Activity staffing concentrated on seated/low-mobility programming
Summary of reviews
Overview
Oakland Heights presents a mix of clearly articulated strengths and recurring operational weaknesses in the reviews. Positive themes center on staff commitment, rehabilitation services, campus ambience, and an array of amenities. However, a set of consistent operational issues—chiefly staffing variability, uneven clinical and medication practices, and maintenance or dining inconsistencies—appear across reviews and have measurable impact on resident experience. Prospective residents and families should weigh the facility’s strong people- and amenity-oriented attributes against these operational risks when evaluating placement.
Care and staff
Many reviewers emphasize that caregiving staff are compassionate, personable, and capable; several accounts specifically praise nursing, therapy teams (PT/OT/Speech), and individual caregivers who supported hospital-to-facility transitions and rehabilitation goals. Long-tenured staff and approachable admissions/tour personnel are repeatedly cited as creating a warm, community-oriented atmosphere. Counterbalancing those positives are recurring concerns about inconsistent staffing levels—notably overnight and after-hours coverage—and lapses in responsiveness to call bells and urgent needs. There are also multiple mentions of medication-timing and medication-management inconsistencies; one review describes a serious medication-related adverse outcome, which has generated concern among families about clinical oversight. In summary: staffing and clinical practice quality appear uneven—excellent in many interactions but with occasional, consequential breakdowns.
Dining and activities
Dining receives mixed feedback. Some residents describe restaurant-style meals, an on-site chef, and plentiful options, while others report irregular menu adherence, meals that run out, limited dietary accommodations (for example diabetes or gluten-free needs), and occasional declines in meal quality. Activities are broadly offered—movies, music, arts and crafts, outings, happy hour, and exercise classes—but reviewers frequently note that programming tends to skew toward seated or lower-mobility participants. Active, ambulatory residents seeking hikes, vigorous fitness, or more varied stimulation report fewer suitable options. Staffing for activities also appears constrained at times, which can limit the frequency or diversity of offerings.
Facilities, safety and maintenance
The campus and grounds are widely praised: well-kept gardens, attractive landscaping, cottages, and multiple common areas are positive differentiators. Physical plant comments are mixed: there are many positive notes about clean public spaces and ongoing renovations, but reviewers also describe dated interiors, inconsistent maintenance, malfunctioning equipment, and localized sanitation or pest-control concerns. Memory-care safety and supervision are an important area of divergence—some families report secure patios and effective dementia care, while others describe lapses in wander-risk management and insufficient supervision that created safety concerns. Security-procedure inconsistencies are also present in reviews, including instances of gate/control issues and uneven visitor screening.
Management, administration and costs
Admissions and front-line leadership receive repeated praise for individualized move-in support, responsiveness, and compassion. Named staff and directors are often singled out as facilitators of smooth transitions. At the same time, reviewers raise concerns about higher-level management responsiveness, ownership/leadership changes, and communication gaps with families—particularly when clinical or behavioral issues arise. Affordability is another recurring theme: periodic price increases, additional service fees, and perceived opaque billing practices have been raised as financial stressors. There are also several comments about laundry and property-management weaknesses and at least one account alleging asset loss, which points to the need for clearer property-tracking and security protocols.
Notable patterns and considerations
The reviews portray a facility that can provide a high-quality, person-centered experience—especially where staffing, therapy, and engagement align—but that also has operational vulnerabilities that can materially affect safety and daily life. Key decision points for families should include verification of current staffing ratios (including overnight), clinical oversight policies (medication administration and incident-response), memory-care staffing and wander-risk management procedures, dietary accommodation processes, and a clear written description of all fees. An in-person tour that reviews recent inspection reports, asks for examples of how the facility addressed prior concerns, and meets the care team on duty can help determine whether Oakland Heights’ strengths will predominate for a particular prospective resident.
Bottom line
Oakland Heights offers strong rehabilitation services, a warm caregiving culture, and attractive grounds and amenities, making it a good fit for many residents. However, the facility shows patterns of inconsistent staffing, clinical practices, maintenance, and administrative transparency that warrant careful vetting. Families should proactively evaluate clinical oversight, memory-care safeguards, activity programming for higher-functioning residents, and the contract/fee structure before committing.
