I've found a warm, clean, well-maintained community with caring, attentive and knowledgeable staff, engaging activities, nutritious meals, and hands-on management that makes residents feel safe - memory care is a strong point. That said, staffing and communication can be inconsistent: some families report unresponsive or rude staff, missed notifications, and occasional safety lapses. Overall I feel it's a solid, home-like choice most of the time, but I recommend visiting and asking about current staffing and communication practices.
mixed reports on food quality (some call it awful)
some areas described as depressing, dim, or not cheery
reports of belongings missing or mishandled
conflicting accounts of cleanliness in some reviews
language barrier issues reported by some families
untrained nursing staff / inconsistent clinical care quality
resident placement or roommate dissatisfaction
security concerns for advanced dementia in some opinions
messy areas and cigarette odor reported in isolated reviews
residents waiting in hallways and limited visible staff sometimes
communication problems due to shift changes
blocked phone numbers / inability to reach caregivers
inconsistent adherence to promised levels of care
Summary review
Overall sentiment: The reviews for Del Monte Assisted Living & Memory Care - Stockton are strongly mixed but lean positive in quantity and tone. A sizable proportion of reviewers highlight warm, family-like care delivered by attentive, compassionate staff, and they consistently praise the facility’s cleanliness, welcoming atmosphere, and robust activities program. Many reviewers emphasize peace of mind resulting from engaged leadership (owners and director), helpful medical services onsite, bilingual staff, and personalized attention to residents’ dietary needs and daily routines. However, a number of serious negative reports create meaningful reservations: recurrent complaints about poor communication, unresponsiveness to family concerns, mishandled personal items, and several accounts of safety lapses (including unreported falls, a lost patient, and claims of abandonment during emergencies). These contrasting clusters produce an overall picture of a facility that can provide excellent, person-centered care but also displays inconsistent operational performance in certain areas.
Staff and care quality: The most frequent positive theme is the staff — described in many reviews as friendly, kind, professional, and willing to go above and beyond. Multiple reviewers single out directors and owners for hands-on involvement and supportive leadership, and many staff members are credited with delivering personalized, respectful care, particularly in memory care transitions. In addition, medication administration and clinical services (wound care, PCP access, X-rays, podiatry) are repeatedly noted as strengths. On the negative side, reviewers report uneven staff competence (mentions of untrained nursing staff), rudeness from some individuals, and high staff turnover that appears to undermine continuity of care. Several family accounts describe delayed or absent callbacks and difficulty reaching caregivers, suggesting a communication and coordination gap that can significantly impact trust and safety.
Safety, security and incidents: Security receives mixed assessments. Some reviews explicitly praise secured hallways, protected outdoor areas, and vaccination/lockdown measures for memory care, indicating a safe environment for residents with cognitive impairment. Conversely, there are alarming reports describing safety incidents: a fall that was not communicated to family, a lost patient, and accusations of abandonment during emergencies (families told to call 911 themselves). These are relatively infrequent in number but high in severity; they underscore a pattern of inconsistent emergency protocol adherence and raise red flags for prospective families who prioritize robust incident reporting and reliable supervision.
Facilities and environment: Many reviewers report an impeccably clean, renovated, and well-maintained facility with a hotel-like or vacation-home feel. Positive comments include spacious resident rooms, pleasant dining rooms, a bustling activity room, and thoughtful interior design that contributes to a dignified, homelike ambiance. Others, however, describe parts of the facility as dated, dim, or depressing and cite localized cleanliness problems (including cigarette odor in isolated comments). This suggests variability by wing or by the time of visit; prospective families should tour the specific neighborhood they’re considering and ask about recent renovations and cleaning routines.
Dining and activities: Dining and programming are frequently praised: reviewers cite nutritious, delicious meals prepared from fresh ingredients, attention to special diets, and an engaged kitchen staff. The activity calendar is another strong theme — bingo, cards, piano, casino outings, pet therapy, volunteering and outdoor walking areas are commonly mentioned, and dining halls are often described as lively social hubs. A smaller number of reviews contest food quality or note that a particular resident refused meals, indicating that meal satisfaction can be subjective and may vary by individual preference and dietary needs.
Management, communication and operational consistency: Several reviews commend strong leadership, quick resolution of concerns, and a positive workplace culture that translates into better resident care. Many families report excellent, consistent communication where they were kept informed and included in care decisions. At the same time, there is a well-documented opposite trend: complaints about unresponsiveness, long gaps without callbacks, messages not returned for weeks, and communication breakdowns across shift changes. These operational inconsistencies appear to be a primary source of family frustration and are often tied to perceptions of understaffing and frequent personnel changes.
Patterns and recommendations: The review set shows a clear dichotomy: a large number of testimony-based endorsements describing Del Monte as a caring, clean, active community where residents thrive, contrasted with a smaller but significant set of reports alleging lapses in safety, communication, and professionalism. For prospective residents and families, the reviews suggest Del Monte can deliver high-quality, compassionate assisted living and memory care—especially where leadership is engaged and consistent staff are present. However, because some incidents are serious (missed fall notifications, lost/abandoned residents), visitors should (1) ask about recent incident reports and staffing levels for the specific neighborhood, (2) request references from current families, (3) tour the exact unit to assess cleanliness and atmosphere, (4) clarify emergency protocols and how family notifications are handled, and (5) confirm continuity-of-care plans for residents with higher clinical needs.
Bottom line: Del Monte appears to excel in culture, activities, dining, and many aspects of hands-on caregiving, creating a homelike environment appreciated by many families. Nevertheless, operational inconsistencies — particularly around communication, staff turnover, and a few high-severity safety incidents — warrant careful vetting. If you prioritize warmth, engaging programming, bilingual staff and onsite medical services, Del Monte may be a strong candidate; if uninterrupted clinical oversight and foolproof communication are paramount, verify those systems thoroughly before committing.
Location
About Del Monte Assisted Living & Memory Care - Stockton
Our Lady Perpetual Help Care Home is a residential care home situated in a quiet, welcoming neighborhood of Stockton, California. Designed to foster both comfort and community, this care home offers seniors a spacious and beautiful group living setting that encourages socialization, engagement, and a true sense of belonging. The tranquil atmosphere of the area is complemented by serene waterfronts and regular opportunities for residents to participate in local events, making daily life both relaxing and stimulating. The home is dedicated to providing seniors with a high standard of care that addresses each individual’s unique needs while ensuring their overall well-being in a supportive environment.
The compassionate and attentive staff at Our Lady Perpetual Help Care Home are available around the clock, focused on creating a comfortable, safe, and secure environment for each resident. Their unwavering commitment ensures that seniors receive not only personalized medical and physical support, but also emotional encouragement and companionship. Meals at the care home are thoughtfully prepared to be nutritious, delicious, and made with high-quality ingredients, delighting residents with a menu that balances both enjoyment and dietary needs.
At Our Lady Perpetual Help Care Home, residents are encouraged to engage in a variety of activities that promote social, physical, and mental stimulation. The home actively fosters a lively and interactive environment, helping seniors create lasting friendships while participating in enriching programs. Room options are tailored to individual preferences and needs, offering both one-bedroom and semi-private accommodations. The facility’s goal is to ensure that every resident feels at home, valued, and empowered to lead a fulfilling life, supported by a caring team and meaningful daily experiences.
The culture at Our Lady Perpetual Help Care Home centers on friendliness and warmth. Each day, staff strive to cultivate an atmosphere filled with kindness, joy, and respect, not only among residents but also extending to visitors and the broader community. Whether providing memory care or general residential care, the home remains dedicated to fostering a nurturing environment where every individual is treated with the utmost dignity and compassion.
People often ask...
Del Monte Assisted Living & Memory Care - Stockton offers competitive pricing, with rates starting at a cost of $3,299 per month.
Del Monte Assisted Living & Memory Care - Stockton offers assisted living, memory care, and board and care.
There are 17 photos of Del Monte Assisted Living & Memory Care - Stockton on Mirador.
The full address for this community is 517 E Fulton St, Stockton, CA, 95204.
Yes, Del Monte Assisted Living & Memory Care - Stockton 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
376
Inspections
85
Type A Citations
77
Type B Citations
6
Years of reports
23 Oct 2024
23 Oct 2024
Confirmed a resident left unassisted, was struck by a vehicle in a hit-and-run while walking, was hospitalized, and later died after hospital and coroner involvement; no deficiencies cited.
14 Oct 2024
14 Oct 2024
Identified an allegation of a deficient room access point and an alternative entry into the shower/bathroom area, first cited on 05/01/2024 and cleared on 10/14/2024.
24 Sept 2024
24 Sept 2024
Investigated the request for an exception for a resident under care with a Stage 3 wound; determined continuing wound care on-site is appropriate and the resident’s Power of Attorney was informed and agrees. Exit interview conducted.
24 Sept 2024
24 Sept 2024
Confirmed that a resident with a Stage 3 wound received on-site treatment and was supported in remaining in the current setting to avoid additional stress, with contingency plans discussed if their condition worsens.
28 Aug 2024
28 Aug 2024
Found five allegations—rough handling of a resident, untimely medication administration, unmet diapering needs, unmet laundry needs, and mold concerns—unsubstantiated.
28 Aug 2024
28 Aug 2024
Reviewed evidence and interviews indicated that residents and staff denied rough handling; some residents showed verbal aggression during medication times, but no mistreatment was confirmed. Examined medication records and observed medication passes confirmed timely administration. Checked diapering and laundry routines, and inspected for mold, all of which met care standards, with no issues found.
11 Jul 2024
11 Jul 2024
Reviewed records for R1 related to an incident dated 7/9/2024; obtained copies of R1's file, including the physician's report, pre-appraisal, and service plan. Noted that details of the incident were provided on a standard form, and a detailed information report was requested; the department may return for further investigation.
11 Jul 2024
11 Jul 2024
Reviewed records related to an incident from July 9, 2024, and provided additional documentation upon request; the department indicated further investigation may be conducted later.
18 Jun 2024
18 Jun 2024
Found hot water in resident bathrooms at 122°F, outside the 105–120°F range; advisory issued. Observed compliant fire safety equipment, centrally stored medications, reviewed resident and staff records with clearances, adequate seven-day non-perishable and two-day perishable food supplies, and a fire drill conducted on 3/11/2024.
18 Jun 2024
18 Jun 2024
Confirmed that the facility maintained appropriate safety measures, sufficient supplies, and proper medication storage, with an advisory issued regarding hot water temperature being above the recommended range.
07 Jun 2024
07 Jun 2024
Identified an ongoing bedbug problem with activity in multiple rooms and a plan for monthly proactive inspections and monitoring. Allegation about scabies treatment noted documentation for 14 residents receiving oral medications and topical ointments, PPE for staff during care not confirmed for all times; allegation of falsifying medication records had no clear evidence.
07 Jun 2024
07 Jun 2024
Identified ongoing bedbug issues throughout the property and confirmed proper treatment of residents for scabies, while findings showed no evidence that staff falsified medication records.
§ 87303(a)
09 May 2024
09 May 2024
Found staff training met regulatory requirements and medications were administered by trained personnel, with no evidence that unqualified staff dispensed medications, and monthly menus were provided and followed with residents satisfied. All allegations unsubstantiated.
09 May 2024
09 May 2024
Found that staff received proper training and dispensed medication through qualified personnel, including for PRN medications, and observed that the staff followed regulatory requirements for resident assistance. Confirmed that the menu was followed most of the time, with residents satisfied with food choices.
01 May 2024
01 May 2024
Found that the resident died from medical complications, including acute respiratory failure with hypoxia and status epilepticus, with end-stage renal disease listed as a secondary cause. Found a privacy violation where the resident's room opened to a shower area and a curtain divided the living space; other concerns about supervision, wounds, call responses, and cleanliness lacked sufficient supporting evidence.
01 May 2024
01 May 2024
Found that the resident's death resulted from medical complications and was not questionable; the privacy violation involved a curtain dividing the resident's room from the bathroom entrance, but staffing and supervision were adequate, and there was no neglect or hygiene issues confirmed.
§ 87307(a)(2)
11 Apr 2024
11 Apr 2024
Found that the deficiencies cited in the 1/24/24 complaint investigation were corrected and the required dates were met.
11 Apr 2024
11 Apr 2024
Reviewed corrective actions and found that cited deficiencies related to resident rights and documentation have been resolved according to the required deadlines.
27 Mar 2024
27 Mar 2024
Investigated the allegation that funds were taken from a resident's SSI account; found that a transaction occurred but there is not a preponderance of evidence of financial abuse, so the allegation is unfounded.
