Mixed private and shared/dorm-style accommodations
Inconsistent food quality and small portioning
Limited off-site outings and activity variety
Pest-control concerns in some resident rooms and bathrooms
Variable cleanliness standards across units
Gaps in communication and follow-up from management
Operational disorganization during ownership transition
Gaps in transfer-safety protocols and incident response
Inconsistent personal-item and clothing management
Summary of reviews
Overall impression: The facility presents a mixed profile. Many comments emphasize consistently warm, helpful caregiving staff, a responsive call system and regular housekeeping; these operational strengths create a baseline of dependable daily care for residents. At the same time, there are recurring operational and environmental concerns related to building condition, food service consistency, cleanliness in some units, and management follow-through that prospective families should evaluate in person.
Care and staff: Staff behavior emerges as a clear strength in numerous accounts: employees are described as kind, prompt, and supportive, with specific praise for on-shift supervisors and the director. Emergency-call responsiveness and hands-on caregiving are frequently noted, and several accounts describe respectful interactions and satisfactory clinical care. However, there are also serious allegations of conduct and safety lapses (including unsafe transfer experiences and problems with personal-item handling) that require direct inquiry and verification with facility leadership and regulators before placement.
Dining and housekeeping: Meal service receives mixed feedback. Some comments praise excellent meals and accommodated room delivery, while other comments note declining food quality, small portions, and less attentive dining service. Daily room cleaning and generally clean common areas are reported, but cleanliness appears uneven across the residence; pest-control concerns in some rooms and bathrooms are cited and should be clarified with management.
Activities and social life: On-site programming is present and consistent: bingo, movies, exercise/wheelchair aerobics, crafts, and church services are offered and valued by residents. The community is described as cozy and not overly crowded, which some families prefer. That said, the facility appears to offer limited off-site outings and a narrower variety of activities than some competing communities.
Facilities and accommodations: The building is older and described as dated in finishes and dining-area design. Room configuration varies between single rooms and two-person, dorm-style rooms; this inconsistency affects privacy and may influence suitability depending on resident preferences. Outdoor courtyard space is a positive asset, but the overall environment would benefit from modernization and stronger pest-control measures.
Management and operations: Recent ownership change and operational disorganization are recurring themes. While some leadership personnel receive strong praise, others note lapses in follow-up, inconsistent communication, and shortfalls in administrative responsiveness. Prospective families should ask about current ownership plans, quality-improvement initiatives, staffing levels, pest-control contracts, transfer-safety protocols, and specific examples of how complaints have been addressed.
Notable patterns and recommendations: The dominant pattern is a facility with attentive, compassionate staff but operational and environmental weaknesses that range from food-service consistency to safety and cleanliness issues. Before making a placement decision, an in-person visit is recommended to inspect room types, ask for recent inspection or pest-control records, observe an activity or meal service, review staff training and transfer protocols, and clarify how management is addressing transition-related disorganization. Given the mix of positive caregiving reports and serious operational concerns, corroboration through a tour, reference checks, and regulatory records will provide the clearest picture of fit and safety.
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Location
Four Seasons California is located at 5400 Stine Rd, Bakersfield, CA, 93313.
About Four Seasons California
Four Seasons California offers assisted living, memory care, and residential care home services for seniors in Bakersfield, California, where you can find housing and daily support for things like bathing, dressing, and medication, or you get memory care in a secure area if you have Alzheimer's or other dementia and need a safe place that reduces confusion and uses a wander alert system with bracelets and computerized checks so staff knows if you go somewhere unsafe, and they've got a memory care section in its own building. The place holds up to 99 residents and has options like studios, single bedrooms, or communal living, and room amenities include washers and dryers, cable TV, and emergency call systems, while throughout the facility you get Wi-Fi, wheelchair accessibility, and easy access features. Meals come three times daily with snacks in between, and they can do pureed, vegetarian, kosher, gluten-free, diabetic, and low-sodium meals on request, plus chefs and meal planners make sure everything is balanced for nutrition. You get help with many needs-personal care, medication, dental care, incontinence, insulin, blood sugar, transfers (even with mechanical lifts), weight management, and special Parkinson's programs, and if you're a caregiver needing a break, respite care is available.
