I found the place clean, bright and well-maintained with nicely sized apartments, a beautiful courtyard, good activities and generally friendly, caring staff. That said, chronic understaffing, use of temp workers, uneven follow-through and some management/transparency and cleanliness issues (a few reports of pests and poor food) made consistency of care a concern. The director seemed responsive and many families praised the memory-care programs and community vibe, so I'd consider it for a short stay or memory care but with caution. Tour thoroughly and ask specifically about staffing levels, pest history, meal and medication management before committing.
Long-tenured, consistent caregivers with an extended-family feel
Strong memory-care focus and programs
Clean facility with no offensive odors and well-maintained common areas
Refurbished front/facility upgrades and hotel-like yet homey feel
Spacious, bright, and airy memory-care dining area with restaurant-style service
Outdoor spaces: terrace, patio, courtyard, and pool
Varied activities program (bingo, cards, painting, movies, arts & crafts, floral arranging)
One-on-one attention for residents and well-developed programs
Good food quality reported by many, with accommodating menu options
Laundry, medication management, and meal services provided
Multiple room options (shared and private) and well-sized apartments
Helpful and responsive administrative/marketing staff and tour guides
Convenient location near hospitals and restaurants
Reasonably priced or perceived good value by many reviewers
Good parking availability reported by several reviewers
Positive experiences with transitions and move-in assistance
Salon services and personal care offerings (manicures, hair care, makeup days)
Recommendation and high overall satisfaction from many families
Cons
Understaffing and low staffing levels, especially mid-afternoon and early periods
Use of temporary/contract staff leading to inconsistent care
Reports of poor-quality care and neglect in some cases
Serious safety and memory-care concerns reported by some reviewers (including hospitalization)
Multiple state complaints and inadequate explanations in at least one account
Complaints about cleanliness in some areas (stairwell, carpeting) and reports of roach infestation
Mixed or high pricing for some room types; complaints about cost versus value
Management turnover and ownership changes causing uncertainty
Perceived lack of transparency from management in some cases
Poor follow-up after tours and incomplete virtual tours (common areas only)
Wait times during tours and occasional visitor parking limitations
Short staffing during COVID lockdowns and related service interruptions
Instances of rude or unhelpful temporary staff reported
Inconsistent continuity of care due to staff turnover
Allegations of serious operational problems (body handling through lobby criticized)
Some reviewers strongly advised to avoid the facility
Variable cleanliness and maintenance across different parts of the building
Mixed feedback about food quality and meal satisfaction in some reports
Summary review
Overall sentiment across the reviews for Terraza Court Senior Living is mixed but leans positive: many families praise the staff, the memory-care focus, the cleanliness of common areas, and the active social programming, while a minority of reviewers report serious concerns about staffing, safety, cleanliness in certain areas, and management transparency. A plurality of reviewers describe warm, caring staff and relate stories of meaningful, positive outcomes for family members (improved independence, thriving grandmother, smooth transitions). Several reviewers explicitly recommended the community and rated it four to five stars, citing helpful leadership, a welcoming reception, and the facility’s inviting, hotel-like yet homey atmosphere. The property offers multiple common-area amenities — a bright memory-care dining room with a restaurant-style feel, outdoor terrace/patio/courtyard and pool, a salon, and activity spaces — that many residents and families appreciate.
Care quality and staff: The most consistent strength in the reviews is the staff: many accounts highlight compassionate, dependable, and knowledgeable caregivers and administrative personnel. Multiple reviewers singled out executive leadership and individual staff members for being caring, proactive, and instrumental in helping residents adjust. Long staff tenure and an extended-family feeling were reported in several reviews, and families often noted punctuality, responsiveness to concerns, and one-on-one attention in memory care. However, there is a significant countercurrent: recurring comments note understaffing, especially during certain shifts or mid-afternoon, and the use of temporary or contract staff that can lead to uneven care. A few reviewers described stressful first days when staff were stretched thin, and others cited turnover and management changes as factors that impacted continuity of care.
Facilities and cleanliness: Many reviewers praised the facility’s cleanliness, lack of odor, recent refurbishments (especially in the front areas), and a bright, open layout. Descriptions of “super clean,” “well-groomed,” and “hotel-like” common areas appear frequently. The dining area and outdoor spaces are repeatedly named as highlights. That said, several reviews cite cleanliness or maintenance problems in specific locations (stairwell, carpeting) and at least one serious allegation of roach infestation. There are also isolated but stark criticisms about handling of deceased residents through the lobby and other operational concerns; these specific claims warrant scrutiny by prospective families and, if true, are red flags.
Dining and services: Food and dining receive largely positive mentions — the dining atmosphere is described as restaurant-style, meals often “smelled good” and “delicious,” and staff reportedly accommodate special requests and deliver meals to rooms when needed. Ancillary services such as laundry, medication management, salon services, and help with furnishing rooms were also noted as helpful elements that smooth transitions. Yet some reviewers reported poor food quality or dissatisfaction with meals, indicating variability in dining experiences across residents and time periods.