27 Mar 2024
27 Mar 2024
Determined that the facility did not financially abuse resident by withdrawing funds from their SSI account, as all identified transactions were either refunded or unrelated to the facility.
25 Mar 2024
25 Mar 2024
Found that the allegation that staff did not respond to residents' requests promptly lacked sufficient evidence; calls were answered within 5 to 15 minutes after residents pressed their call buttons, and residents said staff made good efforts to respond.
Found that the allegation that meals were served too cold lacked sufficient evidence; temperature records showed meals met required temperatures, though some residents described meals as warm.
25 Mar 2024
25 Mar 2024
Reviewed records and resident interviews confirmed that staff responded to call buttons within 5 to 15 minutes, and residents generally reported that calls were answered in a timely manner. The investigation also found that food was served at appropriate temperatures, with residents confirming the meals met their expectations.
05 Mar 2024
05 Mar 2024
Identified a self-reported altercation with a roommate that led to an ER visit on 2/26/2024, which staff learned about on 2/27/2024; police were notified and the resident was moved to another room. No deficiencies cited.
24 Jan 2024
24 Jan 2024
Investigated multiple allegations, including staff hitting a resident and causing a head injury, call button not accessible, leaving a resident in soiled diapers, medication administration concerns, inadequate supervision leading to a fall, and a bed in disrepair. Found insufficient evidence to clearly prove these violations; no deficiencies were identified.
05 Mar 2024
05 Mar 2024
Investigated an incident where a resident visited the emergency room due to a headache and reported an altercation with a roommate; the facility learned of the situation upon reviewing discharge papers and promptly took action.
29 Jan 2024
29 Jan 2024
Determined the allegation of unlawful eviction unfounded after reviewing records and interviewing staff; the resident had voluntarily signed a leave notice and was able to leave unassisted.
29 Jan 2024
29 Jan 2024
Determined that the allegation of unlawful eviction was unfounded after reviewing records and interviewing staff, confirming the resident voluntarily left the facility as signed and stated.
24 Jan 2024
24 Jan 2024
Investigated multiple allegations including that staff hit a resident, caused injury, left a call button inaccessible, left a resident in soiled diapers, did not properly supervise a fall, administered medication correctly, and left a resident in a broken bed; found no evidence to support the claims except for the incident involving the door hitting a resident.
§ 87468.1
§ 87468.2(a)(4)
12 Jan 2024
12 Jan 2024
Found that the questionable death allegation was unfounded; the cause of death on the death certificate was cardiac arrest with senile degeneration of the brain, with no other significant conditions and no excessive lorazepam administered.
12 Jan 2024
12 Jan 2024
Determined that the death was due to natural causes, specifically cardiac arrest and brain degeneration, with no evidence of foul play, and confirmed that the medication administered was appropriate.
07 Dec 2023
07 Dec 2023
Investigated an alleged sexual assault involving a resident; documentation was collected, interviews were attempted, and medical and admission agreement materials were reviewed, while an emergency contact was interviewed. Police and licensing were notified, the case was ongoing with privacy safeguards in place, and no deficiencies were issued.
07 Dec 2023
07 Dec 2023
Reviewed an incident involving an alleged sexual assault, collected relevant documents, interviewed emergency contacts, and observed ongoing investigation efforts without issuing deficiencies.
05 Dec 2023
05 Dec 2023
Identified the allegation that eight residents' debit cards were held by the licensee and that a safeguard agreement allowing the licensee to manage and withdraw funds existed, but this procedure was not included in the plan of operation on file.
05 Dec 2023
05 Dec 2023
Investigated four specific allegations and found no evidence that staff violated residents’ personal rights, including contacting social security offices on residents’ behalf without permission. Found no evidence of inappropriate comments toward residents, no interference in residents’ financial affairs, and no threats of eviction by staff.
05 Dec 2023
05 Dec 2023
Reviewed, that the facility held debit cards for eight residents and had signed agreements to manage their funds, but this procedure was not included in the current plan of operation, leading to citations.
§ 87208(a)(9)
§ 87405(d)(2)
20 Nov 2023
20 Nov 2023
Found no health and safety deficiencies; food supply, building conditions, and staffing were in compliance, and an exit interview was conducted.
20 Nov 2023
20 Nov 2023
Confirmed that a health and safety check found the facility in compliance, with good food supplies, a safe physical environment, and adequate staffing, and no violations were identified.
03 Nov 2023
03 Nov 2023
Found housekeeping staff regularly cleaned residents’ rooms as scheduled, with exceptions where residents declined services. Found no evidence that staff stole residents’ personal property, toilet paper and supplies were available, and residents received meals without any denial.
03 Nov 2023
03 Nov 2023
Reviewed multiple allegations, including that staff did not clean residents’ rooms, stole personal property, failed to provide toilet paper, and denied food; found no evidence to support any of these claims.
06 Sept 2023
06 Sept 2023
Found bed bugs present between 8-24-23 and 8-30-23, with residents moved and belongings cleaned and treatment started on 8-30-23 after pest-control companies were notified. Resulted in a civil penalty for a repeat violation within 12 months because more than ten nearby pest-control companies were not contacted.
06 Sept 2023
06 Sept 2023
Found that bed bugs were present in the facility between August 24 and August 30, 2023, and the licensee failed to promptly address the issue with timely treatment, resulting in a citation and civil penalty.
§ 87303(a)
21 Aug 2023
21 Aug 2023
Determined that a resident discussed and signed a discharge notice, was transported to a local emergency department on 8-14-23, returned to the residence on 8-18-23 at approximately 5:30 pm, and is now occupying the resident's room. The allegation was unfounded.
21 Aug 2023
21 Aug 2023
Determined that resident was transported to the emergency room after discussing discharge and returned to the facility a few days later, with no evidence supporting the allegation.
15 Aug 2023
15 Aug 2023
Identified an increase in 9-1-1 calls from June to August 2023 and noted consideration of non-emergency resources and medical staff to assess emergency needs, while continuing to use 9-1-1 for true emergencies.
15 Aug 2023
15 Aug 2023
Found no deficiencies after a routine quarterly health and safety check; areas were clean, temperatures were within acceptable ranges, safety systems were functioning, and resident records were up to date.
15 Aug 2023
15 Aug 2023
Found no evidence that staff failed to address a change in a resident's condition in a timely manner. Found no evidence of unsanitary restrooms or inadequate cleaning in restrooms.
15 Aug 2023
15 Aug 2023
Determined head lice allegation unsubstantiated after reviewing records and interviewing staff and residents; the resident resided until about May 2023, then transferred to another licensed facility with services documented in the plan, and no corroborating evidence of head lice was found during or after residency.
15 Aug 2023
15 Aug 2023
Found that the facility met all safety, sanitation, and regulatory requirements during the visit, with adequate staffing, proper documentation, and fully functional safety systems in place.
04 Aug 2023
04 Aug 2023
Identified resident-to-resident altercations occurring between afternoon and night shifts from May through July 2023, with one resident involved in several incidents and later discharged. Discussions with leadership addressed mental health resources, de-escalation training, and monitoring of residents' well-being and staff communication.
04 Aug 2023
04 Aug 2023
Reviewed incidents of resident-to-resident altercations occurring between May and July 2023, involving a resident identified as the aggressor who has since been discharged. Discussed the need for staff training, enhanced monitoring, and additional resources to address behavioral challenges and prevent future conflicts.
12 Jul 2023
12 Jul 2023
Determined that the memory care door relocation occurred without fire department consultation, fire clearance update, or a building permit, and that the door alarm did not function due to a malfunctioning bar door. Immediate civil penalties were issued for fire safety hazards and lack of fire clearance.
12 Jul 2023
12 Jul 2023
Determined that the memory care door was relocated and constructed without necessary fire safety approvals or a building permit, and found the door alarm was malfunctioning during the visit, resulting in citations and financial penalties.
§ 87202(a)
§ 87305(a)
§ 87405(h)(5)
§ 87203
20 Jun 2023
20 Jun 2023
Identified deficiencies in regulatory compliance under Title 22, including safety-related issues and gaps in resident and staff documentation. Noted that most systems and records were in order, with a few items not meeting requirements.
20 Jun 2023
20 Jun 2023
Found the facility to be generally compliant with regulations, including proper safety measures, adequate staff and resident files, and appropriate food, supplies, and emergency preparedness; identified some deficiencies during the inspection.
§ 87411(f)
08 Jun 2023
08 Jun 2023
Determined there is not a preponderance of evidence to conclude the resident was abandoned after hospitalization; the abandonment allegation unfounded.
08 Jun 2023
08 Jun 2023
Investigated whether the resident was abandoned after hospital transfer and discharge, and found no evidence to support that the facility staff abandoned the resident; the allegation was deemed unfounded.
17 May 2023
17 May 2023
Identified four resident-on-resident incidents between March and May, with staff intervening and required reports filed; supervision and needs-based service plans for the involved residents were updated.
17 May 2023
17 May 2023
Investigated five specific allegations—safeguarding residents’ personal belongings, providing an extension cord, not cutting off phone calls, communicating dietary needs, and meeting residents’ medication needs—and found that belongings were safeguarded and documented, an extension cord and alternatives were available, phone calls were not interrupted, dietary needs could be communicated, and medication orders were followed with ongoing pharmacy coordination and care notes.
17 May 2023
17 May 2023
Investigated privacy during phone calls; residents used private phones and interviews did not show staff listening in or disrupting conversations.
Reviewed meal charges, mattress comfort, and dietary restrictions; the admission agreement allowed a per-meal charge but it was not applied to the resident, steps were taken to improve mattress comfort, and dietary restrictions were followed with labeled trays to ensure accuracy.
17 May 2023
17 May 2023
Found all six allegations unfounded after reviewing records and interviewing staff and residents; medications were administered on time per orders, no unprescribed medications were given, residents’ needs were attended to, showers were provided as scheduled, rooms and bathrooms were cleaned, and phones were answered promptly.
17 May 2023
17 May 2023
Reviewed multiple incident reports involving resident altercations and disruptive behaviors, with staff interventions and updates to residents’ care plans noted, and no deficiencies observed during the visit.
10 May 2023
10 May 2023
Found that the resident’s showering needs were met, with showers provided per schedule except for one day when the resident refused. Found that the resident’s other needs were met and that excessive noise did not disrupt sleep.
10 May 2023
10 May 2023
Determined that staff met resident showering needs and noise did not interfere with sleep as alleged.
05 May 2023
05 May 2023
Identified that the eviction notice was not provided to Licensing within the required timeframe. Found PPE and isolation supplies available and used for the resident with scabies, and that the prescribed treatment was being followed.
05 May 2023
05 May 2023
Reviewed paperwork related to an eviction notice and confirmed it was not sent to licensing within the required timeframe. Observed proper PPE use and medication treatment for a resident with scabies.
§
07 Apr 2023
07 Apr 2023
Investigated Allegation 1 that a resident remained in soiled clothing for an extended period; found no credible evidence after interviews with staff and residents and review of care logs and on-site observations.
Investigated Allegation 2 that residents lacked adequate storage space for personal possessions; found no credible evidence after tours and interviews.
07 Apr 2023
07 Apr 2023
Found that showers were regularly provided with occasional resident refusals; toilet paper was consistently available; meals were served according to the published menu with no evidence of inadequate food service.
07 Apr 2023
07 Apr 2023
Investigated whether residents remained in soiled clothing for too long and if they lacked adequate storage for personal belongings; both allegations were found to lack sufficient evidence.
24 Mar 2023
24 Mar 2023
Identified Allegation 1: window seal in room 107 damaged for 2-3 weeks and not repaired. Identified Allegation 2: a staff member sent a photograph of a medication bottle to the wrong recipient, exposing medical information.
§ 87303(a)
§ 87468.2(a)(2)
24 Mar 2023
24 Mar 2023
Reviewed incident and physician notes showed that a resident who cannot leave unassisted left the building and was missing for several hours before returning with local law enforcement. Staff are assessing placement in a secured unit, and an immediate civil penalty was issued for a repeat violation within 12 months.
§
24 Mar 2023
24 Mar 2023
Identified a foul odor in room 107 and a used adult diaper on the floor near the bed, indicating odor and cleanliness concerns.
24 Mar 2023
24 Mar 2023
Determined that staff failed to keep the facility free of foul odors and did not maintain a clean and sanitary environment, including leaving a used adult diaper on the floor near a resident’s bed.
