I loved the look - new paint, furniture and a model apartment that smells and feels like home, and there are lots of activities and some very thoughtful, friendly caregivers. But my experience was mixed and ultimately negative: care is inconsistent and often unsafe (fall risk/low beds, catheter mishandling, medication delays, dehydration/ER), rooms and briefs were unsanitary at times, and there were norovirus lockdowns. Phones and front desk were rude or unanswered, management was unavailable and unempathetic, and staff training/coordination is poor. I'm grateful for a few attentive staff and good rehab moments, but I would not recommend this place for loved ones.
Caregivers leaving residents in soiled briefs/diapers and not changing them
Residents left in chairs all day and neglected basic hygiene
Dirty and unsanitary facility areas (floors, smells, used gloves/briefs)
Caregivers making demeaning or hurtful remarks about residents
Unavailable or rude phone/phone system issues; caller ID makes calls appear unknown
Fall risks and safety concerns (low bed height, inadequate precautions) with reported head injury
Frequent resident moves within facility and poor communication
Inconsistent quality of care across shifts and resident experiences
Summary review
Overall sentiment across the reviews is highly mixed and polarized: while a number of reviewers describe a welcoming, improved, and active community with attentive staff and good amenities, an equally loud set of reviews report serious quality-of-care, safety, and cleanliness failures. The positive comments often highlight recent renovations (new paint, furniture, and model-apartment style rooms), active social programming, mobility supports like lifts and scooter access, and individual experiences of good rehab or attentive staff. Several reviewers explicitly say the place "looks amazing" and that loved ones are happy, suggesting visible improvements and a positive environment for some residents.
Conversely, multiple reviews raise major clinical and operational concerns that should not be overlooked. Reported issues include delays and poor coordination with medication orders, unsafe catheter handling and a management team unfamiliar with proper clinical procedures, and at least one instance of dehydration leading to hospital care. There are also accounts of caregivers leaving residents in soiled briefs overnight, failing to change or reposition residents (kept in chairs all day), and making hurtful comments—these describe neglect and disrespect in direct resident care. Several reviewers reported dirty conditions, foul odors, used gloves/briefs left around, and overall unsanitary areas. One review states staff were "appalled" by conditions and moved the resident out; other reviews mention a norovirus-related lockdown, which raises further infection-control concerns.
Staffing and management problems are recurring themes. Reviewers mention limited staff, high turnover, inconsistent care quality across shifts, unresponsive staff, and staff who overstep boundaries. Management is frequently described as unavailable or lacking empathy; phone contact problems were repeatedly noted—phones not answered, rude phone staff, an unavailable emergency contact number, and a caller-ID policy that makes calls show up as "unknown," creating the perception of telemarketing and making communication difficult. These operational failures compound clinical concerns and appear to contribute to family frustration and mistrust.
Dining and resident life are also inconsistent in reports. Some reviewers praised personalized meals and liked the food, while others described poor meals, limited choices, and no diabetic-friendly options. Activities and amenities (beauty shop, exercise area, game/TV rooms) are mentioned positively by several reviewers and contribute to accounts of an active, social community. This contrast suggests that dining and daily life experiences may vary depending on staff on duty, the unit, or individual expectations.
Safety is another significant pattern. Several reviews flagged fall risk and inadequate safety precautions (including a low bed height and a report of a fall with a head injury). Such reports, combined with medication coordination problems and missed care, indicate systemic risk areas that require attention. There are also multiple mentions of the facility moving residents multiple times and internal communication breakdowns (phones not working, no one answering), which can be destabilizing for residents and families.
There is evidence that changes are underway: reviewers note new employees, renovations, improved smell and appearance, and an improving atmosphere. Some families explicitly say things are looking better every day and praise recent staff for being thoughtful and attentive. However, simultaneous reports of dirty, stinky conditions and staff "appalled" at what they found suggest that cleanliness and quality improvements may be uneven and in progress rather than fully resolved.
In summary, Wagner Heights Residential appears to be a facility with real strengths—visible renovations, some compassionate and capable staff, good amenities, and strong social programming—but also with serious and recurring deficiencies in clinical care, cleanliness, staffing consistency, management responsiveness, and communication. The reviews indicate a split experience: some residents and families are very satisfied, while others report neglect, unsafe practices, and administrative failures that led to harm or removal of residents. Prospective residents and families should probe specific, safety-critical areas before placement: staffing levels and turnover, medication management practices, catheter and wound care protocols, fall-prevention measures, infection-control history (including how norovirus was handled), daily hygiene and incontinence care procedures, dining and dietary accommodations (especially diabetic-friendly options), and how the facility handles family communication and emergency contact procedures. Where possible, verify recent inspection reports, ask for references from current family members, and tour the specific unit to observe cleanliness and staff-resident interactions during different shifts.