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Medicare Ratings
5·/ 5
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Oakland Heights Senior Living is located at 2361 E 29th St, Oakland, CA, 94606.
About Oakland Heights Senior Living
Oakland Heights Senior Living sits near downtown Oakland and the Robert W. Crown Memorial State Beach, and you'll find California stucco buildings with red tile roofs, mature palm trees, and flowering gardens tucked inside a safe, gated community that's laid out all on one story, so it's easy to get around. The facility offers a full range of care, so folks who want independence can choose from cottages and condos in studio, one, two, three, or even four-bedroom layouts, with full kitchens, private bathrooms, and the choice of moving into furnished or unfurnished spaces, and there's always help with moving in if it's needed. For those needing more help, the assisted living services cover things like dressing, bathing, mobility, and other day-to-day activities, and the units have wide-open floor plans and wheelchair-accessible showers to make things simpler.
Memory Care is available in private apartments and shared community spaces designed so residents with Alzheimer's or dementia can feel confident and more independent; caregivers are always there around the clock for help as needed. People can bring their cats and dogs, since pets are welcome, and everyone's got their own controls for heat and air conditioning. There's weekly housekeeping, laundry, and linen service, trash removal, and all the utilities are included in the rent, so there's no need to fuss with bills. Each apartment comes with a private bathroom and emergency alert system, and every part of the community is smoke-free, with a 24-hour security system as well.
The community takes pride in having helpful, friendly staff and nurses, a team that does its best to make this feel like home, and there's another care wing called Dimond Care for even more hands-on help. Residents can join in activities from art classes to movie nights in the on-site theater, relax in the library with big, comfy chairs, use the exercise room with modern machines, or enjoy coffee and baked goods in the Bistro. Open dining rooms serve meals all day, and there are sunrooms and media rooms for visiting or quiet time while looking out over the landscaping.
Programs let residents age in place, so moving to a new location isn't needed if care needs change, and support's available to both individuals and couples. Skilled nursing and rehabilitation services round out the health care options. Oakland Heights keeps a positive environment for both residents and staff, offering career advancement, continuing education, and other employee perks, with the goal of keeping a steady, dedicated team in place. The grounds feature easy access to the 880 freeway, and tours with complimentary meals are available so people can get a feel for daily life. Oakland Heights Senior Living's been recognized by Assisted Living Magazine as one of the best in Oakland, but more than anything, the goal is to give seniors a safe, comfortable, and friendly place to live with as much support or independence as each person wants.
Pacifica Senior Living, a division of Pacifica Companies (family-owned since 1978), was founded in 2008 and is headquartered in San Diego, California. Operating over 90 communities across 13-14 states with concentrations in California, Florida, and Arizona, Pacifica has grown to become the 13th largest overall senior care provider in the United States. The company ranks as the 5th largest memory care provider, 10th largest assisted living provider, and 21st largest independent living provider nationally, serving thousands of residents from coast to coast through their comprehensive care offerings.
Pacifica's mission centers on creating a lifestyle of independence, security, and peace of mind for each individual and their family. The company provides personalized, compassionate care services through their signature Heartland™ Assisted Living and Legacies™ Memory Care programs, which focus on the individual while offering customized care plans that respect each resident's needs, preferences, and privacy. Their philosophy emphasizes striking a balance between assistance and independence, providing dignified and compassionate retirement experiences in environments that feel like home. Each community is managed individually, allowing for tailored support of unique resident profiles and communal character, with everything from scheduling to dining menus designed around residents' preferences.
The company's specialized memory care programs demonstrate their expertise in dementia care. Their Legacies™ Memory Care program helps patients with Alzheimer's disease and other forms of memory loss feel safe and secure while providing memory-boosting activities. The innovative Amara Memory Support program creates welcoming and empowering environments that celebrate the essence of people rather than focusing on their diagnosis. Programming encompasses nine Focus Elements of Life: Recreation, Service, Spirituality, Movement, Sensory, Household Connection, Community, Exploration, and Creative Arts, delivered through stimulating activities including gardening, culinary adventures, musical experiences, creative artistic outlets, and mindfulness practices.