§ 87303(a)
§ 87625(b)(3)
02 Feb 2023
02 Feb 2023
Identified multiple resident incidents between 11/16/22 and 1/25/23, including a resident-to-resident altercation, a double dose of a prescribed diuretic, behavior episodes, several falls with injuries, and a wound requiring hospital-level care. Imposed an immediate civil penalty for repeat violations within 12 months.
§
02 Feb 2023
02 Feb 2023
Found no deficiencies at the site during the quarterly health and safety check. Noted strong infection control, safe food storage and temperatures, adequate staffing, and up-to-date emergency planning and safety procedures.
02 Feb 2023
02 Feb 2023
Found that the facility maintained compliance with health, safety, and infection control standards, including proper sanitation, functioning detectors, sufficient supplies, and staff protocols. No deficiencies were observed during the visit.
06 Dec 2022
06 Dec 2022
Investigated the allegation that several checks dated 6/14/22, 8/26/22, 9/2/22, and 9/10/22 bore a resident’s signature and printed name and were cashed by a former staff member; the resident did not write those checks, and how the staff member could have access remains unclear. Found insufficient evidence to conclude the former staff member was employed at the time the checks were written or involved in taking the checks, despite post-discharge bank activity and timing of the incident.
06 Dec 2022
06 Dec 2022
Determined that checks purportedly signed by a resident and cashed were unlikely to have been written by the resident, and found no evidence that staff member responsible at the time had access to the checks; concluded the allegation regarding stolen checks was unsubstantiated.
04 Nov 2022
04 Nov 2022
Identified an unwitnessed fall without injury on 10-29-22, with staff calling 9-1-1 for a lift assist and the resident refusing hospital transport. Found night shift staffing to be one med tech and three caregivers.
04 Nov 2022
04 Nov 2022
Identified that a resident was hospitalized on 10-16-22 for thrombosis and later diagnosed with scabies on 10-19-22; no additional scabies cases have been reported, and ongoing precautions and monitoring have continued.
04 Nov 2022
04 Nov 2022
Determined that a resident experienced an unwitnessed fall without injury and staff responded by contacting emergency services for a lift assist, with staff receiving guidance on proper procedures for resident injuries and emergency calls.
14 Oct 2022
14 Oct 2022
Investigated eight allegations and found snacks were available during the night shift, COVID precautions were followed, and supervision appeared adequate. Interviews and observations indicated residents interacted appropriately, were not left in soiled clothing, the area was not malodorous, there was no indoor insect infestation, and there was no scabies outbreak identified.
14 Oct 2022
14 Oct 2022
Found that on 9-10-22 a resident damaged a ceiling sprinkler in their room, causing water damage and alarms, with memory care residents temporarily relocated to the dining area under adequate supervision and with exits monitored and residents provided fans and hydration. The air conditioning briefly malfunctioned but was repaired the same day, meals remained on time, care continued without disruption, the incident was reported to licensing, no deficiencies were cited, and an exit interview with the administrator was conducted.
14 Oct 2022
14 Oct 2022
Found no deficiencies after an unannounced check of safety, cleanliness, and operations. PPE was stocked, infection control measures and screening procedures were in place, and temperatures and records were within required ranges and up to date.
14 Oct 2022
14 Oct 2022
Found that one resident slapped another three times in a shared room over the TV volume; both residents were separated and 911 was called.
Filed an incident report with licensing, updated the aggressor's behavior in behavior progress notes, interviewed the administrator and staff, and conducted an exit interview, noting that residents remained in separate rooms after authorities were notified.
14 Oct 2022
14 Oct 2022
Determined that a resident caused damage to a ceiling sprinkler, leading to water flooding, temporary relocation of memory care residents, and minor malfunctions of the air conditioning unit, with no impact on overall care or operations.
26 Aug 2022
26 Aug 2022
Determined that a resident eloped on 8-19-22 and was not supervised from 7:10pm that day until about 4:00pm on 8-20-22. An immediate civil penalty of $500 was issued for this absence of supervision.
26 Aug 2022
26 Aug 2022
Determined that a resident eloped from the facility and was unaccounted for for several hours, resulting in a violation of supervision requirements and a civil penalty.
§
10 Aug 2022
10 Aug 2022
Identified allegations that staff spoke to a resident in a demeaning manner and yelled at them over health issues and having to clean their bedroom floor, and that another staff member questioned the resident’s spending and accused them of drug use without evidence, resulting in a personal rights deficiency.
§ 87405(d)(5)
§ 87468.1(a)(1)
10 Aug 2022
10 Aug 2022
Identified two issues: first, dead flies, food debris, and dirt in a resident's room and closet rails; this concern found valid. Second, belongings in the room were observed, but insufficient evidence to prove the related allegation.
§ 87303(a)
10 Aug 2022
10 Aug 2022
Investigated an allegation that a couple of visitors were denied entry during visiting hours in August 2022. Found to meet the standard for substantiation.
10 Aug 2022
10 Aug 2022
Found that visitors were denied entry during visitor hours in August 2022, despite arriving at the facility, confirming the allegation of visitors being refused entry was valid.
§ 87468.1(a)(11)
28 Jul 2022
28 Jul 2022
Determined that the allegation that the resident did not receive a copy of the signed admission agreement was unfounded, as a copy was provided on 6-20-22 and receipt was acknowledged on 10-29-2021.
28 Jul 2022
28 Jul 2022
Found that the concerns about disrepair involved a resident’s room window, air conditioning, and bathroom fan; the window opened and closed normally, the air conditioner produced cold air, the room stayed around 75°F, and the bathroom fan was malfunctioning but repaired the same day.
Found staff addressed residents’ needs, with medications secured on the resident’s return, ongoing ADL and incontinent care provided, and an admission agreement acknowledged by the resident; the resident briefly left the facility and returned the same day.
28 Jul 2022
28 Jul 2022
Reviewed records and interviewed staff confirmed the resident received her signed admission agreement, including necessary disclosures, making the allegation unfounded.
25 Jul 2022
25 Jul 2022
Reviewed evidence indicating that dental and foot care for resident were not adequately provided, including missed follow-up appointments and lack of timely intervention, leading to citations issued.
§
§
12 Jul 2022
12 Jul 2022
Reviewed two resident death reports during an unannounced visit; the first involved a fall with later death attributed to Alzheimer's disease, and the second involved a sudden death with a Do Not Resuscitate order and a physician-directed comfort-measures approach instead of hospice. No deficiencies were issued.
12 Jul 2022
12 Jul 2022
Found no deficiencies after inspecting the site; infection control measures were in place, screenings were conducted, PPE was available, and resident and staff records were up to date.
12 Jul 2022
12 Jul 2022
Found no deficiencies noted; COVID-19 precautions were in place, PPE was stocked, entry screening and sanitation practices were followed, and emergency supplies were available.
12 Jul 2022
12 Jul 2022
Confirmed that the facility maintained proper infection control, safety measures, and sanitation standards, with no deficiencies observed during the inspection.
20 Jun 2022
20 Jun 2022
Found that residents were provided adequate food and had stable blood sugar levels during 5/30/22 through 6/3/22.
20 Jun 2022
20 Jun 2022
Reviewed records and interviews indicated residents received adequate food and their blood sugar levels remained stable; no evidence supported the allegation that residents were not fed properly.
17 Jun 2022
17 Jun 2022
Identified that the licensee did not provide the requested chart records nor retain the resident file, despite multiple attempts to obtain them, including onsite visits, emails, and a subpoena.
17 Jun 2022
17 Jun 2022
Determined that the licensee failed to provide or retain requested resident chart documentation after multiple attempts and a court subpoena.
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10 Jun 2022
10 Jun 2022
Determined that a suspected flu outbreak occurred on 6-5-22 and was not reported to the licensing department within 24 hours.
10 Jun 2022
10 Jun 2022
Investigated the allegation of a flu outbreak among residents and found it unfounded. Testing ruled out additional cases, and temperatures were kept within normal ranges.
10 Jun 2022
10 Jun 2022
Determined that a suspected flu outbreak occurring on 6-5-22 was not reported within 24 hours as required. Identified a deficiency under relevant licensing regulations.
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02 May 2022
02 May 2022
Found that the meeting covered evictions tied to overdue rent and concerns about alcohol and drug use, resident rights during room entries, the signal system, reporting requirements, re-appraisals, and administrator hours, with no deficiencies cited.
02 May 2022
02 May 2022
Reviewed safety and compliance related to eviction procedures, personal rights, signal system functionality, medication reporting, and staff staffing requirements, with ongoing efforts to address equipment issues and ensure proper documentation and resident rights.
22 Apr 2022
22 Apr 2022
Found parts delivered for a new signal system at the site, with programming delayed due to internal staffing issues with the supplier. Observed a technician attempting to program pendants while residents continued to use handheld bells as a temporary signal, with the system expected to be in place by 4/29/22; no deficiencies were observed.
22 Apr 2022
22 Apr 2022
Reviewed eviction letters and the updated admission agreement with attachments, discussed policy on alcohol and drug use with the regional executive director, and noted no deficiencies. Noted reporting requirements regarding eviction letters, changes in plan of operation, and admission agreements.
22 Apr 2022
22 Apr 2022
Determined Allegation 1: the resident’s death was attributed to Parkinson’s disease with contributing COVID-19 and not directly caused by actions at the care setting. Determined Allegation 2: staff met the resident’s needs in a timely manner, and Allegation 3: COVID-19 guidelines were followed; no deficiencies cited.
22 Apr 2022
22 Apr 2022
Reviewed the eviction process and discussed plans to rescind and re-issue eviction letters to residents after previous notices sent in error.
08 Apr 2022
08 Apr 2022
Identified that the signal system malfunctioned due to an internet outage; a hand-held bell system and closer supervision were in use until parts arrived. Parts were on order with shipping delays and expected to restore full operation within about a week; no deficiencies were found.
08 Apr 2022
08 Apr 2022
Found that two residents in the memory care unit engaged in a mutual action on 4-3-22 that did not violate their rights and was reported to licensing, the ombudsman, and local law enforcement. Observed that alarms were functioning, staffing was appropriate, dangerous materials were secured, temperatures ranged from 68 to 85 degrees, fire extinguishers were fully charged, the unit was clean, and no deficiencies were noted.
08 Apr 2022
08 Apr 2022
Found that staff did not follow a physician’s order to administer a resident’s blood pressure medication twice daily and held or stopped the medication without physician authorization. Found that the resident’s physician was not notified in a timely manner about the medication discrepancy.
08 Apr 2022
08 Apr 2022
Investigated allegations that staff failed to follow physician’s orders and did not properly notify the physician regarding a resident’s medication, resulting in medication being held without proper authorization and insufficient communication about treatment concerns.
§ 87465(e)
§ 87465(a)(1)
16 Mar 2022
16 Mar 2022
Found a discrepancy between the physician’s order and the bottle label for a resident’s blood pressure medication, and that the medication was not given for more than three weeks. Found that visitation guidelines were followed and a visitor was allowed to visit through alternative methods.
16 Mar 2022
16 Mar 2022
Determined that the facility received a blood pressure medication for a resident with a discrepancy between the order and the label, which was not given for over three weeks, and found that the resident's medication management was not properly addressed; also confirmed that visitation procedures followed COVID-19 guidelines and were appropriate.
§ 87405(h)(5)
§ 87465(a)(4)
14 Mar 2022
14 Mar 2022
Determined that a resident with dementia left the premises without supervision on 3-12-22 and returned unharmed around 10:30 AM on 3-13-22; the reason for the exit was not determined.
§ 87208
14 Mar 2022
14 Mar 2022
Determined that the downstairs units were planned for conversion to memory care and hospice, with notices given to residents about potential room changes and options to relocate or rent private rooms while bed capacity remains the same. Required forms and fire clearance requirements were discussed, and no deficiencies were cited.
14 Mar 2022
14 Mar 2022
Determined that searches of residents' rooms occurred on 2-8-22 due to suspected drug use and house rule violations, with prior permission from residents and all residents present during the searches. Found that eviction letters were given to two residents but later rescinded; others did not receive eviction notices, and no eviction actions are being pursued while intervention services are organized; no deficiencies were cited.
14 Mar 2022
14 Mar 2022
Determined that room searches conducted on residents due to suspicions of illegal drug use involved resident permission and occurred with all residents present, and confirmed that eviction notices issued to some residents were rescinded after review, with no deficiencies identified.