Nurses and staff are on site 24/7, with nurse checkups, doctor visits, and round-the-clock supervision, and there's a call system in every unit for emergencies, so people can feel safer day or night. For people who want to stay active, Four Seasons California offers fitness classes, games, music, bingo, movie nights, off-site trips, a reading room, greenhouse, beauty and barbershop, wellness spa, garden, business room, and regular parties for holidays and birthdays, and you can always find a walking path outside or use the fitness room. Residents have a full activities program and can join arts and crafts or other social things to keep busy and connected. Housekeeping, laundry, and maintenance are all included, and you can get help managing money or arranging appointments, with free transportation for medical visits, errands, and field trips, so you don't have to worry about getting around.
Safety features include smoke alarms, sprinkler systems, 24-hour secured premises, services, a pharmacy on site, and a system that prevents wandering-especially in the memory care area, which's always supervised and secure. For medical needs, there's wound care, rehabilitation, diabetic support, skilled nursing, regular health checks, special therapy programs, and case management. The community has been recognized with Best of Senior Living awards, has a neighborhood close to hospitals and pharmacies like Good Samaritan Southwest Hospital, CarePharm Pharmacy, and Pacific Pulmonary Services, and uses a community score rating system to help families learn what to expect. Four Seasons California cares for people by tailoring assistance to each person's needs, and offers different options for independent living, assisted care, or full support, so you can get what you need in an environment that's as comfortable as it can be.
People often ask...
Four Seasons California offers competitive pricing, with rates starting at a cost of $4,325 per month.
Four Seasons California offers assisted living and memory care.
There are 15 photos of Four Seasons California on Mirador.
The full address for this community is 5400 Stine Rd, Bakersfield, CA 93313.
No, Four Seasons California does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In California, the Department of Social Services' Community Care Licensing Division licenses residential care facilities for the elderly, conducting inspections and investigating complaints.
Investigated a resident's prescribed aspirin that was not administered as ordered. The review addressed related medication administration practices and other allegations.
Type A87465(a)(4)
14 Jan 2026Inspection
14 Jan 2026Inspection
Identified an incident in which a resident was struck by another resident, resulting in an eye injury and medical evaluation.
Type A87468.1(a)(3)
14 Jan 2026Complaint
14 Jan 2026Complaint
Investigated an eviction allegation; a resident was sent to the hospital and not allowed to return without following proper eviction procedures.
Type B87224(a)
02 Dec 2025Complaint
02 Dec 2025Complaint
Investigated an allegation that staff left a resident unattended during an appointment. Found the resident remained unattended in the lobby from 9:30 AM to 11:00 AM on 10/10/2025.
Type A87464(f)(1)
Type A87101(c)(3)
Type A1569.2(c)
12 Sept 2025Complaint
12 Sept 2025Complaint
Investigated the allegation that safety needs were not met and that dignity was not accorded; concluded the safety and dignity issues were undetermined. Interviews indicated safety needs were being met and records showed a lap belt order for the wheelchair.
12 Sept 2025Complaint
12 Sept 2025Complaint
Investigated pest control, maintenance, and an alleged physical altercation; pests were not observed, a sprinkler issue was noted as being addressed, and the altercation allegation remained unclear.
23 Jul 2025Complaint
23 Jul 2025Complaint
Identified that residents on a physician-prescribed low-carb diabetic diet were not provided sugar-free dessert options. The menu showed pudding and ice cream with no sugar-free alternative available.
Type B87555(b)(7)
23 Jul 2025Complaint
23 Jul 2025Complaint
Investigated four allegations about care practices and billing; the bed-ridden rotation and supervision allegations were undetermined, the trash disposal allegation was unsubstantiated, and the overcharging allegation was unfounded.
23 Jul 2025Complaint
23 Jul 2025Complaint
Investigated allegation that staff did not provide a safe environment for a resident in care; findings were undetermined.
25 Jun 2025Inspection
25 Jun 2025Inspection
Observed a large round dining table blocking a fire exit and improper central storage of medications, creating safety risks for residents. Civil penalties were issued for the fire clearance violation.
Type A87202(a)
Type B87465(h)(5)
25 Jun 2025Inspection
25 Jun 2025Inspection
Identified an elopement involving a resident on 06/13/2025 and cited a deficiency for insufficient staffing to meet residents' individual needs.
Type A87468.2(a)(4)
04 Jun 2025Inspection
04 Jun 2025Inspection
Investigated three incidents involving residents and requested hospice notes and discharge paperwork to clarify the events.