Pacifica offers a comprehensive continuum of care including independent living, assisted living, memory care, respite care, skilled nursing, and adult day care services. All communities focus on promoting well-being by meeting care needs while facilitating social interactions, activities, and wellness programs. Despite recent financial challenges leading to the bankruptcy of one management entity affecting approximately 20 California facilities, the majority of Pacifica's nearly 100 communities continue operating, maintaining their commitment to advancing senior living and providing peace of mind to residents and families through warm, family-like communities where each resident receives individualized attention while maintaining dignity and independence.
People often ask...
Oakland Heights Senior Living offers independent living, assisted living, memory care, and skilled nursing.
There are 111 photos of Oakland Heights Senior Living on Mirador.
Yes, Oakland Heights Senior Living allows residents to age in place and adjust their level of care as needed.
The full address for this community is 2361 E 29th St, Oakland, CA 94606.
No, Oakland Heights Senior Living 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.
Cited deficiencies for not updating resident assessments and medical reports after an incident and for failing to submit an incident report.
Type BCCR 87463(a)Pre-admission appraisal update (reappraisal)
Type BCCR 87458(b)Updated medical assessments/Physician’s Reports
Type BCCR 87211(a)(1)(D)Incident reporting requirement
06 Aug 2026Inspection
06 Aug 2026Inspection
Identified multiple health and safety deficiencies and confidentiality issues, including unsecured sharps and medications, unsanitary conditions, and incomplete staff records. Civil penalties were assessed for repeat violations.
Type ACCR 87309(a)Disinfectants/poisonous substances and sharp objects stored locked outside storage
Type ACCR87465(h)(2)Centrally stored medications kept in a safe, locked place
Type BCCR 87303(a)Facility must be clean, safe, sanitary and in good repair
Type BCCR87555(a)Quality and quantity of daily diet and safe food handling
Type BCCR87555(b)(27)All kitchen areas kept clean and free of pests
Type BCCR87506(c)(1)Confidentiality of resident information; secure storage of records
Type BCCR87307(3)(C)Provision of clean linen and adequate linens for residents
Type BCCR87412(a)Personnel records maintained for licensee, administrator and each employee
Type BCCR87411(c)RCFE staff training on personal activities of daily living; initial and annual training
10 Jul 2026Inspection
10 Jul 2026Inspection
Found no deficiencies. Noted overall compliance with licensing standards.
28 Apr 2026Complaint
28 Apr 2026Complaint
Investigated the allegation that a resident's pendant did not function properly; findings showed staff did not regularly check or monitor the pendant's battery status, which could fail to alert staff during an incident.
Type B87303(i)(B)
28 Apr 2026Inspection
28 Apr 2026Inspection
Identified an amended complaint and noted a specific allegation related to care and safety.
06 Apr 2026Inspection
06 Apr 2026Inspection
Observed safety deficiencies included unlocked medications and bug spray, creating an immediate risk to residents. The hot water temperature was below the required range.
Type A87309(a)
Type B87303(e)(2)
25 Feb 2026Inspection
25 Feb 2026Inspection
Identified a bed bug addendum in the admission agreement that could waive provider responsibility; a deficiency was cited and civil penalties may apply.
Type B87507(h)(2)
09 Feb 2026Inspection
09 Feb 2026Inspection
Identified that a Bed Bug Addendum was included in admissions agreements; the administrator provided a signed copy. No deficiencies were cited.
30 Jan 2026Complaint
30 Jan 2026Complaint
Investigated a complaint that staff did not answer a resident's calls for assistance promptly. The investigation found that a wearable fob failed to alert staff during a fall, and staff actions included contacting 911 and assisting the resident.
30 Jan 2026Complaint
30 Jan 2026Complaint
Investigated a complaint that staff did not answer resident calls for assistance timely.
24 Nov 2025Complaint
24 Nov 2025Complaint
Investigated the allegation that a resident was charged for bed bug treatment and identified issues with the bed bug addendum and related charges.