Activities and engagement: Terraza Court appears to offer a robust activity calendar with a wide variety of options: bingo, card games, painting, floral arranging, movie nights, arts and crafts, exercise, and salon/hygiene events (manicures, hair care, makeup). Many family members reported that activities helped their loved ones remain active, engaged, and socially connected. A few reviewers suggested the need for more mid-afternoon programming or varied class sizes, but the overall consensus supports an engaged resident community.
Management, ownership, and communication: Several reviews mention ownership changes and management turnover. Some families feel the new ownership and directors have improved operations; others cite ongoing issues and lack of visible improvement. Communication quality is mixed — many reviewers praise responsiveness and excellent tour guides, while others report poor follow-up, incomplete virtual tours, transparency concerns about incidents, and slow resolution of problems. There are serious allegations from a minority of reviewers: multiple state complaints and inadequate explanations after incidents in memory care. Those reports are significant and should be validated with licensing/inspection records by any prospective resident or family.
Value, pricing, and logistics: A number of reviewers consider Terraza Court affordable or good value for the services provided, noting a range of room options (private and shared) and reasonable pricing compared with local alternatives. Conversely, several reviewers felt prices were high for certain room types or expressed frustration with costs relative to perceived quality. Practical logistics such as parking were generally reported as adequate by some but busy or limited by others. Tour experiences varied: many praised thorough, personable tours, while others complained of waits during tours or incomplete virtual representations.
Patterns and notable risks: The dominant positive themes are caring staff, strong memory-care programming, active engagement opportunities, and generally clean, welcoming facilities. The dominant negative themes are staffing shortages and inconsistency, management/ownership transitions causing uncertainty, and a small set of severe allegations (safety issues, state complaints, pest problems) that contradict the otherwise positive majority. These severe negative reports are less frequent but high-impact, and they substantially affect overall evaluation and due diligence needs.
Recommendation for prospective families: Prospective residents and families should weigh the common strengths (compassionate staff, good memory-care focus, engaging activities, pleasant dining and outdoor spaces) against the reported weaknesses (staffing variability, occasional maintenance/cleanliness lapses, management turnover, and isolated but serious safety/operational complaints). Visit in person for multiple tours, request recent inspection reports and state complaint history, ask about current staffing ratios and use of agency staff, speak directly with the director about recent ownership changes and improvements, and try a lunch visit if possible. For many families, Terraza Court offers a caring, active environment with good value; for others — particularly those most sensitive to consistency of care and safety issues — additional verification and caution are warranted.
Location
About Terraza Court Senior Living
Terraza Court Senior Living in Culver City is a certified assisted living community that keeps things simple and personal, licensed for up to 6 residents, so everyone gets to know each other and staff can help folks as individuals, and they've got this modern and cozy place that feels a lot like home, with private or semi-private rooms people can adjust to feel just right. The building is purpose-built, with separate sections for assisted living and memory care-memory care sitting in its own area with added security and special features like alarms on bracelets to help prevent wandering for people with dementia or Alzheimer's. There's a peaceful courtyard in the middle, and spaces to gather both inside and outside, with an inviting rooftop terrace, and common rooms like a movie theater, café, library, TV lounge, and a book room, so residents can always find a spot to relax or chat.
The community offers assisted living and memory care services, supporting older adults who might need a little help getting dressed, bathing, taking medicine, or moving around, and for folks needing memory care, the team handles things like reminders for the bathroom, gentle support for incontinence, and monitoring for diabetes with trained staff always around, along with a nurse on staff and a doctor on call if needed. Residents get healthy meals every day-restaurant-style, with a chef on site, room service available, guest meals for visitors, and special diets like low sodium or low sugar for those with health needs, and you'll find personal meal plans for conditions like high blood pressure or diabetes.
Active living gets a boost with regular activities-there's stretching classes, Tai Chi, chair yoga, art sessions, karaoke, lectures, and outings around town or to faith-based services, plus things like music therapy, pet therapy, board games, brain fitness, trivia, and even wine tasting now and then. Folks can join in movie nights or community events, enjoy the outdoor patio garden, or stop by the beautician in the salon, and a mobile barber comes for folks who need a trim or a shave. Transportation is handy, with rides to doctor's appointments, errands, and the store, free or for a fee, and the building sits near bus lines for easy trips.
Terraza Court accepts both cats and dogs so residents don't have to leave pets behind, and they encourage social times together with amenities aimed at building friendships, but people can find private time, too. There's housekeeping, laundry, free Wi-Fi and cable, grocery shopping help, and a steady calendar of everything going on, so people know what's happening each day. If someone needs more care as time goes by, they let residents age in place with changing support, offering assisted living, independent living, continuing care, respite care for short stays, hospice for end-of-life needs, and nursing home services, which means folks won't have to move every time their health changes.