19 Mar 2025Complaint
19 Mar 2025Complaint
Investigated a complaint alleging a resident smoked indoors while an oxygen tank was in use and that a resident rubbed another resident's arms. Based on interviews and records, it could not be determined whether the incidents occurred.
19 Mar 2025Complaint
19 Mar 2025Complaint
Investigated the allegation that staff neglect resulted in a resident developing gangrene. There was not a preponderance of evidence to prove or disprove the allegation.
06 Feb 2025Complaint
06 Feb 2025Complaint
Identified that a resident smoked indoors despite house rules, creating a health and safety risk for residents who require oxygen.
Type A87411(a)
Type A87608
06 Feb 2025Complaint
06 Feb 2025Complaint
Investigated the allegation that staff are not meeting resident medical needs. Evidence did not establish whether the allegation occurred.
04 Sept 2024Complaint
04 Sept 2024Complaint
Investigated a complaint alleging bed repositioning for bedridden residents, feeding assistance, resident conflict, and safeguarding personal property; interviews and records did not provide conclusive proof that the allegations occurred.
22 Aug 2024Complaint
22 Aug 2024Complaint
Identified that towels provided to residents were in poor condition, including a towel with a large hole, indicating inadequate linen supplies.
Type B87307(3)(C)(3)
22 Aug 2024Complaint
22 Aug 2024Complaint
Identified that staff spoke to a resident in an inappropriate manner and did not treat the resident with respect.
Type A87468.1(a)(1)
26 Jun 2024Complaint
26 Jun 2024Complaint
Investigated a complaint that residents smoked in prohibited areas and that staff did not prevent it. Also investigated a complaint that staff spoke inappropriately to a resident.
Type A87468.1(a)(2)
26 Jun 2024Complaint
26 Jun 2024Complaint
Investigated a complaint about denial of a resident's visitor access during visiting hours. Based on records and interviews, there was not enough evidence to determine whether the allegation occurred.
26 Jun 2024Complaint
26 Jun 2024Complaint
Investigated a mold, pest, and resident-needs concern. Found mold present and pest control steps in progress, with unclear evidence that residents' needs were being met.
18 Jun 2024Inspection
18 Jun 2024Inspection
Observed a resident eloped and not reported to the department, and identified failures to report multiple incidents and gaps in medical/dental care and monitoring.
Type A87464(f)(1)
Type A87465(a)(1)
Type B87211(a)(1)
18 Jun 2024Inspection
18 Jun 2024Inspection
Identified multiple health and safety deficiencies, including improper medication administration, unsanitary conditions, missing disaster planning, and gaps in resident care planning and staff training.
Type A87309(a)
Type A87465(a)(4)
Type A87465(a)(5)
Type A87465(a)(5)(D)
Type A87465(h)(4)
Type A87465(b)
Type A87465(e)
Type A87465(a)(8)
Type A87608(a)(1)
Type A87628(a)
Type A87705(c)(4)
Type A87705(j)
Type A87303(a)
Type A87303(e)(2)
Type A87307(a)(3)(C)
Type A87307(d)(2)
Type A87606(b)
Type A87606(f)(3)
Type A87555(b)(7)
Type A87555(b)(17)
Type A87463(a)
Type A87633(a)(2)
Type A87633(a)(4)
Type A87633(b)(6)
Type A87633(d)
Type A1569.695(a)
Type B87303(a)
Type B87303(e)(2)
Type B87555(b)(7)
Type B87555(b)(17)
Type B87465(a)(8)
Type B87465(c)(3)
Type B87463(a)
Type B87606(b)
Type B87606(f)(3)
Type B87609(b)(4)
Type B87628(a)
Type B87633(a)(2)
Type B87633(a)(4)
Type B87633(b)(6)
Type B87633(d)
Type B87705(c)(3)
Type B1569.72(f)
Type B87458(b)(1)
11 Jun 2024Inspection
11 Jun 2024Inspection
Identified multiple health and safety deficiencies, including missing special-diet menus and dietician-planned menus, sanitation issues in the community bathroom with mold, outdoor hazards from a broken south-side fence and fallen branches, and insufficient staff training for mobility-assistance and care of bedridden residents.
26 Apr 2024Complaint
26 Apr 2024Complaint
Identified deficiencies related to emergency response after a resident's fall, notifying a resident's authorized representative about an injury, and safeguarding a resident's personal property. Investigations into other concerns regarding timely hospital pickup and answering phones had indeterminate results.