Type B87507(h)(2)(h)
24 Nov 2025Complaint
24 Nov 2025Complaint
Identified that residents were asked to pay for bed bug treatment through a bed bug addendum added to admissions agreements, with rollout starting in 2020 and a resident signing the addendum in March 2024.
Type B1569.269(a)(5)
Type B87468.1(a)(2)
Type B87303(a)
06 Aug 2025Complaint
06 Aug 2025Complaint
Investigated the allegation that staff were not properly addressing pests; interviews indicated a scabies outbreak among residents, who were diagnosed, treated per physician plans, and cleared by physicians.
06 Aug 2025Inspection
06 Aug 2025Inspection
Conducted an unannounced case management visit to request pest control documentation; no deficiencies cited.
24 Jul 2025Complaint
24 Jul 2025Complaint
Investigated the allegation of illegal eviction and found the eviction notice wasn't valid because it did not itemize the outstanding balance.
Type B1569.269(a)(22)
24 Jul 2025Complaint
24 Jul 2025Complaint
Investigated a wrongful eviction allegation and determined that issuing an eviction after a resident became SSI/SSP eligible violated the requirement to provide basic services at no additional charge.
Type B87464(e)
24 Jul 2025Complaint
24 Jul 2025Complaint
Investigated an illegal eviction allegation; the investigation found no preponderance of evidence to prove the violation.
24 Jul 2025Inspection
24 Jul 2025Inspection
Conducted an unannounced case management visit and requested invoices related to bug bed treatment for 2025 by 7/30/2025.
02 Jul 2025Complaint
02 Jul 2025Complaint
Found ongoing bed bug issues in a resident’s apartment, with weekly pest-control visits and on-site maintenance addressing problems as they arise. Found insufficient evidence to prove the allegation that staff did not keep the space pest-free or charged the resident for pest treatment.
02 Jul 2025Complaint
02 Jul 2025Complaint
Investigated the allegation that staff did not keep the premises free from pests; there was not a preponderance of evidence to support the claim.
25 Jun 2025Inspection
25 Jun 2025Inspection
Observed no deficiencies identified during the required annual review. Noted safe conditions, functional detectors, secured medications, and adequate food supplies.
05 Jun 2025Complaint
05 Jun 2025Complaint
Investigated the allegation that staff did not keep premises free of rodents and found no evidence to support it.
19 May 2025Complaint
19 May 2025Complaint
Investigated the allegation that staff allowed residents to smoke. Concluded that the allegation could not be proven.
01 May 2025Complaint
01 May 2025Complaint
Investigated wrongful eviction allegation; found no eviction notices issued and noted confusion about the resident’s finances and resources, with staff actively trying to coordinate with the guardian and ombudsman.
01 May 2025Inspection
01 May 2025Inspection
Investigated an allegation that incorrect information about PIN 24-13 was provided. Regulation related to SSI after admission was reviewed, and no deficiencies were issued.
01 May 2025Complaint
01 May 2025Complaint
Investigated an allegation of wrongful eviction related to a resident's financial change. The investigation included interviews and review of communications with the resident's guardian and facility staff.
27 Mar 2025Complaint
27 Mar 2025Complaint
Identified three allegations: unlawful eviction, failure to provide a comfortable temperature, and retaliation against a resident. Investigated and found no evidence to support these allegations.
21 Nov 2024Complaint
21 Nov 2024Complaint
Investigated the allegation that staff stole a resident's valuables and found multiple walkers in a resident's apartment, with the resident denying misplacing items.
21 Nov 2024Complaint
21 Nov 2024Complaint
Investigated an allegation that cigarette odor was not kept off the premises; evidence showed a posted no-smoking policy and witnesses reported no smoking inside.
08 Nov 2024Complaint
08 Nov 2024Complaint
Investigated allegations of ongoing bed bug infestations and residents being pressured to sign an admission agreement addendum for bed bug treatment under threat of eviction.