Memory care residents benefit from extra safety steps, like monitored exits, reminders for daily tasks, and trained caregivers who know how to manage the ups and downs of memory loss. All staff keep an eye out for everyone at all hours, helping with grooming, bathroom needs, or even just finding the TV remote, making sure no one feels left behind or forgotten. There's a focus on keeping people as independent as possible and helping them stay active in mind and body, whether that means joining a stretching group or just having a quiet walk in the courtyard with a friend and a cup of coffee. Managed by Northstar Senior Living, Terraza Court Senior Living has a rating of 3.7 out of 5 from 18 reviews, and it tries to make things comfortable rather than fancy, aiming for a relaxed, neighborly place where older adults can feel safe, enjoy good company, and have support as they need it.
Founded in 2008 and headquartered in Redding, California, Northstar Senior Living has established itself as one of the premier providers of senior living management and consulting services in the United States. Under the leadership of President and CEO Rick Jensen, who co-founded the company, Northstar has built a reputation for excellence in senior care management through its commitment to setting industry gold standards. The privately owned company operates approximately 40-51 communities across nine states, offering comprehensive management services that span the full spectrum of senior living operations.
People often ask...
Terraza Court Senior Living offers competitive pricing, with rates starting at a cost of $3,250 per month.
Terraza Court Senior Living offers independent living, assisted living, and memory care.
There are 50 photos of Terraza Court Senior Living on Mirador.
Yes, Terraza Court Senior Living allows residents to age in place and adjust their level of care as needed.
The full address for this community is 10955 Washington Blvd, Culver City, CA, 90232.
Yes, Terraza Court Senior Living offers 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.
State of California Inspection Reports
132
Inspections
6
Type A Citations
25
Type B Citations
6
Years of reports
26 Jun 2025
26 Jun 2025
Determined there was not enough evidence to support either allegation—that staff failed to prevent a resident from sustaining a fracture while in care and that staff failed to prevent a resident from eloping from the premises.
13 Jun 2025
13 Jun 2025
Found the four allegations unfounded: a resident fell due to staff neglect; staff did not respond promptly to requests for assistance; meals did not follow dietary restrictions; and medications were not properly managed.
11 Jun 2025
11 Jun 2025
Identified overcharging of a resident, including duplicate charges for May 2025 and billing for a period before move-in, with finances managed by the resident's representative. Found that a copy of the admission agreement was not provided to the resident's representative, and staff did not consistently respond to communications from the representative.
§ 87468(a)(b)
§ 87468.1(a)(9)
§ 87507(b)(4)
28 May 2025
28 May 2025
Found insufficient evidence to prove the allegation that staff did not provide adequate care and supervision to a resident.
14 May 2025
14 May 2025
Found that the allegation that staff did not meet a resident's indwelling urinary catheter needs was unsubstantiated, and the allegation that staff did not provide adequate transportation for a resident was unsubstantiated.
14 Nov 2024
14 Nov 2024
Investigated two allegations: that staff did not prevent a resident from sustaining a fracture, and that staff did not prevent a resident from eloping. Found insufficient evidence to support either allegation.
23 Apr 2025
23 Apr 2025
Found the allegation of lack of supervision resulting in a resident eloping unsubstantiated; records and interviews indicated staff were with the resident and redirected them back inside after the behavioral episode.
12 Mar 2025
12 Mar 2025
Found insufficient evidence to prove the allegation that staff did not provide the resident's responsible party with the requested records.
15 Jan 2025
15 Jan 2025
Investigated the allegation that staff did not provide adequate care and supervision to a resident. Found insufficient evidence to prove the allegation.
14 Jan 2025
14 Jan 2025
Identified that a staff member verbally abused a resident who attempted to leave memory care, and the staff member was terminated the following day.
02 Oct 2024
02 Oct 2024
Found no corrections needed after the pre-licensing change of ownership evaluation; all areas including medications, living spaces, dining room and kitchen, records, administration, activities, and safety systems met licensure requirements for 170 residents.
02 Oct 2024
02 Oct 2024
Found no credible evidence to support Allegation 1 (resident sustained injuries while in care), Allegation 2 (staff did not seek medical attention), Allegation 3 (rooms not kept clean), and Allegation 4 (failure to notify the responsible party of an incident). No deficiencies cited.
02 Oct 2024
02 Oct 2024
Found the allegation that staff refuse to assist residents in care to be unsubstantiated; records and interviews showed staff follow a falls protocol, involve a supervisor or MedTech, and call 911 when appropriate. Found the allegation of conduct inimical to be unsubstantiated; policy directs avoiding movement unless needed and paramedic transportation is governed by the resident’s power of attorney, with no evidence of improper use of 911.
30 Sept 2024
30 Sept 2024
Investigated the allegation that staff did not properly supervise residents, resulting in one resident ingesting another resident’s medication and being hospitalized. Found insufficient evidence to support the allegation and observed no deficiencies.
13 Sept 2024
13 Sept 2024
Found a malfunctioning thermostat on the second floor near room 237 that also controls hallway temperatures on the first floor, including Memory Care.
13 Sept 2024
13 Sept 2024
Investigated the allegation that staff did not keep the home at a comfortable temperature. Thermostat readings ranged from 70 to 75 degrees, staff and the manager said air conditioning was kept on, and interviews indicated warmth did not contribute to medical issues such as falls or low blood pressure.