Type A87465(g)
Type B87211(a)(1)
Type B87217(b)
04 Apr 2024Inspection
04 Apr 2024Inspection
Identified that residents lacked hospice care plans and staff were not trained on turning bedridden residents.
Type A87633(a)(4)
Type B87633(a)(6)
04 Apr 2024Complaint
04 Apr 2024Complaint
Investigated a complaint that staff did not provide water and did not respond to residents' calls for assistance. A separate complaint about rodents was unfounded; findings showed the water and call allegations were unsubstantiated and the rodent allegation unfounded.
22 Mar 2024Complaint
22 Mar 2024Complaint
Identified that cleanliness and sanitation were not maintained, with mold found in the communal shower and toilets.
Type B87303(a)
18 Jan 2024Complaint
18 Jan 2024Complaint
Investigated allegation that staff served cold meals to residents receiving tray service; interviews indicated meals were served cold.
Type B87555(b)(9)
03 Jan 2024Complaint
03 Jan 2024Complaint
Investigated allegations that staff did not safeguard resident funds, failed to keep the environment free of insects, and billed residents receiving SSI beyond the basic rate; found the allegations unfounded.
03 Jan 2024Complaint
03 Jan 2024Complaint
Investigated allegations of poor hygiene, not providing residents with water, and smoking in non-designated areas; observed a water jug accessible to residents, a shower schedule, and a designated smoking area, and no violations were established.
18 Dec 2023Complaint
18 Dec 2023Complaint
Investigated the allegation that a resident sustained unexplained bruising while in care. Found no preponderance of evidence to prove or disprove the allegation.
18 Dec 2023Complaint
18 Dec 2023Complaint
Investigated a complaint alleging staff did not ensure a resident's incontinence needs were met and that residents were not provided activities. Evidence did not establish whether the allegations occurred.
15 Nov 2023Complaint
15 Nov 2023Complaint
Identified multiple concerning allegations: staff made inappropriate comments toward residents, did not treat residents with dignity, and did not communicate effectively; medications were mismanaged for several residents. There were also concerns about inappropriate touching and safeguarding residents' personal items.
Type A87468.1(a)(1)
Type A87465(a)(4)
30 Oct 2023Complaint
30 Oct 2023Complaint
Found that the claim that staff abandoned a resident at a hospital was unfounded.
04 Oct 2023Inspection
04 Oct 2023Inspection
Observed that a resident's file was returned to the administrator and an exit interview conducted.
29 Sept 2023Inspection
29 Sept 2023Inspection
Identified that full bed rails were being used for a resident, but the hospice care plan did not specify the need for full bed rails.
Type A87468.2(a)(5)
Type A87468.2(a)(8)
13 Sept 2023Inspection
13 Sept 2023Inspection
Identified concerns about governance, administrator qualifications and duties, care and supervision, medications, and reporting requirements during an informal meeting.
06 Sept 2023Complaint
06 Sept 2023Complaint
Investigated an allegation that staff did not respond in a timely manner to a resident's calls for assistance. The investigation found that staff did not respond for over an hour, with one caregiver assigned per hall.
Type A87411(a)
22 Aug 2023Inspection
22 Aug 2023Inspection
Found regulatory noncompliance related to hot water temperatures and self-administered medications not properly logged. Also identified missing plan of operation, inadequate evaluation of residents for admission, missing admission agreements, insufficient staff training, and cleanliness issues.
Type A87303(e)(2)
Type A87465(a)(4)
Type B87208(a)
Type B87303(a)
Type B87506(b)(15)
Type B87456(a)
Type B87411(d)
22 Aug 2023Complaint
22 Aug 2023Complaint
Found mold on the ice and juice machines that required cleaning. Observed a resident in a wheelchair outside calling for help.
Type B87303(a)
Type B87468.1(a)(1)
22 Aug 2023Complaint
22 Aug 2023Complaint
Investigated a complaint alleging staff overmedicated a resident and did not seek medical attention; emergency services were sought after a fall, and the resident was later discharged from the hospital back to the site.
22 Aug 2023Complaint
22 Aug 2023Complaint
Investigated a complaint alleging staff did not seek timely medical attention after a resident's fall.
22 Aug 2023Complaint
22 Aug 2023Complaint
Investigated allegation that staff abandoned a resident at the hospital; found the allegation unfounded.