Type B87303(a)
Type B87468.1(a)(3)
08 Nov 2024Complaint
08 Nov 2024Complaint
Found the allegation that staff did not follow the bed bug payment clause in the admissions agreement to be unsubstantiated.
08 Nov 2024Complaint
08 Nov 2024Complaint
Identified that bed bugs persisted in a resident's apartment despite treatments. Residents were pressured to sign an addendum paying for bed bug treatments or face eviction.
Type B87303(a)
Type B87468.1(a)(3)
08 Nov 2024Inspection
08 Nov 2024Inspection
Identified a bed bug addendum in the admissions agreement that improperly waived responsibility for residents' health and safety. It was not in compliance with regulations.
Type B87507(h)(2)
24 Oct 2024Inspection
24 Oct 2024Inspection
Identified changes to the plan of operation made without approval that could affect health and safety.
Type B87208(a)
23 Aug 2024Complaint
23 Aug 2024Complaint
Investigated a pest-related allegation and found no evidence of pests during the visit.
23 Aug 2024Complaint
23 Aug 2024Complaint
Investigated the allegation that staff allowed walkways to be in disrepair and found they were in good repair.
16 Jul 2024Inspection
16 Jul 2024Inspection
Identified hot water in the hallway bathroom exceeded safe temperatures and several days of pre-poured medications were present in the med room.
Type ACCR87303(2)
Type BCCR87465(h)(5)
19 Jun 2024Complaint
19 Jun 2024Complaint
Investigated a complaint alleging staff unlawfully evicted a resident. Found the allegation unfounded.
30 Apr 2024Complaint
30 Apr 2024Complaint
Investigated an allegation of neglect of physical care involving a resident; interviews and records were reviewed. The findings did not establish that the alleged neglect occurred.
04 Apr 2024Complaint
04 Apr 2024Complaint
Investigated allegations of abuse and neglect; found no preponderance of evidence to prove the events occurred.
20 Dec 2023Complaint
20 Dec 2023Complaint
Investigated the allegation of illegal eviction and determined there was not enough evidence to prove the violation.
20 Dec 2023Complaint
20 Dec 2023Complaint
Investigated an allegation that the elevator was in disrepair and that pests were not kept under control; found the refundable agreement issue unfounded.
08 Sept 2023Complaint
08 Sept 2023Complaint
Investigated the allegation of lack of supervision resulting in resident-on-resident altercations. Concluded there was not a preponderance of evidence to prove the violation.
29 Aug 2023Complaint
29 Aug 2023Complaint
Investigated an allegation that staff did not prevent bed bugs in a resident's room; found insufficient evidence to support the allegation.
25 Aug 2023Complaint
25 Aug 2023Complaint
Investigated allegations of disrepair, residents left in soiled diapers for an extended period, and staff not cleaning residents' rooms.
10 Aug 2023Complaint
10 Aug 2023Complaint
Investigated allegations about diaper changes, repositioning, weight loss, elevator operation, and a fall. Found them unsubstantiated.
10 Aug 2023Inspection
10 Aug 2023Inspection
Observed overall safe conditions and adequate food supplies; no deficiencies were cited.
02 Aug 2023Complaint
02 Aug 2023Complaint
Investigated a bed bug allegation and found no evidence to support it.
02 Aug 2023Complaint
02 Aug 2023Complaint
Investigated three allegations about gate operation and a resident's flooded original residence; observed the front gate functioning during the visit and noted that repair work on the original residence was underway.
13 Jul 2023Inspection
13 Jul 2023Inspection
Found no deficiencies cited during the visit.
13 Jul 2023Inspection
13 Jul 2023Inspection
Observed hot water at 118.5 degrees F in the hallway bathroom; refrigerator at 38 degrees F with adequate food supplies; medications secured in the med room; smoke and carbon monoxide detectors present; no deficiencies cited.
12 May 2023Complaint
12 May 2023Complaint
Investigated the mold and safety allegation; findings did not establish the issue.
24 Feb 2023Inspection
24 Feb 2023Inspection
Identified that staff personnel records were not available for review. This deficiency related to access to personnel records during licensing review.