13 Sept 2024
13 Sept 2024
Observed deficiency related to a malfunctioning thermostat during the visit.
§ 87303(a)
09 Sept 2024
09 Sept 2024
Found no deficiencies. Temperature and cooling were generally adequate across areas toured, though a Memory Care hallway was warm and the thermostat location was initially unclear, later clarified as controlled by a second-floor thermostat; all observed air conditioners functioned, and temperature was monitored hourly.
09 Sept 2024
09 Sept 2024
Conducted unannounced health and safety check, no deficiencies observed, no citations issued.
31 Jul 2024
31 Jul 2024
Verified identities of the applicant and administrator at an RCFE and confirmed their understanding of licensing laws; obtained identification and related documentation. Confirmed knowledge of operation, admission policies, staffing and training, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
31 Jul 2024
31 Jul 2024
Confirmed successful completion of Component II requirements during the inspection.
25 Jul 2024
25 Jul 2024
Investigated claim that staff did not distribute a resident's medication as prescribed. Interviews with staff and residents, along with MARs and medical records, showed medications were dispensed per orders, with Morphine managed by a hospice nurse and no narcotics administered by staff; insufficient evidence to determine whether the claim occurred.
30 Apr 2024
30 Apr 2024
Found Allegation 1, neglect/lack of supervision resulting in delay of medical care for a resident, occurred. Allegations 2 and 3, regarding missing window blind slats and missing personal items, were not established.
30 Apr 2024
30 Apr 2024
Confirmed neglect of a resident due to lack of supervision and substantiated a complaint regarding missing blind slats, but did not find enough evidence to prove missing personal items were not safeguarded.
§ 87405(h)(8)
§ 87615(a)(1)
25 Apr 2024
25 Apr 2024
Investigated allegations that a resident sustained unexplained bruises, that bathing assistance was not provided, and that emergency services were not contacted promptly. Findings showed mixed responses from residents and staff, with some reporting inadequate night supervision and others confirming care as needed, and emergency services reportedly contacted promptly when urgent care was required.
25 Apr 2024
25 Apr 2024
Confirmed inadequate supervision of residents, while allegations of unexplained bruising, lack of bathing assistance, and untimely emergency response were not supported by sufficient evidence.
28 Dec 2023
28 Dec 2023
Found no evidence that lack of supervision resulted in a resident being found on the ground. Interviews with staff and residents indicated there were no staffing issues and that falls were addressed promptly with no injuries reported.
28 Dec 2023
28 Dec 2023
Investigated allegation of lack of supervision resulting in a resident found on the ground; determined that the allegation was not supported by enough evidence.
19 Apr 2023
19 Apr 2023
Found two specific allegations: no skilled professional to meet residents' needs and inadequate food service. Based on interviews with staff and residents and kitchen observations, these allegations were unsubstantiated.
31 Aug 2023
31 Aug 2023
Investigated two allegations—medications not given as prescribed and not calling 911 promptly. Found UNSUBSTANTIATED.
17 Nov 2023
17 Nov 2023
Identified a capacity increase to 170 (160 non-ambulatory and 10 bedridden) after a tour and fire clearance approval; no deficiencies observed.
17 Nov 2023
17 Nov 2023
Confirmed no deficiencies were observed during the inspection. Capacity increase requested by licensee recommended for approval.
§ 87405(h)(8)
§ 87615(a)(1)
01 Nov 2023
01 Nov 2023
Found no deficiencies during the on-site, unannounced annual visit. Resident rooms, common areas, kitchen, medications, safety systems, and infection-control measures were in good order, with residents and staff expressing satisfaction with care.
01 Nov 2023
01 Nov 2023
Completed an inspection using the full CAREs tool, ensuring cleanliness, safety, and proper care for residents. No deficiencies were found during the visit.
§ 87468.2(4)
31 Aug 2023
31 Aug 2023
Reviewed allegation regarding staff not providing medications as prescribed and found insufficient evidence to support it. Additionally, investigated the claim of staff not calling 911 in a timely manner and found it to be unsubstantiated.
§ 87303(a)
24 Aug 2023
24 Aug 2023
Found that staff regularly reassessed residents for changes in level of care, updated records as needed, and promptly notified physicians and families about significant changes. Also found that bathing needs were met, incontinent residents were checked every two hours, and meals (three per day plus snacks) were provided with diverse options; residents reported satisfaction, and there was insufficient evidence to prove the allegations.
24 Aug 2023
24 Aug 2023
Confirmed adequate care and service provision, with no deficiencies cited during the visit. Residents reported satisfaction with food and care received.
04 Aug 2023
04 Aug 2023
Found insufficient evidence to prove the allegation that residents were left in soiled clothing for extended periods.
04 Aug 2023
04 Aug 2023
Found insufficient evidence to support the allegation of residents being left in soiled clothing for extended periods of time.
03 Aug 2023
03 Aug 2023
Identified a memory care resident's elopement and related investigations, with citations issued and a civil penalty assessed; an exit interview was conducted.