19 Aug 2023Inspection
19 Aug 2023Inspection
Observed an unannounced visit that led to the return of R1's file.
16 Aug 2023Complaint
16 Aug 2023Complaint
Investigated a complaint about medication management; found that a discontinued medication was still logged as dispensed and PRN doses were inconsistently recorded, with missing pills and timing concerns.
Type A87465(b)(3)
Type B87506(a)(14)
28 Jun 2023Inspection
28 Jun 2023Inspection
Identified numerous deficiencies at this site, including medication management errors and storage problems, absent staff training and operation plans, sanitation and pest issues, unsafe hot water temperature, and incomplete or unsecured resident records.
21 Jun 2023Complaint
21 Jun 2023Complaint
Investigated a resident's unwitnessed fall, a smoking situation in a room, allegations of inappropriate behaviors, and unmet hygiene needs; findings concluded no deficiencies were cited.
09 Jun 2023Inspection
09 Jun 2023Inspection
Identified a resident with a prohibited health condition retained without a health care plan, and injections were administered by staff not skilled for this task; later, another resident with a restrictive health condition was admitted without a care plan.
Type A87615(a)(1)
Type B87616(a)(b)(1)(2)
Type B87405(d)(2)
Type B87629(b)(1)
20 May 2023Inspection
20 May 2023Inspection
Investigated a case where a resident was retained with a prohibited health condition and no health care plan was provided. Administrator did not contact Licensing before the person was released from the hospital to seek an exception.
18 May 2023Complaint
18 May 2023Complaint
Investigated a complaint alleging several issues with staff interactions and resident safety; interviews indicated residents felt safe and staff interactions were positive.
26 Apr 2023Complaint
26 Apr 2023Complaint
Identified lack of a restricted health care plan for a resident with a restricted health condition and missing hospitalization, incident, and home health records.
Type B87209
Type B87616(a)(b)(1)(2)
26 Apr 2023Inspection
26 Apr 2023Inspection
Investigated and identified failures to submit incident reports for hospitalizations and to train staff for a resident's restricted health condition.
Type B87211(a)(1)
Type B87613(a)(2)(A)(B)
09 Feb 2023Complaint
09 Feb 2023Complaint
Investigated allegations of improper use of postural supports and staff not changing a resident's clothing.
Type B87608(a)(2)
Type B87608(a)(5)(B)
27 Jan 2023Complaint
27 Jan 2023Complaint
Investigated a complaint about eviction procedures, dignity in relationships, and resident interactions. Interviews and records indicated eviction procedures were followed, and there was no evidence of inappropriate interactions or lack of care.
18 Jan 2023Complaint
18 Jan 2023Complaint
Identified an allegation that showers were not functioning in multiple rooms and required repairs. Three of six rooms observed had showers not functioning or not functioning properly.
Type B87303(a)
18 Jan 2023Complaint
18 Jan 2023Complaint
Investigated a complaint about staff medication training and found that staff who administer medications had not completed the required eight hours of in-service training in the past year; records showed last medication trainings were in 2019.
Type A1569.69(b)
18 Jan 2023Inspection
18 Jan 2023Inspection
Identified deficiencies from a prior complaint, including a sign at the front entrance restricting visitors due to renovations, food improperly stored in the freezer, and chemicals accessible in a laundry area.
Type B87468.1(11)
Type B87555(g)
Type B87705(f)(2)
18 Jan 2023Complaint
18 Jan 2023Complaint
Investigated a complaint alleging linens were not in good repair and improper food service; interviews and inspections found no evidence to support those concerns.
04 Jan 2023Inspection
04 Jan 2023Inspection
Investigated a case management incident from 12/31/2022 and reviewed updates after touring the affected area.
18 Nov 2022Complaint
18 Nov 2022Complaint
Investigated an allegation that staff did not assist a resident with toileting. The allegation was found unsubstantiated.
28 Oct 2022Complaint
28 Oct 2022Complaint
Investigated a complaint alleging staffing did not meet residents' needs and a resident developed bedsores due to neglect; found no preponderance of evidence to support either allegation.
25 Oct 2022Complaint
25 Oct 2022Complaint
Found unfounded the allegation that staff spoke inappropriately to a resident, failed to safeguard a resident's personal belongings, and that a resident's room was in disrepair.