08 Mar 2022
08 Mar 2022
Investigated a complaint on 3-8-22 and found eight tested rooms could not send emergency alerts due to a nonfunctioning signal system. Conducted interviews with leadership, and deficiencies were issued.
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08 Mar 2022
08 Mar 2022
Found that a February 2022 incident involved a resident not receiving prescribed blood pressure medication for about three weeks and that it was not reported to licensing.
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08 Mar 2022
08 Mar 2022
Determined that the privacy rights allegation was not supported by the evidence, with no entries into resident rooms without permission and proper protocol followed. Found that the television access allegation was not supported, since residents had access to a working TV in the dining area and the admission agreement did not include a TV in the room.
08 Mar 2022
08 Mar 2022
Determined there was no evidence that staff or outsiders entered resident rooms without permission or violated residents' privacy rights, and found that resident had reasonable access to a television, with her own TV repaired promptly and available in a common area.
23 Feb 2022
23 Feb 2022
Investigated the allegation that a monthly fee change was implemented without proper notice. Found that the admission agreement requires 60-day notice for fee changes, and the general rate increase notice dated 10-1-21 was not addressed to a specific resident, lacked a signature, did not provide an adequate reason or description of additional costs, and a resident reported a notice issued 1-24-22 reflecting a 2-1-22 rate change.
23 Feb 2022
23 Feb 2022
Determined that the facility did not provide a proper written notice of a resident fee increase, as required by regulations, and that the notice issued was inadequate, meeting the criteria for the complaint allegation.
§ 1569.655(a)
09 Feb 2022
09 Feb 2022
Identified that knowledge of suspected abuse existed but was not reported timely per regulatory requirements after an incident between two male residents. Found that one resident sustained redness of a body part following an encounter with the other.
09 Feb 2022
09 Feb 2022
Determined that staff knew about suspected abuse but did not report it promptly, and documented an incident where one resident sustained redness after an encounter with another resident.
§ 15630(b)(1)
24 Jan 2022
24 Jan 2022
Investigated an early January incident involving two male residents that required separation. Found COVID-19 precautions in place during the visit, including masks, available hand sanitizer, signage, social distancing, and entry screening; one staff member was unavailable for interview, and additional time was needed to complete the case management.
24 Jan 2022
24 Jan 2022
Reviewed an incident involving two male residents separated after an encounter on January 4th, with overall safety protocols in place, and noted additional time needed to complete the case review.
19 Jan 2022
19 Jan 2022
Found no evidence that COVID-19 precautions were not followed on a routine basis. Observations showed PPE use, dedicated quarantine areas, proper signage, and social distancing, with staff and residents reporting ongoing precautions.
19 Jan 2022
19 Jan 2022
Reviewed that COVID-19 precautions, including PPE use, social distancing, and quarantine protocols, were being followed consistently by staff and residents.
06 Jan 2022
06 Jan 2022
Identified concerns at the site related to staffing coverage when regular staff were absent, improper repositioning and lifting of a resident, and untimely incident reporting. Also noted delays in informing the responsible person about a fall, inadequate supervision leading to a fall with injury, delays in responding to residents’ representatives, and outdated reappraisals.
06 Jan 2022
06 Jan 2022
Identified several compliance issues related to staffing, resident care, incident reporting, and resident rights, stemming from multiple site inspections conducted during 2021.
21 Dec 2021
21 Dec 2021
Reviewed incident records from 12-10-21 to 12-21-21 and interviewed staff, found reporting timely and documentation appropriate, with resident service plans updated. Found a routine site tour with no hazards observed, comfortable temperature, use of outside services as needed, and staffing levels appropriate, with no deficiencies identified.
21 Dec 2021
21 Dec 2021
Found that a prior citation was amended to update the applicable regulation reference, resulting in the civil penalty being removed. An exit interview was conducted and phone notification about the amendment was provided.
21 Dec 2021
21 Dec 2021
Reviewed a previous citation, which was amended to update the relevant regulation, resulting in the removal of a civil penalty. The visit included discussing the matter with staff and providing notification of the changes.
09 Dec 2021
09 Dec 2021
Identified that a resident's physician's report was not obtained and was missing from the chart, and deficiencies were noted.
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09 Dec 2021
09 Dec 2021
Investigated Allegation 1 found an unwitnessed fall with injuries occurring at 5:00 am on 10-27-21 in memory care, with bruise markings observed later and only one staff on duty at the time.
Investigated Allegations 2-4 found that the responsible party was not notified of the fall, a reappraisal for change of condition was not completed or updated, and records requested by the responsible person were not provided promptly (not provided until 11-19-21).
09 Dec 2021
09 Dec 2021
Investigated a resident fall that occurred at 5 a.m. on October 27, 2021, and found that only one staff member was present at the time, with no notification sent to the responsible party, and found that reappraisal and documentation related to the resident's condition and fall were not properly completed or provided.
§ 87211(a)(1)
§ 87463(a)
§ 87468.1(a)(9)
§ 87411(a)
30 Nov 2021
30 Nov 2021
Found that two residents maintained a mutual friendship with private visits, meals, and activities, with no interference by staff; identified no infringement of resident rights; no deficiencies cited.
30 Nov 2021
30 Nov 2021
Determined that two residents maintained a mutual friendship through private visits and activities without interfering with their rights, and found no violations during the visit.
23 Nov 2021
23 Nov 2021
Found that six of fourteen incident reports were submitted beyond seven days and four were unwitnessed falls, with fall-prevention services in place for several residents; one resident could self-administer medications accurately, and a civil penalty was assessed for repeat violation.
23 Nov 2021
23 Nov 2021
Reviewed incident reports revealed multiple unwitnessed falls and delayed reporting to authorities, and deficiencies were cited resulting in a civil penalty due to a repeat violation.
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05 Nov 2021
05 Nov 2021
Found that six resident falls occurred between 9-25-21 and 10-14-21, four unwitnessed, and that all reporting requirements were met. Reviewed needs and service plans and observed fall-prevention measures in resident rooms; no deficiencies were cited.
05 Nov 2021
05 Nov 2021
Reviewed resident fall incidents and safety measures, confirming that a fall prevention program and safety protocols were in place, and no deficiencies were identified during the visit.
06 Oct 2021
06 Oct 2021
Found no deficiencies; safety and emergency systems, sanitation, and infection-control measures were in place and functioning, with proper screening and adequate supplies.
06 Oct 2021
06 Oct 2021
Found that the facility was in compliance with regulations, with all safety systems functioning properly, adequate food and supplies available, and effective infection control measures in place. No deficiencies were observed during the inspection.
13 Sept 2021
13 Sept 2021
Identified an incident in which a resident obtained and recorded visitors' temperatures upon entry; observed that designated staff now verify and record all temperatures and ask screening questions for visitors.
13 Sept 2021
13 Sept 2021
Verified that staff now consistently screen visitors and record temperatures upon entry, following state guidelines, with no safety issues observed during the visit.
08 Sept 2021
08 Sept 2021
Identified Allegation 1: staff did not provide lift assist; two staff were on duty during two 9-1-1 calls, while fire department personnel provided the lift and repositioning for a resident.
Identified Allegation 2: residents were left unattended while two staff on duty accompanied fire department personnel in the assisted living area during the two 9-1-1 calls, leaving the memory care section unattended.
08 Sept 2021
08 Sept 2021
Investigated allegations found that staff did not provide proper lift assistance to a resident and left residents unattended during emergency calls.
§ 87413(a)(1)
§ 80078(a)
03 Sept 2021
03 Sept 2021
Identified gaps in communication and reporting when a resident with a wound was sent to the ER on 8/5/21 after a nurse noticed oozing pus; a prior ER visit occurred on 7/12/21 for the same wound. Found that the day program attempted to contact using an outdated phone number, delaying notification, and licensing did not receive incident reports for 8/5/21 and 8/7/21 until 9/3/21 and 8/18/21.
03 Sept 2021
03 Sept 2021
Determined that staff were not notified promptly when a resident was sent out to the emergency room after a wound was discovered, leading to delays in communication and documentation related to the incident.
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30 Jul 2021
30 Jul 2021
Found caregivers were on duty across morning, evening, and night shifts and able to meet residents’ needs. Observed lunch portions sufficient and food quality acceptable, with residents requesting more menu variety; the home was clean and well-maintained with a comfortable temperature and adequate food supplies, and no deficiencies identified.
30 Jul 2021
30 Jul 2021
Determined that staff were adequately on duty to meet residents' needs, with sufficient food supplies and appropriate menu options, and observed the facility to be clean, sanitary, and in good repair, with no deficiencies noted.
23 Jul 2021
23 Jul 2021
Issued an amended licensing document after reviewing the allegation from a prior complaint investigation, correcting the deficiency page and the deficiency codes cited earlier; an exit interview was conducted with the site administrator.
23 Jul 2021
23 Jul 2021
Reviewed the licensing documents and corrected errors in a prior report related to a complaint investigation.
20 Jul 2021
20 Jul 2021
Investigated and reviewed records and observations, found insufficient evidence to prove Allegations 1 through 5, including lack of care and supervision, unmet incontinent care needs, inadequate meals, failure to report incidents, and unsafe accommodations.
20 Jul 2021
20 Jul 2021
Found that the facility met residents' care, supervision, and nutritional needs, properly reported incidents, and provided a safe environment, with no evidence to support the allegations of neglect, inadequate incontinent care, poor nutrition, unreported incidents, or unsafe accommodations.
07 Jul 2021
07 Jul 2021
Found that an eviction notice given to a resident lacked required information and appears to have been issued improperly on 6-30-21. Missing items included the eviction date, resources offered, the right to appeal, and the required safety statement; an exit interview with the administrator was conducted and deficiencies were noted.
07 Jul 2021
07 Jul 2021
Found that during the nights of 6/12/21 and 6/13/21, not all scheduled staff were available to meet residents’ care, supervision, and incontinence needs.
07 Jul 2021
07 Jul 2021
Determined that an eviction notice issued to Resident1 was incomplete and did not meet legal requirements, leading to cited violations of regulations.
§ 87224
07 Jul 2021
07 Jul 2021
Investigated staffing shortages on nights of June 12 and 13, 2021, which led to residents not receiving adequate care and supervision, including help with incontinent care.
§ 87413(a)(1)
§ 87464(f)(1)
30 Jun 2021
30 Jun 2021
Found the memory care delayed call system was serviced and functioning. Noted multiple improvements across the property—roof work, memory care cabinet and patio repairs, upgraded telephone system, and resident rights postings—and no deficiencies were identified.
30 Jun 2021
30 Jun 2021
Found the memory care delayed egress system was serviced and fully functional after testing, with no deficiencies identified.
30 Jun 2021
30 Jun 2021
Confirmed that the memory care delayed alarm system was repaired and fully operational after servicing, with no other deficiencies noted during the visit. Inspected areas included safety, maintenance, and resident rights, all of which were in compliance.
30 Jun 2021
30 Jun 2021
Confirmed that the memory care's delayed egress system was serviced and fully operational, and that various repairs and updates throughout the facility, including safety features and resident accommodations, were completed without any deficiencies noted.
29 Jun 2021
29 Jun 2021
Found no health and safety deficiencies after an unannounced visit; temperature was 75°F, supplies and staffing met requirements, and chemicals were kept inaccessible to residents.
29 Jun 2021
29 Jun 2021
Found that the facility met safety and health standards during a surprise visit, with properly functioning equipment, adequate food supplies, appropriate staffing, and no observed hazards or regulations violations.
28 Jun 2021
28 Jun 2021
Identified completed repairs and improvements, including lobby roof replacement, removal of an RV and a non-working bus, battery replacement in the Ansul system, upgraded telephone system, and repairs to memory care cabinets, window screens, and patio components. Required items to proceed with license approval were memory care door and alarm with appropriate signage, verification of the fire inspection for the Ansul system, and an elevator permit.
28 Jun 2021
28 Jun 2021
Found that the facility was generally in good condition with repairs made to various areas, but noted that the memory care door and alarm, fire inspection verification, and elevator permit still require attention for license approval.
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27 Jun 2021
27 Jun 2021
Found no deficiencies after a health and safety check, with adequate staffing and food available; residents were engaged in activities such as bingo and watching television, and med-techs assisted with care.
27 Jun 2021
27 Jun 2021
Confirmed that staff provided appropriate activities and care, with sufficient food, staffing, and safety measures in place, and no violations of state regulations observed during the visit.