03 Aug 2023
03 Aug 2023
Identified deficiencies in the management of a resident eloping from the facility, resulting in a civil penalty being assessed.
26 Jul 2023
26 Jul 2023
Investigated Allegation 1: resident left soiled while in care; evidence did not establish that this occurred. Investigated Allegation 2: staff did not follow physician’s orders; evidence did not establish that this occurred.
26 Jul 2023
26 Jul 2023
Confirmed that staff did not leave residents soiled while in care and did not follow physician's orders based on interviews and record reviews.
21 Jul 2023
21 Jul 2023
Found that the allegation that staff assaulted a resident was unsubstantiated after interviews and records found no corroborating evidence. Interviews with staff and residents did not confirm the incident, and there was no video evidence available.
21 Jul 2023
21 Jul 2023
Found meals were nutritionally balanced and served according to guidelines. Found air conditioning functioning properly with comfortable indoor temperatures and all units working, and found new staff training provided online with monthly sessions, with residents reporting staff training as adequate.
21 Jul 2023
21 Jul 2023
Confirmed that nutritional meals were being served and that the air conditioning units were functioning properly based on interviews and records reviewed.
29 Jun 2023
29 Jun 2023
Identified the allegation of wrong medications given to a resident on 6/22/2023 during morning rounds; EMS arrived, the resident refused transport, and caregivers monitored for 48 hours. Interviews with staff and residents supported the allegation.
29 Jun 2023
29 Jun 2023
Confirmed mismanagement of medication, leading to an incident with a resident.
04 Jun 2023
04 Jun 2023
Found Allegation 1 that staff did not safeguard resident personal property. Found Allegation 2 that staff denied visits were not supported by a preponderance of evidence.
04 Jun 2023
04 Jun 2023
Reviewed allegations involving staff not safeguarding resident personal property and restricting visitor access; determined there was insufficient evidence to support these claims. Interviews and records indicated residents in the memory care unit often misplaced items, and no unauthorized visitation denials occurred.
01 Jun 2023
01 Jun 2023
Investigated a resident eloping from the premises without staff knowledge on 03/19/23; the resident was found outside after exiting through an emergency door, EMS was called, and a representative was contacted. Interviews and records, along with alarm testing, supported the allegation and noted that there were no surveillance cameras on site.
01 Jun 2023
01 Jun 2023
Confirmed allegations of a resident leaving the facility unattended, resulting in a substantiated finding.
03 May 2023
03 May 2023
Found no evidence staff yelled at residents. Found the kitchen areas clean with temperature logs posted, chemicals stored securely and inaccessible to residents, and residents received three meals daily with snacks and available alternatives.
03 May 2023
03 May 2023
Investigated allegations of resident mistreatment, kitchen cleanliness, availability of toxic substances, and food provision. Found no substantial evidence to support the allegations.
§ 87468.1(a)(2)
26 Apr 2023
26 Apr 2023
Found residents received daily activities, no odor concerns were identified in the memory care unit or other areas, and grooming needs were met. Allegations not supported by evidence.
26 Apr 2023
26 Apr 2023
Determined that the allegation that medical records were not provided timely was not supported; interviews and records showed the attorney's request was received on 04/18/23 and the documents were delivered by fax and mail on that date.
26 Apr 2023
26 Apr 2023
Confirmed that the complaint alleging a failure to provide medical records in a timely manner was unfounded, with records showing that the documents were delivered promptly as requested.
19 Apr 2023
19 Apr 2023
Found no evidence to support the allegation of a malodorous environment; observations showed cleanliness and proper maintenance. Found no evidence to support the allegations of delayed mail delivery or insufficient snacks; staff and residents reported timely mail and ample snacks.
19 Apr 2023
19 Apr 2023
Confirmed clean and sanitary conditions, timely mail delivery, and availability of snacks for residents at the facility.
23 Mar 2023
23 Mar 2023
Found no evidence to support the allegation that incontinent residents were not cared for or left soiled; interviews with staff and residents and on-site observations showed regular checks, timely restroom assistance, cleanliness, and respectful care.
23 Mar 2023
23 Mar 2023
Investigated a complaint about neglect, specifically the improper care of incontinent residents, and determined there wasn't enough evidence to support it, with residents and staff reporting proper care practices were in place.
13 Dec 2022
13 Dec 2022
Identified that a medication technician had no background clearance and was not associated with this site. Found that the Business Office Manager and a Regional Operations Specialist were not associated with the site. Conducted an exit interview and discussed appeal rights.
13 Dec 2022
13 Dec 2022
Found the allegation that a toxic chemical was accessible to a resident in care. The resident admitted reaching for and attempting to drink from a bottle of cleaner; a witness and several staff confirmed the incident, and the resident was transported to a hospital for evaluation, which indicated no definite ingestion and no symptoms.
13 Dec 2022
13 Dec 2022
Identified deficiencies related to personnel background clearances and associations with the facility during a recent visit.
09 Dec 2022
09 Dec 2022
Found insufficient evidence to prove the two allegations: that staff did not respond to requests for documents in a timely manner (including medical records) and that staff did not respond to communications in a timely manner.