Type B87412(f)
24 Feb 2023Complaint
24 Feb 2023Complaint
Identified staff shortages, pest infestation in storage areas, failure to conduct fire drills on a regular basis, and unsanitary trash conditions.
Type B87411(a)
Type B87303(a)
Type B87705(l)(8)
24 Feb 2023Complaint
24 Feb 2023Complaint
Investigated a complaint alleging staff failed to respond promptly to residents' call buttons; reviewed concerns about checks, heating, and visitation.
Type A1569.269(a)(5)
15 Feb 2023Complaint
15 Feb 2023Complaint
Identified an out-of-order clothes washer and could not produce repair records.
Type B87303(a)
19 Jan 2023Complaint
19 Jan 2023Complaint
Found roaches observed in the kitchen, elevator, and bathrooms, with a history of pests over several months.
Type B87555(b)(27)(b)
17 Jan 2023Complaint
17 Jan 2023Complaint
Investigated allegations related to a resident's death and accompanying care concerns; found no evidence to support the alleged violations.
17 Jan 2023Complaint
17 Jan 2023Complaint
Investigated two allegations about rodents in the kitchen and kitchen cleanliness. Evidence did not establish violations.
28 Dec 2022Complaint
28 Dec 2022Complaint
Investigated a resident fall and delays in emergency medical response; 9-1-1 was not immediately called after the injury.
Type B87465(g)
28 Dec 2022Inspection
28 Dec 2022Inspection
Identified a deficiency for not providing documents requested by the department during a prior complaint investigation. It involved the licensing authority's right to inspect, audit, and copy records upon demand.
Type B87755(c)
13 Dec 2022Inspection
13 Dec 2022Inspection
Observed an unannounced case management visit; one resident from another care facility was living at the site, and the resident reported a smooth transition and feeling safe.
29 Nov 2022Complaint
29 Nov 2022Complaint
Investigated allegations of bed bugs, incomplete showers, misplacement of belongings, dirty showers, staff not wearing gloves, pendant calls not answered, and insufficient incontinence care. Found no preponderance of evidence to prove the alleged violations.
29 Nov 2022Complaint
29 Nov 2022Complaint
Investigated the allegation that staff were not aware of a resident's DNR status. Found the allegation to be unfounded.
13 Oct 2022Complaint
13 Oct 2022Complaint
Investigated an allegation of financial abuse, including blocking calls from family and lack of communication with the POA; found the allegation unfounded.
30 Aug 2022Complaint
30 Aug 2022Complaint
Identified that a staff member lacked administrator qualifications because there was no active certified administrator in January–February 2022, and that a new administrator began duties on March 1, 2022.
Type B87405(a)
30 Aug 2022Complaint
30 Aug 2022Complaint
Investigated issues about administrator certification and key fob access; found that no active administrator was associated with the site in January and February 2022 and that key fobs failed to open doors.
Type B87405(a)
Type B87303(a)
25 Jul 2022Complaint
25 Jul 2022Complaint
Investigated allegations that staff did not respond promptly to residents' call buttons and that pendant alerts were unreliable due to wifi issues. Findings show multiple long response times and problems with the alert system.
Type B87468.2(a)(4)
01 Jul 2022Inspection
01 Jul 2022Inspection
Investigated a priority 1 complaint about health and safety and observed generally safe conditions with no issues found.
16 Jun 2022Complaint
16 Jun 2022Complaint
Investigated the allegation that a resident was not assisted with activities of daily living and found there was insufficient evidence to prove it occurred.
02 Jun 2022Complaint
02 Jun 2022Complaint
Investigated the complaint that doors were not properly maintained and found that the keypads on the doors to the independent living buildings did not read the key fob, requiring manual opening and posing safety risks for residents using walkers or wheelchairs. Staff sometimes propped those doors open during meals while awaiting replacement bids.
Type A87303(a)
12 May 2022Inspection
12 May 2022Inspection
Observed infection control measures in place, including screening at a central entry, PPE, and posted safety guidance; no deficiencies were noted.