26 Jun 2021
26 Jun 2021
Found no health and safety deficiencies after a check, with adequate staffing, no call outs, and residents exercising. Noted 75-degree temperature, fixed air conditioning, and memory care areas under construction, with 53 residents, 4 receiving hospice, 19 in memory care, and a capacity of 114.
26 Jun 2021
26 Jun 2021
Confirmed that a health and safety check was conducted, revealing no deficiencies, and noting that staff were adequately present, residents were engaged in activities, and the facility maintained a comfortable temperature despite ongoing construction.
25 Jun 2021
25 Jun 2021
Found no deficiencies after a health and safety check; observed a comfortable temperature, adequate food supplies, and sufficient staff, with repairs underway.
25 Jun 2021
25 Jun 2021
Confirmed that the facility was in compliance with health and safety regulations during a visit that included a tour of the premises, review of food supplies and staffing, and observation of safety measures, with no deficiencies noted.
24 Jun 2021
24 Jun 2021
Found no health and safety deficiencies. Observed adequate staffing, meals for residents, updated call system monitoring on staff phones, a remodeled memory care area with new appliances, a comfortable 74-degree temperature, and plans to implement walkie-talkies for staff.
24 Jun 2021
24 Jun 2021
Reviewed a health and safety check that confirmed the facility was well-maintained, with adequate staffing, proper food supply, and functional safety systems, and no violations were observed.
23 Jun 2021
23 Jun 2021
Identified multiple health and safety deficiencies, including nonfunctional phone lines, failure to notify emergency contacts, unresolved bed bug issues with a resident’s room lacking a bed and pest control records, missed medications for two residents, and an open gate near construction that could allow unsupervised access.
23 Jun 2021
23 Jun 2021
Found ongoing issues with non-functioning phone lines, unaddressed bed bug treatment, and security concerns related to construction areas left accessible to residents. Documented medication errors, incomplete pest control records, and room maintenance deficiencies during the visit.
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22 Jun 2021
22 Jun 2021
Found staff on duty, residents eating in the dining hall, and schedules accessible electronically, with construction at the main entrance and safety signs posted. Found food available for residents, staffing adequate, and no deficiencies observed.
22 Jun 2021
22 Jun 2021
Reviewed during an unannounced visit, the facility maintained safe conditions, adequate staffing, proper food supply, and compliance with safety regulations despite ongoing construction at the entrance. Safety precautions were observed, and no deficiencies were identified.
21 Jun 2021
21 Jun 2021
Found no deficiencies; temperatures and hot water met requirements, safety equipment and a securely stored medications area were in place, food supplies were adequate, and no hazards were observed. Completed exit interview.
21 Jun 2021
21 Jun 2021
Ensured no COVID-19 symptoms or exposures among residents and staff, and observed that the facility’s safety and sanitary conditions met regulatory standards during a unannounced health and safety check.
20 Jun 2021
20 Jun 2021
Found no deficiencies or safety concerns; observed residents eating in the dining area, with staff on duty and some residents using the activity area as a cooling station. Six air conditioners were set to 70 degrees, with room temperatures measured at 78 degrees on the lower assisted living side, 79 degrees on the upper side, and 80 degrees in memory care; day staffing totaled five, including three med-techs, two direct care staff, and two kitchen staff.
20 Jun 2021
20 Jun 2021
Observed staff and residents during a health and safety check, with temperatures inside the facility slightly above recommended levels; no safety violations or deficiencies were identified.
19 Jun 2021
19 Jun 2021
Found no deficiencies during the visit; residents were engaged, safety measures and food supplies were in place, and staff were on site.
19 Jun 2021
19 Jun 2021
Confirmed that the facility maintained appropriate safety measures, adequate food supplies, and sufficient staffing levels during an unannounced visit, with no deficiencies observed.
18 Jun 2021
18 Jun 2021
Identified health and safety deficiencies, including a broken thermostat in room 124 and an unknown unassociated employee occupying room 222 who was told to vacate, and civil penalties were issued.
18 Jun 2021
18 Jun 2021
Found multiple temperature control issues, including broken thermostats and high AC temperatures, as well as unapproved and unassociated personnel residing onsite, leading to cited deficiencies and civil penalties.
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17 Jun 2021
17 Jun 2021
Found no deficiencies after the health and safety visit; prior COVID screening was conducted, temperatures were kept between 68 and 85 degrees, air conditioning was functioning, and food supplies were adequate. Found 53 residents (including 4 on Hospice), with knives and toxins secured, residents engaged in activities, and staff on site during the visit.
17 Jun 2021
17 Jun 2021
Confirmed that the facility maintained a safe environment with proper temperature control, sufficient food supplies, secured toxins, and appropriate staffing, with no deficiencies observed during the visit.
16 Jun 2021
16 Jun 2021
Found no deficiencies observed or cited after a health and safety check. Conditions included safe temperatures, adequate and properly stored food supplies, secured storage for knives and toxins, residents engaged in activities, and staff present on site to support care.
16 Jun 2021
16 Jun 2021
Found no violations during a COVID-safety inspection, with proper food supplies, functioning cooling systems, secure storage of toxins, engaged residents, and adequate staffing levels observed during the visit.
15 Jun 2021
15 Jun 2021
Found no deficiencies after an unannounced health and safety check, with 54 residents on site (including four hospice and 18 memory care), temperatures in common areas within 68–85 F, 10 air conditioning units working, and seven days of nonperishable and two days of perishable foods on hand. Administrator said ordering would begin with Cisco, with the first delivery scheduled for that afternoon and a schedule to be set after a Cisco meeting; seven caregivers including two med techs were on staff.
15 Jun 2021
15 Jun 2021
Confirmed that the facility was in compliance with health and safety regulations during the unannounced visit, with adequate staffing, proper temperature controls, sufficient food supplies, and no observed deficiencies.
14 Jun 2021
14 Jun 2021
Found no health or safety concerns, including no COVID-19 symptoms, exposures, or related travel among residents, caregivers, or staff. Observed adequate food, ongoing medication passes, staffing on both Memory Care and Assisted Living sides, a functioning elevator with a recent inspection notice, and portable air conditioners; no hazards were identified.
14 Jun 2021
14 Jun 2021
Confirmed no COVID-19 symptoms, exposures, or infections among residents or staff in the past 10 to 30 days; observed residents receiving medication, meal service, and the facility operating safely without deficiencies.
§ 87464(f)(1)
§ 87413(a)(1)
12 Jun 2021
12 Jun 2021
Identified deficiencies included no administrator of record on file with the licensing agency and debris on patios with a water-damaged room under repair. Noted generally adequate health and safety conditions, including temperatures between 75 and 80 degrees Fahrenheit, hot water at 119.2 F, sufficient food, functioning cooling, engaged residents, and medications counted as expected.
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12 Jun 2021
12 Jun 2021
Identified deficiencies related to debris in outdoor patio areas and the absence of a designated administrator of record, as well as confirming proper medication counts, adequate food supplies, and functional safety measures during the visit.
11 Jun 2021
11 Jun 2021
Identified 53 residents (4 on Hospice) and no administrator on record since 6/10/2021. On-site staffing included caregivers, med techs, dietary staff, a housekeeper, and drivers; indoor temperatures ranged 78–83°F with cooling operating; food supplies were ample; rights were provided; an exit interview was conducted; civil penalties may be assessed for violations.
11 Jun 2021
11 Jun 2021
Found that a health and safety inspection was conducted after an unannounced visit, revealing adequate temperature control, sufficient food supplies, and staffing, but also noting the absence of an on-record administrator since last year.
10 Jun 2021
10 Jun 2021
Identified that during a COVID-19 outbreak a resident died after not receiving prescribed dialysis and due to transportation and care gaps, and that staff did not promptly return representatives' phone calls.
10 Jun 2021
10 Jun 2021
Found no deficiencies during the visit; temperatures were between 72 and 85 F, food supplies were ample, residents were eating and socializing, and staffing appeared sufficient.
10 Jun 2021
10 Jun 2021
Found no deficiencies during a health and safety inspection, which confirmed proper staffing, adequate food supplies, and safe environmental conditions with no issues observed.
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09 Jun 2021
09 Jun 2021
Found that a staff member scheduled for the shift during which a resident fell did not work that shift and was not replaced, resulting in a shorter staffing schedule. Reviewed resident records and other documents along with interviews and determined that the normal staffing schedule is designed to meet residents' care needs.
09 Jun 2021
09 Jun 2021
Found no deficiencies related to health and safety after a visit on 6/9/21, with temperatures within the required range, cooling units functioning, adequate food supplies, and sufficient staffing.
09 Jun 2021
09 Jun 2021
Found that insufficient staffing during a shift contributed to a resident fall, due to a staff member not working and not being replaced, resulting in shorter staffing than normally scheduled.
§ 87411(a)
08 Jun 2021
08 Jun 2021
Found no deficiencies cited after an unannounced health and safety check; all COVID-19 questions were negative with no symptoms, positive tests, exposures, quarantines, or high-risk travel reported. Observed meals being served, medication passes on both sides, staff on duty, a locked kitchen key kept by the administrator, functioning elevator and portable AC units on both floors, and available snacks and beverages.
08 Jun 2021
08 Jun 2021
Confirmed no recent COVID-19 symptoms, positive tests, exposures, or quarantines among residents, staff, or caregivers; observed residents receiving meals and medication in a safe environment with no hazards noted.
§ 87468.1(a)(2)
§ 87463(a)
§ 87411(a)
§ 87465(a)(2)
07 Jun 2021
07 Jun 2021
Found that the resident's responsible person did not receive a prorated refund after the resident's death, despite the admission agreement allowing refunds after belongings were removed.
§ 1569.652(c)
07 Jun 2021
07 Jun 2021
Found an unannounced health and safety inspection conducted; entry permitted after meeting with the administrator, with a census of 53 residents including 4 hospice. Temperatures ranged 74–77°F, all air conditioning units were functioning, and food supplies and staffing were adequate; no deficiencies observed.
07 Jun 2021
07 Jun 2021
Found that the responsible person's request for a refund after Resident 1's death was not fulfilled, confirming the allegation that a refund was not issued.
§ 1569.652(c)
06 Jun 2021
06 Jun 2021
Found no deficiencies; residents were eating in the dining area, some used the activity area as a cooling station, air conditioners were set to 70 degrees, and room temperatures measured 83 to 85 degrees. Eight staff were on duty, including two med-techs, four direct care staff, and two kitchen staff, with dinner, snacks, and breakfast available and more food planned for purchase on 6/7/2021.
06 Jun 2021
06 Jun 2021
Found no deficiencies during a health and safety check, noting that the facility maintained adequate food supplies and staffing, but indoor temperatures on upper floors reached 85 degrees despite air conditioning set at 70 degrees.
05 Jun 2021
05 Jun 2021
Found staff on duty and residents dining, with some using a cooling area; six air conditioners set to 70 degrees and room temperatures measured at 81 on the lower floors, 85 on the upper floors, and 81 in memory care. Food available for dinner, snacks, and breakfast; ten staff on shift (two med-techs, five direct care, three kitchen); administrator planned to buy more food on 6/7/2021; no deficiencies noted; exit interview completed.
05 Jun 2021
05 Jun 2021
Reviewed safety and health conditions during an unannounced visit, observing adequate staffing and food supplies, with temperature levels in different areas above recommended standards but no violations identified.
04 Jun 2021
04 Jun 2021
Found no health and safety deficiencies after an unannounced visit to the site. Indoor temperatures and air conditioning were within the required range, food supplies were on hand, and staff were on site; online ordering was planned to begin.
04 Jun 2021
04 Jun 2021
Verified that the facility maintained appropriate safety, temperature, and food supplies, with adequate staffing and no violations observed during the inspection.
03 Jun 2021
03 Jun 2021
Found adequate food supplies and lunch prepared according to the posted menu, temperatures throughout the home around 79 degrees Fahrenheit, the main air-conditioning unit not functioning for about 30 days with 10 portable units in use, and no deficiencies identified.
03 Jun 2021
03 Jun 2021
Confirmed food supplies were adequate, meal preparation occurred as planned, and indoor temperatures remained comfortable at 79 degrees Fahrenheit despite the main air conditioning unit being non-operational for about 30 days, with additional portable units in use. No deficiencies were identified during the visit.
02 Jun 2021
02 Jun 2021
Found no health and safety deficiencies; residents and staff were engaged in activities, meals were prepared, food supply was sufficient, and daytime staffing totaled sixteen.