25 Oct 2022Inspection
25 Oct 2022Inspection
Observed that previous deficiencies were cleared and no deficiencies were cited during this visit.
21 Sept 2022Complaint
21 Sept 2022Complaint
Identified unsanitary conditions including bodily fluids on hallway walls, cobwebs around light fixtures, dirt on hallway doors, and fly traps above dining tables. For the supervision allegation, records and interviews did not establish that supervision was lacking.
Type B87303(a)
Type B87470(a)(2)(B)
21 Sept 2022Complaint
21 Sept 2022Complaint
Observed holes in interior doors leading to the outside and disrepair in the entry flooring; residents reported the call-light beeping was continuous and distressing.
Type B87303(a)
Type B87307(d)(2)
21 Sept 2022Complaint
21 Sept 2022Complaint
Investigated a complaint about unsanitary conditions and supervision, and observed dirty walls, cobwebs, dirt stains on doors, and infection control concerns. Records related to a supervision allegation were reviewed.
Type B87303(a)
Type B87470(a)(2)(B)
21 Sept 2022Complaint
21 Sept 2022Complaint
Investigated two allegations—staff rough handling of a resident and staff not meeting the resident's medical needs; both were unfounded.
21 Sept 2022Inspection
21 Sept 2022Inspection
Conducted an unannounced case-management visit after information that staff were not wearing masks. Observed staff wore masks throughout and received technical guidance on the latest CDPH order; no deficiencies cited.
06 Sept 2022Complaint
06 Sept 2022Complaint
Investigated two allegations: the ice machine was moldy, and staff did not follow a resident's diet order. Both were unfounded.
15 Aug 2022Complaint
15 Aug 2022Complaint
Identified that medications were not consistently given according to doctor's orders and the shower door did not latch properly.
Type A87465(a)(4)
Type B87303(e)(6)
15 Aug 2022Complaint
15 Aug 2022Complaint
Investigated a water safety concern and a mold concern in the ice machine. Findings indicated no safety issues were observed.
15 Aug 2022Complaint
15 Aug 2022Complaint
Investigated allegations of staff retaliation, improper handling, and inappropriate language toward residents; interviews and record reviews found no specific incidents supporting those claims.
15 Aug 2022Complaint
15 Aug 2022Complaint
Investigated a complaint about resident care and behavior; found no evidence to support the allegations.
15 Aug 2022Complaint
15 Aug 2022Complaint
Investigated allegations that staff did not follow COVID-19 testing protocols for a symptomatic resident, did not assist with showers, and did not safeguard personal belongings. Interviews and records review showed proper COVID protocol for isolation and testing and proper handling of showers and personal belongings.
15 Aug 2022Complaint
15 Aug 2022Complaint
Investigated allegations that staff did not properly care for a resident's wound, that insects were present, and that trash was not disposed of; findings determined these allegations were unsubstantiated.
15 Aug 2022Complaint
15 Aug 2022Complaint
Investigated allegations that resident care needs were not being met, pests present, cleaning not kept up, and staffing was short; all allegations were found unsubstantiated.
10 Aug 2022Complaint
10 Aug 2022Complaint
Identified three allegations of inappropriate touching, inappropriate comments to a resident, and air conditioning in disrepair; they were unsubstantiated.
26 May 2022Complaint
26 May 2022Complaint
Investigated an allegation that staff did not provide adequate supervision to a resident, which led to a fall in the courtyard. The report noted there were no other residents nearby and that the resident did not report being pursued by another person.
26 May 2022Inspection
26 May 2022Inspection
Verified that a former staff member was no longer employed or on the premises; administrator provided written confirmation.
16 May 2022Inspection
16 May 2022Inspection
Confirmed universal entry screening and infection control measures were in place; no deficiencies were issued.
16 May 2022Complaint
16 May 2022Complaint
Investigated an allegation that residents had inappropriate interactions; a resident intervened before anything inappropriate occurred, and another resident denied the allegation. The investigation found insufficient evidence to support the allegation.
02 Feb 2022Inspection
02 Feb 2022Inspection
Identified a deficiency where ointment was applied to a resident without a physician's written order and proper labeling.
Type B87465(e)
02 Feb 2022Complaint
02 Feb 2022Complaint
Investigated allegations that a resident requiring higher care was admitted without proper pre-assessment, that wheelchair passage was hindered by room design, and that staffing led to unwitnessed falls. Records and interviews showed proper pre-assessment, accessible doorways, and adequate staffing.