27 Apr 2022Complaint
27 Apr 2022Complaint
Investigated the allegation that COVID-19 protocols were not followed; observed signage, masks, symptom checks, sanitizers, and cleaning, and COVID antigen testing with negative results. Found insufficient evidence to support the allegation.
26 Apr 2022Complaint
26 Apr 2022Complaint
Identified three specific issues: a resident developed infected pressure injuries due to contamination with urine and inadequate incontinence care; staff did not promptly change the resident's diaper after incontinence; and staff failed to reposition the resident every two hours using proper technique.
Type B87468.2(a)(4)
Type B87464(f)(4)
Type B87411(c)(3)(B)
26 Apr 2022Complaint
26 Apr 2022Complaint
Investigated allegation that residents were not provided a safe environment and found that exterior doors did not function automatically and the elevator/controls in the garage were nonfunctional, creating safety risks for residents.
Type B87307(d)(2)
14 Apr 2022Complaint
14 Apr 2022Complaint
Investigated allegation that a resident sustained multiple pressure injuries while in care. There wasn't enough evidence to prove neglect occurred.
22 Mar 2022Complaint
22 Mar 2022Complaint
Identified vermin access in the kitchen stock room; pest control was engaged and a wall opening was closed to prevent further access.
Type B87555(b)(27)(b)
16 Mar 2022Complaint
16 Mar 2022Complaint
Investigated a complaint that the site was in disrepair. Observed the elevator from the garage to residential levels was inaccessible, and residents reported they could not use it for several months.
Type B87303(a)
10 Mar 2022Complaint
10 Mar 2022Complaint
Investigated the allegation that there was no certified administrator. Found the allegation unfounded based on staff interviews and verification of a current administrator certificate.
02 Feb 2022Complaint
02 Feb 2022Complaint
Investigated a complaint alleging COVID-19 protocol violations and disrepair; no evidence supported the allegations.
06 Jan 2022Complaint
06 Jan 2022Complaint
Investigated a complaint that the location was in disrepair. Exterior doors did not open automatically and could not be opened from inside, creating a potential safety risk.
Type B87303(a)
04 Jan 2022Complaint
04 Jan 2022Complaint
Investigated the allegation that there was no heat. Found thermostat set to 80 degrees, residents provided with space heaters and extra blankets, and a planned power shutoff occurred to repair an electrical circuit.
06 Dec 2021Complaint
06 Dec 2021Complaint
Investigated a complaint alleging lack of pre-admission assessments, bed bugs, and pests. The investigation included reviewing records and interviewing staff.
04 Nov 2021Inspection
04 Nov 2021Inspection
Observed infection control measures and supplies in place; no deficiencies were cited.
11 Oct 2021Inspection
11 Oct 2021Inspection
Observed hot water temperatures outside the safe range and a dresser blocking an exit, creating an immediate safety risk to residents.
Type A87303(e)(2)
Type A87307(d)(6)
18 Aug 2021Complaint
18 Aug 2021Complaint
Identified safety hazards in the hallways, including protruding cables and pails of paint and Pennzoil near a running generator, related to the allegation that the site did not provide a safe and healthful environment for residents.
Type A87303(a)
02 Jun 2021Inspection
02 Jun 2021Inspection
Arrived unannounced, met with staff, and conducted an exit interview while receiving amended reports dated 03/24/2021.
29 Apr 2021Complaint
29 Apr 2021Complaint
Investigated a safety-related complaint and found the community gate remained inoperable and not repaired.
Type B87303(a)
25 Mar 2021Inspection
25 Mar 2021Inspection
Identified that a resident's change of condition was not updated in the pre-admission appraisal and that two staff had associations that had ended, while another was working without current background clearance. Determined to issue technical violations.
24 Mar 2021Complaint
24 Mar 2021Complaint
Identified failures to follow COVID-19 infection control and insufficient staff training, including non-distancing during activities, mask misuse, and medication training gaps.
Type A87468.1(a)(2)
Type B1569.69(b)
Type B87405(h)(8)
Type B87307(d)(2)
Type B87303(a)
Type B87555(b)(6)
24 Mar 2021Complaint
24 Mar 2021Complaint
Identified disrepair, incomplete menus, ineffective communication with social agencies, and bed bugs affecting residents.