02 Jun 2021
02 Jun 2021
Found the facility to be clean and safe, with residents enjoying activities and meals, adequate staffing and food supply, and no violations of health and safety regulations observed during an unannounced visit.
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01 Jun 2021
01 Jun 2021
Found no deficiencies cited under Title 22 regulations after a health and safety visit. Temperatures measured 82 degrees on the first floor and 85 on the second floor, with ten portable air conditioners in use due to the main system not functioning; observed a seven-day food supply, residents engaged in activities, and staffing levels including caregivers, med techs, dietary staff, administrative staff, and housekeeping.
01 Jun 2021
01 Jun 2021
Confirmed that the facility was visited for a health and safety check, with staff and residents observed, temperature levels and food supplies checked, and multiple portable air conditioners in use due to a malfunctioning main system; no deficiencies were identified.
31 May 2021
31 May 2021
Found staff on duty, residents dining, and some using the activity area as a cooling station; six air conditioners were set at 70 degrees. Temperatures ranged from 81 degrees in the lower floors to 85 degrees on the upper floors, with memory care at 81 degrees; eleven staff were on the day shift, food was available for dinner and breakfast, and no deficiencies were found; an exit interview was conducted.
31 May 2021
31 May 2021
Reviewed an unannounced health and safety check revealing temperatures higher than recommended, adequate staffing, sufficient food supplies, and no violations of regulations. Some residents used the activity area as a cooling station, and additional air conditioning units are pending delivery.
30 May 2021
30 May 2021
Identified safety concerns, including toxins left unlocked in the memory care kitchen near a housekeeping closet and a patio gate latch that was not functioning. Noted medications were securely stored and accounted for, temperatures and air conditioning were within acceptable ranges, and on-site staff included caregivers, med techs, dietary staff, and administrative personnel.
29 May 2021
29 May 2021
Found no deficiencies after a health and safety check; observed staff on duty with residents eating and noted a day shift of 10 staff (two med-techs, six direct care, two kitchen) with an adequate food supply. Noted a hospice resident had recently died and the room was closed and secured.
30 May 2021
30 May 2021
Found safety issues including unlocked cabinets with toxins, malfunctioning patio gate, and insufficient climate control, alongside adequate staffing and proper medication storage during a health and safety check.
29 May 2021
29 May 2021
Found no deficiencies during a health and safety check, which included observing staff, residents, food supplies, and the physical environment, following the passing of a hospice resident; the facility was appropriately staffed and maintained.
28 May 2021
28 May 2021
Found no deficiencies after an unannounced visit on 5/28/2021, with 54 residents (including 3 hospice). Observed temperatures within the required range, six air conditioning units in working order while the main unit was not functioning, a locked centrally stored medications area, adequate food supplies (nonperishables for one week and perishables for two days), nutritious meals planned for the week, and the stated staffing on site.
28 May 2021
28 May 2021
Found no deficiencies during a health and safety inspection of the facility, which had appropriate temperatures, functioning air conditioning units, secure medication storage, adequate food supplies, and proper meal preparation procedures.
27 May 2021
27 May 2021
Found meals in progress with adequate food supplies and a posted menu followed; staffing included 3 caregivers and 3 med techs for 54 residents, plus 2 dietary staff and 2 housekeeping cross-trained as caregivers. Noted main air-conditioning unit not working for about 30 days, six portable units in use, temperature at 78 degrees Fahrenheit; no deficiencies identified.
26 May 2021
26 May 2021
Found the main air-conditioning unit not operable for about 30 days; six portable units were brought in, temperatures in the care home reached 78 degrees, and a deficiency was identified.
27 May 2021
27 May 2021
Found that the facility was prepared for meal service with adequate food supplies and proper staffing, despite the main air conditioning unit being non-operational for about 30 days, and temporarily cooling with portable units; no deficiencies were identified.
§ 87411(a)
26 May 2021
26 May 2021
Found that the main air conditioning unit was not working for about 30 days, prompting the use of portable units, while indoor temperatures reached 78 degrees Fahrenheit.
14 May 2021
14 May 2021
Found that 9-1-1 was not called after a resident fell and sustained a bruise to the forehead, despite a policy indicating it should be for head injuries. Found that medications were not given from May 1 to May 4 due to an unpaid pharmacy balance, and identified deficiencies under Title 22 regulations.
14 May 2021
14 May 2021
Reviewed documentation and interviews revealed that staff failed to notify 9-1-1 after a resident fell and sustained a head injury, and the resident did not receive medications for several days due to an unpaid pharmacy balance.
§ 87355(e)(1)
11 May 2021
11 May 2021
Identified the need for a lease-back agreement due to a property sale and pending CHOW, with the sale expected to close soon and repairs to follow after closing. Noted that all required documents were submitted, but a health screening for the new administrator and updating the LIC200 page to reflect the correct administrator were still needed, and an exit interview was conducted.
11 May 2021
11 May 2021
Reviewed a recent office visit regarding the sale of a property, noting that a lease back agreement was discussed and pending, with specific documents still needing submission and updates.
24 Feb 2021
24 Feb 2021
Identified several safety and health deficiencies, including nonfunctional emergency call systems in multiple rooms, a chirping fire alarm, hot water temperatures up to 124 degrees, missing PPE and cleaning supplies, and a resident needing assistance with bathing.
08 Apr 2021
08 Apr 2021
Found no deficiencies after a health and safety check; observed PPE availability, masks worn by residents and staff, sanitizer and safety signs, dining in common areas, an isolation-ready room, and routine cleaning with disinfectant.
04 May 2021
04 May 2021
Identified that the applicant and administrator completed COMP II by telephone, confirmed understanding of licensing requirements, resident populations, staff qualifications and responsibilities, staff training, grievances and community resources, food service, and medication management, and reviewed documents including the pre-licensing inspection and COVID-19 mitigation plan materials; they were advised to submit signed LIC 809 with photo ID.
04 May 2021
04 May 2021
Verified that the applicant and administrator successfully completed a required competency exam via telephone, demonstrating understanding of facility operations, staff requirements, resident care, and related topics.
30 Apr 2021
30 Apr 2021
Identified health and safety deficiencies, including hot water temperatures exceeding safe levels, nonfunctional air conditioning, water damage and ceiling/lighting problems, and Memory Care doors that did not close properly or were propped open. Also noted lapses in entry COVID screening and maintenance-related safety concerns.
30 Apr 2021
30 Apr 2021
Identified multiple safety and maintenance issues at the site, including non-working air conditioning, door closers on resident doors needing repair, not working lighting, a delayed egress door, a non-working van/bus, and a door to the memory care activity room needing repair. Not approved for licensure at this time.
30 Apr 2021
30 Apr 2021
Found several safety and maintenance issues, including inoperable air conditioning, non-functional door closers, broken lighting, and unsafe egress doors, preventing licensure approval pending corrections.
30 Apr 2021
30 Apr 2021
Reviewed lapses in COVID screening, hot water temperatures, and maintenance issues with the HVAC units, as well as deficiencies in emergency signage, medication storage, and door security.
28 Apr 2021
28 Apr 2021
Identified a serious injury to a resident on 4/13/2021 caused by heavy doors. The resident was assessed on site by staff and a home health nurse and transported to the hospital by EMS.
§
28 Apr 2021
28 Apr 2021
Reviewed a resident injury caused by heavy doors that closed quickly; staff reported no prior similar incidents in the past two years.
27 Apr 2021
27 Apr 2021
Identified that the location's office phones were not functioning and staff had lowered the ring volume, and that during a COVID-19 outbreak there were not enough staff to meet residents' care needs. Identified that transportation for a resident to dialysis was not provided when the resident tested COVID-positive and no alternative arrangements were made, resulting in missed medical appointments.
27 Apr 2021
27 Apr 2021
Identified four issues: a resident did not receive a copy of the rental agreement at admission; staff were unavailable to residents' concerns and basic needs; weekly housekeeping was not provided; and medications were missed. Noted staffing shortages during the COVID-19 outbreak and communication gaps between staff and residents' families.
27 Apr 2021
27 Apr 2021
Identified the allegation that staff do not communicate effectively at this site. Reports from residents, family members, and emergency contacts described failures to relay falls, changes in medical status (including a COVID-positive result), medication needs, transportation arrangements, and room moves, and noted that phones were reportedly not working.
27 Apr 2021
27 Apr 2021
Found that the resident experienced multiple falls, staff did not meet hygienic care needs, personal property was not safeguarded, and staff did not communicate effectively.
27 Apr 2021
27 Apr 2021
Investigated whether residents received their rental agreements, proper care, and medication management, as well as staff communication with families; found that the resident was not provided a rental agreement, staff did not consistently meet basic needs or communicate effectively, and medication administration issues occurred during a period of staffing shortages.
20 Apr 2021
20 Apr 2021
Found 54 residents on site with 4 in isolation and no active COVID cases; noted new staff hires, a new transportation contractor, and PPE, cleaning schedules, daily logs, and ongoing resident monitoring in place.
20 Apr 2021
20 Apr 2021
Logged that the facility maintained appropriate COVID-19 precautions, staffing, and resident care procedures during an unannounced visit, including proper PPE usage, sanitation measures, and safety protocols.
14 Apr 2021
14 Apr 2021
Identified several health and safety deficiencies, including improper isolation posting for a resident, incomplete medication documentation, and insufficient PPE supplies, plus temperature control issues. Observed some adherence to safety practices—staff and residents wore masks and surfaces were disinfected—though several gaps remained.
14 Apr 2021
14 Apr 2021
Found that staff properly followed COVID-19 safety protocols, including PPE use, resident masking, and social distancing, but identified issues such as improper posting of isolation start and end dates, medication documentation lapses, and insufficient PPE supplies.
08 Apr 2021
08 Apr 2021
Found the allegation that staff could not use proper precautions because they weren’t notified of the resident’s condition to be unfounded. Records showed the resident did not have MRSA but had shingles, PPE was provided for care, and the resident was hospitalized on 1/7/2021 and died on 1/10/2021.
08 Apr 2021
08 Apr 2021
Confirmed that COVID-19 safety protocols, including masking, sanitizing supplies, and social distancing, were appropriately implemented and maintained during the visit. Observed sufficient PPE, proper sanitation, and adherence to health guidelines throughout the facility.
§
02 Apr 2021
02 Apr 2021
Identified deficiencies in health and safety practices during an unannounced visit, including incomplete visitor screening and isolation room readiness for PUIs. Noted HVAC and temperature control concerns and some equipment issues, with residents observed in communal activities wearing masks.
02 Apr 2021
02 Apr 2021
Reviewed COVID-19 safety protocols, resident status, and staffing conditions during an unannounced visit, noting proper screening, PPE availability, and communication efforts, while also observing issues with cooling systems and resident activity restrictions.
01 Apr 2021
01 Apr 2021
Found ongoing safety and staffing concerns at the residence, including a missing narcotic incident, malfunctioning phone lines, indoor temperatures reaching 88 degrees, several staff not fit tested, and ongoing staffing and administrator changes; a resident death occurred.
01 Apr 2021
01 Apr 2021
Reviewed staff and resident concerns, including incidents involving medication and environmental issues, and noted ongoing staffing, communication, and maintenance challenges within the facility.
§
§
26 Mar 2021
26 Mar 2021
Identified an ongoing COVID-19 outbreak with 50 residents testing positive (35 cleared, 4 in higher care, 8 deaths; 7 in isolation as PUI) and 6 hospice residents; vaccination records were being verified. Noted missing records and several infection-control gaps, including use of personal phones for resident communication, PPE handling, and posted signage.
26 Mar 2021
26 Mar 2021
Reviewed infection control and staff practices during a visit, noting PPE protocols, cleaning procedures, resident isolation, and vaccination verification. Identified areas needing improvement, including signage, signage, documentation, and communication equipment.
24 Mar 2021
24 Mar 2021
Found a significant COVID-19 outbreak with 50 residents positive (35 cleared, 4 at a higher level of care, 8 deaths), 7 under isolation as PUIs, and 6 hospice residents. Identified a bed bug infestation in multiple rooms, a resident readmitted to hospital with hospice referral, and ongoing staffing issues plus several administrative items (care plans, vaccination records, and incident reports).
24 Mar 2021
24 Mar 2021
Reviewed ongoing staffing and resident health concerns amid COVID-19, including positive cases, hospitalizations, medication adjustments, and pest infestation issues. Discussed documentation updates and required reports to ensure compliance and resident safety.