09 Dec 2022
09 Dec 2022
Investigated allegations of staff not responding to document and communication requests in a timely manner; determined insufficient evidence to prove or disprove claims.
§ 80075(b)
28 Oct 2022
28 Oct 2022
Found an unwitnessed fall resulting in stitches for a resident, with no clear explanation of how it occurred. Found insufficient evidence to prove cleaning lapses, laundry delays, unaddressed soiled diapers or bedding, or disrepair of window blinds.
28 Oct 2022
28 Oct 2022
Confirmed allegations related to a fall resulting in injury and unsubstantiated others regarding room cleanliness, timely laundry, diaper changes, soiled bedding, and disrepair of window blinds.
21 Oct 2022
21 Oct 2022
Found Allegation 1: a resident sustained a knee injury after a fall during a walk, with inconsistent accounts between residents, staff, and records. Found Allegations 2, 3, and 4: residents reported delays in responding to call buttons and administering medications and described rude staff, while staff and management denied these issues, with testing showing a 10-minute call-button response and other accounts indicating longer delays.
21 Oct 2022
21 Oct 2022
Reviewed allegations of a resident's injury, delayed call button response, and late medication administration, finding insufficient evidence to support these claims, while confirming staff rudeness based on interviews; issued a citation for observed deficiencies.
27 Jun 2022
27 Jun 2022
Found that a resident with dementia did not have a current physician's report on file, with only a 2017 report located and no newer one identified. Also found that the resident did not receive an annual medical assessment as required.
27 Jun 2022
27 Jun 2022
Identified deficiency in not conducting annual medical assessments for a resident with dementia.
05 Apr 2022
05 Apr 2022
Found no deficiencies after an unannounced case management visit; confirmed the site was clear of COVID-19 infection, observed a sanitizing station and screening logs, and collected supporting documents for five complaints.
04 Feb 2022
04 Feb 2022
Investigated the allegation that staff did not assist residents as needed. Confirmed through interviews with staff and residents, and record review, that residents received necessary care with adequate staffing, supported by an outside agency during COVID-19, and that positive COVID-19 cases were promptly reported to families and appropriate agencies.
11 May 2022
11 May 2022
Determined that the prior allegation about staff testing positive for COVID-19 was amended to refer to unqualified staff. No deficiencies were found.
11 May 2022
11 May 2022
Confirmed positive COVID-19 cases among unqualified staff.
§ 1569.17(b)
05 Apr 2022
05 Apr 2022
Visited facility clear of COVID-19. No deficiencies found during the inspection.
§ 87705(f)(2)
01 Apr 2022
01 Apr 2022
Found no preponderance of evidence to prove or disprove the allegation that the resident's records were not released to the responsible party and that the reporting party was not notified of the resident’s passing.
01 Apr 2022
01 Apr 2022
Reviewed resident records and conducted interviews regarding lack of notification to family of resident's passing and failure to have emergency contact information on file.
§ 87468.1(a)(1)
25 Feb 2022
25 Feb 2022
Found no evidence to support the allegation that staff did not safeguard residents' personal belongings; staff safeguarded belongings and residents reported no missing items.
29 Dec 2021
29 Dec 2021
Investigated Allegations #1 through #5. Found insufficient evidence to confirm Allegations #1 (scabies), #2 (reporting requirements), #3 (isolation), and #5 (safeguarding personal items); Allegation #4 (residents unkempt) was not supported by the evidence.
04 Jan 2022
04 Jan 2022
Found insufficient evidence to prove or disprove that staff hindered residents' complaint investigations.
Stated that requested documents were provided and access to records was given, with no interference reported.
08 Dec 2021
08 Dec 2021
Investigated seven allegations about medication management, activities, belongings, adherence to care plans, oral hygiene, daily hygiene, and incident reporting at the home through staff and resident interviews, observations, and records review. Found no evidence to support the allegations; residents received medications per orders, participated in activities, belongings were not missing, care plans were followed, oral and daily hygiene were provided, and incidents were reported as required.
21 Dec 2021
21 Dec 2021
Investigated; Allegation 1 found no evidence staff were inadequately trained. Allegation 2 found no scabies and that doctors' orders were followed; Allegation 3 found staff informed authorized representatives of changes in condition; Allegation 4 found toileting needs met; Allegation 5 found dental care coordinated by families.
14 Mar 2022
14 Mar 2022
Identified concerns about call buttons not being answered promptly, along with issues raised about showers, changing, dining access, cleaning, and medications. Found there was not enough evidence to prove any of the allegations occurred.
14 Mar 2022
14 Mar 2022
Investigated multiple allegations, including untimely response to residents' call buttons, inadequate showering, delayed changes, lack of dining room access, insufficient room cleaning, medications being accessible, neglect of medication administration, and rough treatment of residents. Determined that while the allegations may have occurred, insufficient evidence existed to confirm any violations.
11 Mar 2022
11 Mar 2022
Investigated an allegation that a resident had scabies; interviews and medical records showed the resident was treated for a skin rash, not scabies, and there was insufficient evidence to confirm the allegation.