Type B87405(h)(8)
Type B87307(d)(2)
Type B87303(a)
Type B87555(b)(6)
30 Nov 2020Complaint
30 Nov 2020Complaint
Identified bed bugs and rodents in multiple rooms. Found no evidence of contaminated food or inadequate wound care.
Type B87303(a)(1)
30 Nov 2020Complaint
30 Nov 2020Complaint
Determined that the three allegations—failure to report an incident to the authorized representative, failure to seek emergency medical services, and inadequate supervision to prevent risky behavior—were not supported by a preponderance of evidence.
18 Nov 2020Complaint
18 Nov 2020Complaint
Found no evidence to support the allegation that residents were kept in an unhealthful environment; interviews and records showed bathroom trash was managed by housekeeping and care staff across shifts, and a tele-visit did not observe full bathroom trash bins.
23 Oct 2020Complaint
23 Oct 2020Complaint
Found no evidence to support the allegation that a resident's room was infested with bed bugs. Interviews and reviewed records showed no bed bugs or bites in the room, and no related medical or vector control findings were documented.
21 Aug 2020Complaint
21 Aug 2020Complaint
Investigated allegations of resident-to-resident aggression; found no evidence of inadequate supervision or that R1 or R2 posed a sexual threat. Examined a 9/28/20 incident where R3 pushed R4, causing a minor contusion; concluded there was not enough evidence to prove staff failed to protect residents, and R3 had no prior aggression history.
10 Aug 2020Inspection
10 Aug 2020Inspection
Confirmed no health or safety concerns during the inspection. Residents were observed engaging in activities and appeared safe.
15 Jul 2020Complaint
15 Jul 2020Complaint
Investigated allegations that a resident sustained an injury while in care and that the facility failed to seek timely medical attention, but lacked sufficient evidence to prove these claims.
Type B87307(d)(2)
04 Jun 2020Complaint
04 Jun 2020Complaint
Investigated allegations of resident injury and rough treatment were not proven to have occurred. No evidence of neglect for seeking medical attention was found.
Type A87468.1(a)(2)
Type B1569.69(b)
Type B87405(h)(8)
Type B87307(d)(2)
Type B87303(a)
Type B87555(b)(6)
04 May 2020Complaint
04 May 2020Complaint
Reviewed allegations of insufficient staffing and inadequate staff training; found no substantial evidence to support these claims after evaluating staff schedules, training files, and conducting interviews.
31 Jan 2020Inspection
31 Jan 2020Inspection
Found high water temperature in the sink during the inspection.
30 Jan 2020Inspection
30 Jan 2020Inspection
Identified deficiencies in reporting and documenting resident injuries, with failure to follow protocols for skin integrity and conduct full pre-admission appraisals.
23 Jan 2020Inspection
23 Jan 2020Inspection
Identified deficiencies included improper storage of medications, lack of grab bars in bathrooms, maintenance issues, stained carpets, and faulty sink. Staff files were also found to be incomplete.
22 Jan 2020Inspection
22 Jan 2020Inspection
Confirmed annual inspection conducted at the facility on January 22, 2020, found compliance with regulations in areas including resident safety, medication storage, and fire safety protocols.
Type B87303(a)(1)
21 Jan 2020Complaint
21 Jan 2020Complaint
Confirmed the facility failed to issue a proper eviction notice.
08 Jan 2020Complaint
08 Jan 2020Complaint
Found that the allegation of interrupted utility service could not be proven.
04 Dec 2019Complaint
04 Dec 2019Complaint
Found no evidence of roaches or insects during the inspection, leading to the allegation being unsubstantiated at this time.
12 Nov 2019Inspection
12 Nov 2019Inspection
Inspection confirmed compliance with health and safety regulations.
30 Oct 2019Complaint
30 Oct 2019Complaint
Investigated an allegation of an incident on October 7, 2019, and determined it was unsubstantiated due to lack of sufficient evidence, as all interviewed staff denied the occurrence.
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