22 Mar 2021
22 Mar 2021
Found ongoing health and safety concerns, including many residents testing positive with several deaths, plus bed bugs in multiple rooms and shortages of food and supplies. Found gaps in documentation, such as care plans, room assignments, and vaccination records.
22 Mar 2021
22 Mar 2021
Reviewed conditions at a facility experiencing COVID-19 outbreaks, staffing and supply issues, pest problems, and concerns about resident safety, including fall prevention and care plan updates.
19 Mar 2021
19 Mar 2021
Identified an ongoing COVID-19 outbreak with about 50 positive residents, eight deaths, several in higher care, and five under isolation as PUI. Noted staffing shortages, vaccination efforts, and gaps in resident room readiness along with ongoing infection control and screening practices.
19 Mar 2021
19 Mar 2021
Reviewed COVID-19 containment efforts, staffing plans, resident conditions, and safety protocols during an outbreak, noting ongoing challenges with staffing, resident health, and facility safety measures.
12 Mar 2021
12 Mar 2021
Found 63 residents total, with 53 on site and 7 under isolation as a person of interest; 50 had tested positive—35 cleared, 5 remain in a higher level of care, and 8 deaths.
12 Mar 2021
12 Mar 2021
Reviewed a case management visit documenting current resident status, COVID-19 testing updates, facility maintenance and staffing developments, and ongoing efforts to address resident care needs amid pandemic challenges.
§ 87465
§ 87465
11 Mar 2021
11 Mar 2021
Identified a significant COVID-19 impact with 8 deaths, 5 residents in higher care, 7 in isolation, and 50 positives overall; observed safety measures (PPE, screenings) and no communal dining due to kitchen plumbing problems, with several administrative items requested.
11 Mar 2021
11 Mar 2021
Reviewed protocols and conditions during a COVID-19 response, including resident health status, infection control measures, staff and visitor screening, food safety, and facility maintenance, with ongoing efforts to address specific resident needs and facility repairs.
§ 87303(e)(3)
§ 87303(a)
10 Mar 2021
10 Mar 2021
Reviewed notes from a teleconference on 3/10/2021, noting a total census of 62 residents (51 on site), with 7 in isolation as a person of interest and 50 who tested positive (35 cleared, 5 still in higher care, 8 deaths). The materials described resident-specific needs, documentation requests, and ongoing medication reviews.
10 Mar 2021
10 Mar 2021
Reviewed the current COVID-19 status, staffing, and resident conditions, including delayed documentation and ongoing health concerns related to positive cases, resident isolation, and medication reviews.
09 Mar 2021
09 Mar 2021
Found an ongoing COVID-19 situation with 52 residents on site, 8 in isolation as persons of interest, and 50 testing positive (35 cleared, 6 at a higher level of care, 8 deaths) after two rounds of negative tests, with one resident hospitalized for weakness. Noted that two residents in isolation left yesterday without signing out, eight residents remained isolated, and safety issues were observed, including improper PPE use and limited cleaning supplies.
09 Mar 2021
09 Mar 2021
Reviewed conditions related to COVID-19, identifying ongoing challenges with resident isolation compliance, PPE use, staff training, and safety protocols, amid high resident case numbers and recent testing efforts.
08 Mar 2021
08 Mar 2021
Identified that two residents did not receive their 8pm medications on 2/13/2021 as prescribed when the medication pass was managed by a staff member who later resigned and left the building. An emergency meeting followed, and deficiencies in medication management were noted.
08 Mar 2021
08 Mar 2021
Reviewed census data, isolation status, and recent resident notes from a case management visit. Found 50 residents had tested positive (35 cleared), eight deaths, and five remaining in higher care, with a weekend power outage affecting part to all of the building.
08 Mar 2021
08 Mar 2021
Reviewed recent resident care updates, infection control measures, staff and resident movement plans, and facility operations following a COVID-19 outbreak and power outage.
§ 87303(e)(2)
§
05 Mar 2021
05 Mar 2021
Identified ongoing COVID-19 impact at this location, with 63 residents (53 on site), five in isolation as PUI, and 50 positive cases including eight deaths (35 cleared; six in higher care). A second round of negative testing was completed for 14 residents and 48 staff, PPE and signage remained in place, no deficiencies were found, and an updated LHD contact was provided at exit.
05 Mar 2021
05 Mar 2021
Reviewed infection control procedures and COVID-19 precautions, including PPE use, resident tracking, and staff adherence, amid ongoing COVID-19 cases and isolation measures in the facility.
§ 87303(a)
§ 87466
04 Mar 2021
04 Mar 2021
Found that the allegation that equipment was in disrepair and that a hoyer lift was not provided to assist a resident with care was accurate.
04 Mar 2021
04 Mar 2021
Identified that the facility failed to provide a functioning Hoyer lift and necessary equipment for a resident's mobility and incontinence care, resulting in the resident being unable to leave bed for months.
§ 87303
02 Mar 2021
02 Mar 2021
Identified extensive safety and compliance deficiencies at the site, including unsecured medications, improper drug storage, expired equipment, damaged doors and windows, unlocked chemicals, and incomplete resident and staff records. Not approved for licensure at this time.
02 Mar 2021
02 Mar 2021
Identified extensive safety and health deficiencies at the site, including unsecured medications and expired meds, improper medication handling, and incomplete resident and staff records. Found additional concerns such as improper food storage with spoiled items and missing temperature logs, PPE noncompliance, and multiple maintenance and security hazards affecting resident care.
03 Mar 2021
03 Mar 2021
Identified ongoing concerns, including a resident on hospice, a resident who refused a medical assessment, a walk-out by another resident, a bed bug finding with treatment scheduled, and updates on staffing with new hires and cross-training.
03 Mar 2021
03 Mar 2021
Reviewed resident care and staffing updates, noted a bed bug infestation identified by canine inspection, and discussed staff training and recent incidents involving resident refusals and behaviors.
§ 87465(a)(2)
§ 87303(a)
02 Mar 2021
02 Mar 2021
Identified numerous health, safety, and recordkeeping violations, including expired food, unlocked medication carts, damaged building structures, and incomplete resident and staff documentation, preventing licensure approval.
02 Mar 2021
02 Mar 2021
Identified multiple safety and health violations, including unsafe medication storage, expired and improperly stored food, broken environmental hazards, unlocked med carts, and staff non-compliance with PPE protocols, with deficiencies cited under regulatory standards.
§ 87465(a)(5)
§ 87464(d)
§ 87507(e)
§ 87464(f)(1)
01 Mar 2021
01 Mar 2021
Identified multiple care concerns, including a resident head injury with hospice follow-up, another resident referred to hospital care with placement planning pending, and lapses in daily line-list updates and COVID-19 precautions. Noted ongoing building repairs and equipment issues, and civil penalties were assessed for repeat violations.
01 Mar 2021
01 Mar 2021
Confirmed multiple health and safety deficiencies, including incomplete documentation, COVID-19 precautions not fully implemented, and issues with staff PPE use and facility repairs, leading to civil penalties.
§ 87218(a)
§ 87466
§ 87464(d)
§ 87464(f)(4)
23 Feb 2021
23 Feb 2021
Identified ongoing COVID-19 activity with residents testing positive onsite and offsite, including refusals to testing and a recent hospitalization, while no current positive staff and weekly testing continues. Identified maintenance and safety concerns, including a sewage backup in the kitchen, a disrepair water heater, a bed bug issue in one room, overdue fire alarm and sprinkler inspections, and staffing changes with temporary staffing and recruitment.
§ 87465
§ 87303(a)
§ 87203
§ 87555(27)
22 Feb 2021
22 Feb 2021
Confirmed COMP II completed by telephone with CAB; identification verified; applicant and administrator demonstrated understanding of Title 22 and key topics—operation, staff qualifications and responsibilities, and staff training—and advised to submit signed LIC 809 with photo ID.
24 Feb 2021
24 Feb 2021
Found that the kitchen and bathroom water temperatures were above recommended levels, fire alarm systems in some resident rooms were not working, and deficiencies related to safety and sanitation were identified. Also observed were adequate cleaning supplies, proper food labeling, social distancing measures, and screening protocols in place.
23 Feb 2021
23 Feb 2021
Completed COMP II via telephone, verified identity, and confirmed understanding of Title 22, reviewing license type, client populations, and programs; staff qualifications and responsibilities; staff training; applicant and administrator qualifications; grievances, complaints, and community resources; food service; medication management; and pre-licensing document review.
10 Feb 2021
10 Feb 2021
Investigated the allegation that the licensee was not financially solvent and identified overdue payments and substantial liabilities.
§ 87213
23 Feb 2021
23 Feb 2021
Confirmed successful completion of Component II for the applicant and administrator via telephone, verifying their understanding of facility operations, staff qualifications, training, medication management, and other licensing topics.
23 Feb 2021
23 Feb 2021
Reviewed ongoing COVID cases, staffing and infection control issues, infrastructure concerns including sewage backup and water heater problems, and a bed bug infestation, with various inspections and documentation follow-ups pending.
22 Feb 2021
22 Feb 2021
Confirmed that the applicant and administrator completed the required competency examination remotely, demonstrating understanding of facility operations, staff qualifications, and training.
19 Feb 2021
19 Feb 2021
Found safety and infection-control concerns during a case management visit, including missing basic personal care items in memory care rooms, hand hygiene supplies, and smoking area management. Noted structural water damage in the lobby ceiling and resident health notes such as COVID monitoring and dementia-related care plan reappraisals in progress.
19 Feb 2021
19 Feb 2021
Reviewed conditions and resident care, observed ongoing repairs and adherence to safety protocols, and confirmed staff training and documentation updates in response to recent assessments and COVID-19 procedures.
§ 87303
18 Feb 2021
18 Feb 2021
Identified one new COVID-19 case and ongoing resident reappraisals under a new medical director, with several residents on hospice or needing higher levels of care. Noted safety and maintenance concerns, including two restrooms out of order, an unlocked staff area, and outdated fire safety equipment, along with updates to activity planning and dementia care documentation.
18 Feb 2021
18 Feb 2021
Reviewed current conditions, resident health statuses, and safety protocols, noting a new COVID-positive case, ongoing reappraisals, and updates to treatment and activity plans while documenting facility operations and compliance with health and safety requirements.
§
§ 87468.1
17 Feb 2021
17 Feb 2021
Found an active COVID-19 outbreak at the home with 48 current positive residents and seven deaths, with 26 cleared. PPE was available and screening in place, while several administrative tasks such as staff testing updates and resident reappraisals were in progress.
17 Feb 2021
17 Feb 2021
Reviewed COVID-19 precautions, infection control practices, resident care updates, staffing support, and documentation related to ongoing cases at the facility during a virtual visit.
§ 87465
§ 87468.1
§ 1569.695(f)(1)
16 Feb 2021
16 Feb 2021
Identified ongoing COVID-19 status among residents, with several positives and many on hospice or in hospital/SNF settings, while medical reappraisals and routine care updates were noted.
16 Feb 2021
16 Feb 2021
Reviewed ongoing COVID-19 outbreak, resident conditions, staff testing, and response efforts, with multiple residents on hospice and positive cases, while facility staff coordinated testing, cleaning, and care planning amidst pandemic challenges.
10 Feb 2021
10 Feb 2021
Investigated allegations about the sale of each site and concerns over COVID-19 infection control, and the department continued to monitor resident transitions as needed; an exit interview was conducted.
10 Feb 2021
10 Feb 2021
Identified several health and safety concerns, including unlabelled disinfectants and unclear disinfection procedures, a broken door with unsupervised entry, and PPE stations lacking labels or inventory; observed cleanliness and maintenance issues in resident rooms and common areas, cluttered closets, and water damage in the lobby ceiling.
06 Feb 2021
06 Feb 2021
Identified ongoing COVID-19 concerns with recent tests showing several residents positive and no staff positives, and noted daily updates and coordination for vaccines and external services at this site.
01 Sept 2020
01 Sept 2020
Found that a staff member held the resident's hands and wrist during a change, causing discoloration. The staff member resigned, no investigation was completed or documented, and information from management was minimal.
05 Feb 2021
05 Feb 2021
Identified ongoing infection-control issues and management deficiencies at the home, including an unlocked front entrance with no screening, inconsistent masking, and poor sanitation and waste practices in rooms. Also noted concerns about PCR test turnaround times, lack of staff fit testing, and training gaps for food handling.
10 Feb 2021
10 Feb 2021
Reviewed a complaint regarding COVID-19 infection control practices and the sale of a care facility, including discussions on resident relocation, closure plans, and ongoing support during the outbreak.