02 Feb 2022Complaint
02 Feb 2022Complaint
Investigated allegations that a resident developed pressure injuries from being left in a wheelchair for extended periods and that a proper bed was not provided; the allegations were unfounded.
02 Feb 2022Complaint
02 Feb 2022Complaint
Concluded that the allegation that staff retaliated by forcing a resident to move rooms did not occur and that the resident's ceiling was not in disrepair.
20 Dec 2021Complaint
20 Dec 2021Complaint
Investigated allegations that a resident overdosed and that staff did not ensure sufficient liquid intake; no evidence supported the claims.
22 Nov 2021Complaint
22 Nov 2021Complaint
Investigated a complaint and identified problems with medication administration records and the storage of centrally stored medications.
Type A87465(a)(5)
Type A87645(h)(2)
22 Nov 2021Complaint
22 Nov 2021Complaint
Investigated complaints about call buttons, dignity, food service, medication administration, masking, and roach infestation; medication administration and roach control issues were found.
Type A87465(a)(5)
Type B87303(a)
22 Nov 2021Complaint
22 Nov 2021Complaint
Investigated two complaints: air conditioning was broken and hot water was unavailable; hot water was available and temperatures were comfortable. The pest complaint found no infestation.
22 Nov 2021Complaint
22 Nov 2021Complaint
Investigated a complaint alleging disrepair, staff yelled at a resident, transportation issues, central medication storage, and failure to notify a physician of a change in condition. Investigators found the allegations were not supported by the evidence.
22 Nov 2021Complaint
22 Nov 2021Complaint
Investigated the allegation that residents were sexually assaulted while in care and that residents take illegal drugs on the premises; interviews and records showed lack of evidence.
22 Nov 2021Complaint
22 Nov 2021Complaint
Investigated a complaint alleging staff did not safeguard residents' personal items, did not maintain adequate sanitation procedures, and did not assist with medical care in a timely manner. The allegations were unsubstantiated.
22 Nov 2021Complaint
22 Nov 2021Complaint
Investigated allegations that staff did not assist the resident with hygiene needs and did not ensure the resident received nutritional meals.
26 Aug 2021Inspection
26 Aug 2021Inspection
Observed a cleaning cart with disinfectants and bug spray in a hallway outside resident rooms, making cleaning supplies accessible to residents.
17 Aug 2021Complaint
17 Aug 2021Complaint
Investigated four specific allegations: mismanagement of residents' money, use of chemical restraints, inadequate access to liquids, and insufficient supervision, and found no evidence to support them.
04 Aug 2021Inspection
04 Aug 2021Inspection
Found cleaning chemicals were unsecured and accessible to residents, and there was no centrally stored medication log for residents.
Type A87309(a)
Type B87506(b)(14)
Type B87465
04 Aug 2021Complaint
04 Aug 2021Complaint
Identified that staff did not administer medications as prescribed and recorded inaccurate medication logs.
Type A87465(a)(5)
Type B87207
24 May 2021Inspection
24 May 2021Inspection
Observed infection-control measures and entry screening; no deficiencies were issued.
29 Mar 2021Complaint
29 Mar 2021Complaint
Found that the allegation that staff harassed residents was not supported by interviews and observations. Confirmed that the resident referenced in the allegation is no longer present, and no deficiency was observed.
22 Jan 2021Complaint
22 Jan 2021Complaint
Found that the allegation that dentures were lost and no replacement was provided due to hospice status was unfounded.
01 Dec 2020Complaint
01 Dec 2020Complaint
Found that a resident had a bed and pillow and sought a hospital bed with a prescription; a doctor’s visit and a new wheelchair were scheduled after admission. Found that the resident chose to manage her own appointments and medications, reported no stolen belongings, and staff denied unmet needs or missed medications; there was not sufficient evidence to prove violations.
26 Aug 2020Complaint
26 Aug 2020Complaint
Found the allegation regarding medication management and related recordkeeping unsubstantiated.
05 Jun 2020Complaint
05 Jun 2020Complaint
Confirmed that allegations regarding resident needs not being met, understaffing, missed medications, and missed meals were unsubstantiated after interviews, record reviews, and inspections.
11 Nov 2019Complaint
11 Nov 2019Complaint
Confirmed allegation of physical abuse resulting in a resident being struck with a golf club while sleeping.
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