11 Mar 2022
11 Mar 2022
Investigated an allegation of scabies; confirmed it was unfounded as interviews and records indicated treatment for a skin rash, not scabies.
§ 87468.1(a)(2)
25 Feb 2022
25 Feb 2022
Investigated a complaint of staff failing to safeguard residents' personal belongings; determined there was insufficient evidence to prove the alleged violation occurred or did not occur.
04 Feb 2022
04 Feb 2022
Investigated allegations of staff not assisting residents as needed and having unqualified staff, determined insufficient evidence to support these claims; staff was found to be trained and competent, meeting required standards.
04 Jan 2022
04 Jan 2022
Determined there was insufficient evidence to support the allegation that staff hindered residents' complaint investigations, as documents were reportedly made available to the Ombudsman, and no interference was noted by interviewed parties.
28 Dec 2021
28 Dec 2021
Found that the four allegations were unsubstantiated. Staffing was adequate, laundry services were provided as needed, no items in residents’ rooms were covered in feces, and there were sufficient bed linens.
29 Dec 2021
29 Dec 2021
Interviews and observations revealed that allegations of scabies, isolation, unkempt residents, and mishandling of personal items at the facility were unsubstantiated. Staff were found to be following reporting requirements and residents were well-groomed.
28 Dec 2021
28 Dec 2021
Investigated allegations of insufficient staffing, failure to provide laundry services, rooms having items covered in feces, and lack of bed linens, finding no sufficient evidence to prove the allegations occurred. Confirmed that staffing, laundry services, cleanliness, and bed linen supply were adequate according to the staff and residents interviewed.
21 Dec 2021
21 Dec 2021
Reviewed five allegations against a care facility, including inadequate staff training, failure to follow medical orders to prevent scabies, lack of communication with residents' representatives, inadequate toileting support, and delayed dental care, all of which were deemed unsubstantiated due to insufficient evidence.
§ 87705
15 Dec 2021
15 Dec 2021
Investigated allegations of an unsafe environment, staff threats, and illegal eviction; interviews and record reviews did not establish a preponderance of evidence to prove these claims.
15 Dec 2021
15 Dec 2021
Investigated claims of an unsafe environment, staff threats, and illegal eviction; determined that evidence did not conclusively support any of these allegations.
08 Dec 2021
08 Dec 2021
Confirmed allegations of resident medication mismanagement were unfounded, as residents reported they were receiving medications as prescribed. Allegations of missing belongings, inadequate activities, and staff non-compliance with care plans and hygiene assistance were also found to be unsubstantiated.
§ 87468.1(a)(2)
12 Nov 2021
12 Nov 2021
Investigated Allegation 1 that staff did not remove a resident from isolation after scabies treatment; found the resident was released per physician orders and no other residents were diagnosed with scabies. Investigated Allegation 2 that staff did not adhere to public health guidelines; found staff stated they followed guidelines and a nurse’s email indicated one resident does not constitute an outbreak, with no evidence of a violation.
12 Nov 2021
12 Nov 2021
Investigated allegations revealed insufficient evidence to prove staff failed to remove a resident from isolation after scabies treatment or that staff did not adhere to public health guidelines.
12 Oct 2021
12 Oct 2021
Found infection-control measures in place, with screenings for visitors and staff, PPE readily available, and vaccination status reportedly up-to-date; no deficiencies were cited.
12 Oct 2021
12 Oct 2021
Inspection of the facility found compliance with infection control measures, ample PPE supplies, and proper resident care practices, resulting in no deficiencies cited.
24 Sept 2021
24 Sept 2021
Found insufficient evidence to prove the allegation that changes in a resident's health were not observed, including claims tied to short staffing. Documentation showed the resident tested positive for COVID-19, declined, entered hospice, and died with COVID-19 noted; hospice indicated the family agreed to comfort care.
24 Sept 2021
24 Sept 2021
Found during the visit that there was an allegation of failure to observe a resident's change in condition due to staffing issues, but there was not enough evidence to prove the allegation.
17 Sept 2021
17 Sept 2021
Found insufficient evidence to prove the following allegations: resident did not have access to a phone; staff did not safeguard residents' personal belongings; residents' hygiene needs were not met; and bedding was soiled. Interviews and records did not support these claims.
17 Sept 2021
17 Sept 2021
Found four concerns: a resident-on-resident injury, mismanagement of medications, inadequate diapering and showering care and supplies, and dirty restrooms. Concluded there was insufficient evidence to prove or disprove any of these concerns.
17 Sept 2021
17 Sept 2021
Investigated two medication-related allegations: that staff were not trained to pass out medications and that residents received medications late. Evidence showed conflicting statements between staff and residents and records indicating some doses were missed.
17 Sept 2021
17 Sept 2021
Confirmed allegations of resident altercation resulting in injuries and mismanagement of medications. Unsubstantiated allegations of unmet diapering and showering needs, as well as inadequate diapering supplies and dirty restrooms.