§ 87468(a)(2)
08 Feb 2021
08 Feb 2021
Found incomplete records and a need to update the line list, with a census of 74: 48 active positive residents (9 in one unit and 6 in another), 26 cleared, 7 deaths, and 17 positive staff (13 recovered, no staff deaths). Five weekend-positive residents were doing well, one was noncompliant and ripping signs from doors; three residents were hospitalized (one COVID-related) with no discharge plans, and seven residents in skilled nursing also had no discharge plans; staffing shortages persisted, with about 10 staff supporting operations and no Aya staff present, and some workers had stopped showing up while management indicated they planned to work elsewhere.
08 Feb 2021
08 Feb 2021
Reviewed staffing and resident COVID-19 status, noting incomplete records, ongoing efforts to update documentation, lack of designated staff for positive residents, and communication conflicts regarding scheduled meetings.
06 Feb 2021
06 Feb 2021
Reviewed COVID-19 testing, staffing, infection control practices, and safety protocols, including PPE use and resident monitoring, amidst ongoing concerns related to the pandemic and facility operations.
§ 87303
05 Feb 2021
05 Feb 2021
Identified ongoing infection control issues, including inadequate PPE use, improper sanitation practices, and unsecured building entry, despite multiple Department interventions and visits. Concerns regarding staff compliance, reporting, and safety protocols highlighted the need for continued Department support.
§ 87555
§ 87618
22 Jan 2021
22 Jan 2021
Identified ongoing infection-control problems across care units, including missing soap and towels, uncovered trash cans and trash in rooms, understocked PPE carts, and unlabeled cleaning supplies; about half of residents were infected and a positive test was not reported.
07 Jan 2021
07 Jan 2021
Verified PPE protocols were followed, with staff wearing N95 masks and face shields and performing proper donning and doffing, and sanitizer available with signage of the steps posted. Continuing testing at 25% and restricting access to essential personnel while plans are reviewed by health authorities; new supplies have been received and no issues were noted.
22 Jan 2021
22 Jan 2021
Found ongoing issues with infection control practices, including improper trash management, lack of proper sanitation supplies, and insufficient PPE stocking, which contributed to a COVID-19 outbreak affecting half of the residents.
06 Jan 2021
06 Jan 2021
Found an allegation that COVID-19 safety was not properly managed, including insufficient PPE, unclear or missing isolation signage, and poor sanitation in the COVID wing and memory care areas.
07 Jan 2021
07 Jan 2021
Confirmed that staff wore appropriate PPE, followed proper donning and doffing procedures, and implemented infection control measures amid COVID-19 concerns, including testing protocols and restricted visitation.
06 Jan 2021
06 Jan 2021
Found numerous deficiencies in infection control practices, including improper PPE use, inadequate signage, and unsafe resident care procedures related to COVID-19 precautions.
07 Dec 2020
07 Dec 2020
Found that staff did not administer prescribed medications to a resident at scheduled times during August 2020. Records showed the medications were not received from the pharmacy and were not documented as given.
§ 87506(b)(8)
§ 87465(h)(6)
§ 87465(c)(2)
07 Dec 2020
07 Dec 2020
Confirmed that staff did not administer prescribed medications to a resident as scheduled between August 7 and 27, 2020, due to a lack of documentation and medications not being received from the pharmacy.
§ 87465
25 Nov 2020
25 Nov 2020
Investigated an allegation that a resident was left in urine at the day program and that staff did not arrange transportation to a medical appointment. Found the allegations valid.
25 Nov 2020
25 Nov 2020
Found that the allegation that staff failed to arrange transportation for a resident's medical appointment, as required by the care plan, was supported by evidence. Other program staff subsequently provided transportation.
25 Nov 2020
25 Nov 2020
Found that there was not a preponderance of evidence to prove the allegation. While the allegation may have occurred, its occurrence could not be established.
25 Nov 2020
25 Nov 2020
Found that staff failed to provide necessary transportation for Resident 1 to a scheduled medical appointment, as required by the resident's care plan, leading to a cited deficiency.
§ 1569.58(a)(2)
§ 87468.1
§ 87307
28 Oct 2020
28 Oct 2020
Investigated and found that a resident did not receive several prescribed medications between September 26 and 28, 2020, per the Medication Assistance Record. Identified a deficiency in medication administration for that period.
28 Oct 2020
28 Oct 2020
Investigated the eviction-related allegation of increased verbal aggression and physical altercations between a resident and staff, reviewed care plans, and noted a bruise on the resident that staff could not explain. Found the eviction letter did not include specific facts to support the eviction, such as date, place, witnesses, and circumstances.
28 Oct 2020
28 Oct 2020
Reviewed discussions on change of ownership, leaseback and purchase arrangements, closure planning, eviction notices, retention and limitations, and the ALWP; the licensee agreed to provide eviction notices to residents and their responsible parties, notify ALWP of the sale, share the closure plan, and furnish a leaseback agreement between the new owners and the current licensee.
28 Oct 2020
28 Oct 2020
Found that interviews with the administrator, residents, and staff did not support the allegation; a tele-visit observed a resident’s door open and secured to the wall by a doorstop wedge, and there was not a preponderance of evidence to prove the violation occurred, so the allegation is unsubstantiated.
28 Oct 2020
28 Oct 2020
Identified abuse of a resident with dementia by a staff member on 9/12/2020 during kitchen assistance, observed by two other staff; internal review led to the staff member's voluntary separation.
28 Oct 2020
28 Oct 2020
Investigated an allegation regarding resident safety, interviewing staff and residents, and observed that the evidence did not support the claim. Concluded that there was not enough evidence to determine whether the violation occurred.
§ 87465
§ 87464
§ 87625
§ 87303
§ 87303
§ 1569.58(a)(2)
§ 87465
§ 87465
§ 87203
§ 87555
§ 87705
12 Oct 2020
12 Oct 2020
Found insufficient evidence to prove or disprove the allegation that staff stole medication; interviews and reviews of resident medication files did not support the claim.
12 Oct 2020
12 Oct 2020
Investigated a report of medication theft and found no sufficient evidence to support that staff members stole medication from residents.
05 Oct 2020
05 Oct 2020
Investigated the allegation of a questionable death; found insufficient evidence to prove it. Interviews and record reviews showed no evidence to support the allegation.
05 Oct 2020
05 Oct 2020
Investigated the allegation of questionable circumstances surrounding a resident’s death; found no evidence supporting any wrongdoing or suspicious activity.
02 Oct 2020
02 Oct 2020
Identified ongoing telephone system problems at the care setting that prevented some calls from reaching staff, with families reporting missed calls and voicemail backlogs.
02 Oct 2020
02 Oct 2020
Identified ongoing phone system issues at the facility that prevented calls from consistently reaching staff or families, leading to communication challenges during COVID-19 precautions.
01 Oct 2020
01 Oct 2020
Found multiple health and safety concerns, including unlocked medications, strong odors, unlabelled dirty clothing, and a non-working memory care air conditioner. Residents reported marijuana use in common areas and a staff member tested positive for Covid with no clear plan to reduce exposure; outdated service plans and missing orientation training were identified.
01 Oct 2020
01 Oct 2020
Identified an allegation of solvency problems due to unpaid vendor bills and PG&E costs; noted an auditor’s document request, potential ownership changes being explored, and safety measures like separating residents by COVID status and using PPE.
01 Oct 2020
01 Oct 2020
Identified financial and operational concerns, including unpaid bills and facility solvency, during a conference call with various representatives. Discussed the need for mitigation plans, resident COVID separation, staff PPE use, and communication with administrators.
§ 80072
15 Sept 2020
15 Sept 2020
Found a resident with a bandaged shin during a tele-visit, and the administrator discussed the wound status. The administrator was to send discharge documentation from the 9/3/2020 hospital visit, along with skin checks and home health notes dated 9/1/2020 to present.
15 Sept 2020
15 Sept 2020
Reviewed a case management visit where the licensing analyst discussed a resident’s wound condition with the administrator and requested medical documentation; no deficiencies were cited.
§ 1569.58(a)(2)
§ 87405
§ 87411(a)
§ 80087
03 Sept 2020
03 Sept 2020
Identified health and safety deficiencies, including no updated medical assessment for a resident with dementia and a lack of follow-up wound care after hospital discharge. Also noted incomplete narcotic destruction records and missing details (dates and pharmacy) in the central medication storage log.
03 Sept 2020
03 Sept 2020
Reviewed issues including inadequate wound care follow-up, missing updated medical assessments for a resident with dementia, and incomplete medication destruction records, leading to identified regulatory deficiencies.
§ 87411(a)
§ 87219(f)
§ 87468.1
§ 80087(a)
§ 87618
01 Sept 2020
01 Sept 2020
Identified that staff member held a resident’s hands and wrist during a change, causing discoloration, violating the resident’s personal rights.
§ 87405
§ 87405
§ 87211
25 Jun 2020
25 Jun 2020
Investigated whether resident 1's allegation of a specific incident occurred; findings showed insufficient evidence to confirm or deny the claim.
19 May 2020
19 May 2020
Identified that a resident developed a rash suspected to be scabies, leading to precautions such as isolation and monitoring, with no other residents affected.
04 May 2020
04 May 2020
Investigated whether the air conditioning system was functioning properly; found all units operational and maintained at comfortable temperatures.
24 Apr 2020
24 Apr 2020
Investigated sexual misconduct between two residents, revealing staff failed to follow the residents’ care plans and adequately address safety concerns, leading to the finding that the allegation was substantiated.
§ 1569.58(a)(2)
§
05 Mar 2020
05 Mar 2020
Reviewed issues related to personal rights, basic needs, eviction notices, care, financial concerns, medical care, and reporting requirements during an informal meeting addressing prior citations.
§ 87224(d)
§ 87466
04 Mar 2020
04 Mar 2020
Reviewed the case involving missing personal items after resident 1's stay, with evidence indicating some items were not returned to the family and their whereabouts are unknown; these findings support the allegation of missing belongings.
§ 87625(b)(3)
§ 87466
21 Feb 2020
21 Feb 2020
Investigated an incident where a resident had red marks on her face, confirming that staff failed to report an injury and an alleged scratching incident; also identified issues with water damage not reported and inadequate call systems in memory care.
§ 87468.1
§ 80087
§ 87219(f)
14 Feb 2020
14 Feb 2020
Reviewed concerns regarding resident rights, care services, staffing ratios, and record keeping following prior complaint inspections, leading to discussions on compliance and facility improvements.
13 Feb 2020
13 Feb 2020
Reviewed staff records and identified 15 staff members with criminal background clearances who were not associated with the facility, resulting in a cited deficiency and civil penalties.
§ 87464(f)(6)
11 Feb 2020
11 Feb 2020
Reviewed resident files and interviewed staff regarding a resident who left the facility unassisted and has not returned, while police follow up on her whereabouts; no deficiencies identified.
27 Jan 2020
27 Jan 2020
Reviewed a facility's compliance with health, safety, and staffing regulations during an unannounced annual inspection, noticed adequate precautions and conditions but identified one deficiency related to TB testing for staff.
§
23 Jan 2020
23 Jan 2020
Reviewed a resident incident involving a minor burn, with follow-up medical care and safety issues observed, including hot water temperature exceeding safe levels.
§ 87468.1
06 Jan 2020
06 Jan 2020
Reviewed resident files and found that one resident’s admission agreement was not signed by the resident, responsible party, or facility representative. Noted a deficiency related to this issue during the visit.
§
17 Dec 2019
17 Dec 2019
Confirmed that a resident left the facility without signing out, requiring higher-level care and refusing medication, with behaviors such as yelling reported; additional time was needed to complete the case management review.
§ 87101(c)(3)
§
§ 87405
05 Dec 2019
05 Dec 2019
Reviewed medication and documentation issues, including missing or incomplete medical records, discrepancies in resident behavior reports, and unavailability of prescribed medications. Found deficiencies related to resident care records and medication management.
21 Nov 2019
21 Nov 2019
Identified that the resident needed a higher level of care and had been bedridden since 2018, but the facility failed to issue a timely eviction notice, and it was found to be in violation of fire clearance requirements due to the resident’s status.
15 Oct 2019
15 Oct 2019
Identified deficiencies related to inadequate emergency evacuation plans and lack of proper clearance for a bedridden resident, with civil penalties to be assessed later.
§ 87458
§ 87465(a)
§
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Del Monte Assisted Living & Memory Care - Stockton