention was not provided. Based on the facility investigation, S1 was terminated and medication staff participated in an in-service training as a review of medication processes and protocols. On 9/5/23, when speaking with R1, S3 observed that R1 was at baseline and was able to recall what happened the day of the error. However, the resident was not provided medical attention. Based on the documents submitted to CCL and interviews, the preponderance of evidence standards has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
2023-09-07Other VisitNo findings
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/7/23 at 8:30am to conduct a Case Management visit. LPA met with Administrator Benji Doctolero and stated the purpose of the visit. LPA inquired if staff #1 (S1) was presently on the premises during this visit. Administrator Benji Doctolero stated the staff has never worked for the Licensee. LPA served notice of "ORDER TO INDIVIDUAL OF IMMEDIATE EXCLUSION" for S1 who was not present at the time of visit. Administrator was advised an immediate removal is warranted and requested the Personnel Report (LIC500) and Guardian account be updated to remove S1 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL). LPA informed Administrator that S1 is not allowed to be employed and/or on any facility premises. The Order to Individual of Immediate Exclusion came into effect as of 09/05/2023 upon receipt of the letter. A copy of the letter was given to the facility during this visit. The facility understands this is an Immediate Exclusion and has agreed S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services unless otherwise ordered by the Department. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held, A Copy of report given.
2023-09-07Complaint InvestigationNo findings
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The investigation revealed that residents are not happy that so many staff were laid off due to the current census of the facility. The complaint was called into Community Care Licensing (CCL) not due to a care and supervision issue. R1 is independent and self sufficient with Activities of Daily Living (ADLs). However, after smoking, during the day and night, R1 wants staff to push the wheel chair from the courtyard into the building even though R1 can do it alone. R1 stated this assistance was being done when the facility had 3 caregivers and 1 medication technician on duty. Based on interviews and observation, the allegation is deemed UNFOUNDED. The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint. Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.
19 older inspections from 2022 are not shown above.
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