27 Aug 2021
27 Aug 2021
Investigated multiple complaints and found that a resident assaulted another resident. Found that staffing levels were not sufficient to meet residents’ needs; showering needs were not consistently met; there were odor and sanitation concerns; and dignity in meals and staff interactions was questioned.
§ 87468.1(a)(1)
27 Aug 2021
27 Aug 2021
Found allegations of resident assault and staffing shortages to be substantiated, while allegations of inadequate showering assistance, malodorous conditions, unsanitary practices, and lack of dignity were unsubstantiated.
23 Jul 2021
23 Jul 2021
Found sufficient evidence to support the allegations that a resident fell while in care, a resident was left on the floor for an extended period, and the telephone was not properly manned; found insufficient evidence to support the allegation that staff did not provide adequate activities.
06 Nov 2020
06 Nov 2020
Identified that no current administrator could be confirmed; two staff members were overseeing the operation until a new administrator is hired.
23 Jul 2021
23 Jul 2021
Confirmed staff provide activities for residents, resident fell while in care, resident left on floor, and facility's telephone not properly manned.
24 Mar 2021
24 Mar 2021
Determined the allegation that fire alarms were in disrepair did not meet the standard, as interviews and records showed no ongoing malfunctions and that alarms are maintained by an outside vendor with regular checks and drills.
24 Mar 2021
24 Mar 2021
Investigated fire alarm complaint, no issues found.
24 Jan 2021
24 Jan 2021
Investigated two dietary-related allegations; found cooks were in the kitchen and meals followed doctor orders for pureed diets, while staff certifications were not confirmed and some residents reported getting enough food though taste varied. Evidence did not establish a definite violation.
24 Jan 2021
24 Jan 2021
Investigated allegations about staff not meeting residents' dietary needs and staff qualifications for food preparation, ultimately finding lack of evidence to prove the allegations true or false.
§ 87452
23 Nov 2020
23 Nov 2020
Investigated allegations that a resident lost significant weight while in care, and that laxatives were continued after a doctor’s order was discontinued. Also identified concerns about a bathroom not being cleaned promptly due to staffing and housekeeping gaps, and about insufficient staffing affecting residents’ showers and overall care.
23 Nov 2020
23 Nov 2020
Confirmed significant weight loss, medication error, delayed cleaning, and staffing shortages at a care facility.
§
10 Nov 2020
10 Nov 2020
Found there was not enough evidence to prove the dogs acted aggressively. Observations and interviews with residents and staff, along with reviewed documents, showed no harm or aggressive behavior by the dogs.
10 Nov 2020
10 Nov 2020
Reviewed a complaint alleging that a dog in the facility exhibited aggressive behavior; findings indicated insufficient evidence to support the claim.
§ 87464(f)(4)
§ 87307(a)(2)
06 Nov 2020
06 Nov 2020
Identified deficiencies were cited during the visit, and the administrator for the facility could not be confirmed.
30 Oct 2020
30 Oct 2020
Identified inadequate staffing as the reason residents' needs were not met, based on observations, interviews, and records. Interviews with residents and staff consistently indicated there were not enough staff to meet needs.
30 Oct 2020
30 Oct 2020
Confirmed lack of sufficient staffing to meet residents' needs based on interviews with residents and staff, as well as review of records and tour of the facility.
02 Jul 2020
02 Jul 2020
Investigated complaints about leaking toilets in resident rooms and sewage leaking into kitchen dry storage; found insufficient evidence to confirm these issues.
01 May 2020
01 May 2020
Investigated complaints regarding staff not safeguarding residents' property, providing inadequate food service, failing to refill medication, and not responding promptly to call buttons; none were proven due to insufficient evidence.
03 Jan 2020
03 Jan 2020
Investigated whether hallway lights and residents' door knobs were malfunctioning or in disrepair and found no sufficient evidence to support the allegations; all inspected lights and door knobs appeared operational and well-maintained. Allegations regarding broken or missing door knobs and lights were unverified based on interviews and observations.
§ 87411(a)
05 Dec 2019
05 Dec 2019
Investigated the allegation that facility staff failed to safeguard residents' personal property; however, a preponderance of evidence was not found to support this claim, rendering it unsubstantiated.
§ 87303(a)
§ 87465(c)(2)
§ 87411(a)
§ 87466
23 Nov 2019
23 Nov 2019
Investigated complaints included staff administering timely medication, adequate staffing levels, and bed bug presence in one room. Found sufficient evidence for bed bug issue being present and addressed, while medication and staffing complaints lacked enough evidence to confirm or deny occurrences.
21 Nov 2019
21 Nov 2019
Interviews, observations, and record reviews did not provide enough evidence to support the allegation of inadequate care, staffing shortages, or facility maintenance issues. The allegations were deemed unsubstantiated, with no deficiencies found during the inspection.
17 Nov 2019
17 Nov 2019
Investigated complaints about inadequate supervision and unlawful eviction; determined insufficient evidence to prove or disprove the allegations.
§ 87468.2(a)(4)
§ 87311
§ 87468.1
20 Jul 2019
20 Jul 2019
Confirmed poor food quality and inadequate administration oversight at the facility.