Location
About Wagner Heights Residential
Wagner Heights Residential in Stockton, California, serves people aged 55 and older and has room for up to 80 residents, offering different levels of care like assisted living, independent living, memory care, skilled nursing, and rehabilitation therapy, so folks can stay as their needs change. The staff includes visiting nurses, podiatrists, physical therapists, occupational therapists, and speech therapists, and they're around every day, all day for emergencies or health monitoring, plus they've got helpers for bathing, dressing, grooming, medication, and blood sugar checks, but they'll only monitor insulin, not give injections. Residents get housekeeping, laundry, and meals-there are vegetarian and special diet options, and meals get served restaurant-style, with guest meals and a choice of one to three meals a day, and there are two extra snack times.
Rooms come furnished with bedding and private patios, and every room has an emergency call system, plus indoor and outdoor common spaces, a lounge with TV and DVD, patios with garden views, and the place sits near bus lines, parks, doctors, pharmacies, restaurants, and other things people might want. Amenities include beautician and barber services onsite, Wi-Fi, parking, scheduled transportation for doctor visits or errands, and the chance to smoke outdoors. Wagner Heights Residential runs activities like bingo, shopping, theater and casino trips, country drives, birthday parties, live entertainment, and games, along with devotional services held onsite and offsite, and there's a focus on keeping residents active and social, with group outings and daily programs.
The staff also helps with non-ambulatory care and two-person transfers, and they support residents with bowel or bladder incontinence if they're able to manage it themselves. Memory care helps those with Alzheimer's or dementia, aiming to keep folks safe and reduce confusion or wandering, and the facility supports aging in place, meaning everything from independent living through hospice and respite care is an option, depending on what's needed. Wagner Heights will help with chores and has a 24-hour call system for help, plus medical and medication management, personalized care plans, and a nurse on duty for 12 to 16 hours each day. The environment's meant to be safe and welcoming for folks from all backgrounds, and there are patios off every room, a large garden area, tree-lined streets, and even lake views to enjoy. Wagner Heights Residential is licensed by the state and gets inspected by local government and other agencies, and while it doesn't take Medicare unless certified, it aims to support each resident's dignity, well-being, and highest abilities with a variety of services and activities right on site.
People often ask...
Wagner Heights Residential offers competitive pricing, with rates starting at a cost of $3,502 per month.
There are 23 photos of Wagner Heights Residential on Mirador.
The full address for this community is 2435 Wagner Heights Rd, Stockton, CA, 95209.
Yes, Wagner Heights Residential 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
157
Inspections
49
Type A Citations
64
Type B Citations
6
Years of reports
11 Oct 2024
11 Oct 2024
Investigated the allegation that staff financially abused a resident; after reviewing records and interviewing the resident and staff, there was not a preponderance of evidence to prove the allegation.
13 Sept 2022
13 Sept 2022
Identified a resident eloping twice without supervision; a physician's note indicated the resident cannot leave unassisted, and an immediate civil penalty of $1,000 was issued for repeat violations within 12 months.
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04 Apr 2023
04 Apr 2023
Found two residents went missing on 03/26/23 and 04/02/23; they were located by police near a quick-stop store and returned. No deficiencies were observed, and an exit interview with the administrator occurred.
29 Jul 2022
29 Jul 2022
Investigated the allegation that a 30-day eviction notice for a resident was not sent to licensing as required. Found that the notice was issued to the resident's responsible party on 6-17-22 but was not sent to licensing.
§ 87224(f)
06 Sept 2022
06 Sept 2022
Identified that a resident cannot leave unassisted without staff supervision per the physician's report, and copies of the resident's functional assessment and service plan were not in the file. Noted the kitchen fire suppression system was outdated, last serviced in 2021, a zero-tolerance violation that will incur a civil penalty.
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§
§
05 Jul 2023
05 Jul 2023
Identified two power outages on 06/30/23 and 07/01/2023; during outages, residents were checked every 30 minutes, emergency lights remained on, flashlights were available, and fans were provided; no deficiencies observed.
24 Jun 2022
24 Jun 2022
Identified a morning staffing shortfall on May 22, 2022, delaying the morning medication pass. Review of medications and orders found no scheduled administration time and the evidence did not prove a regulatory violation; no deficiencies were cited.
§ 87411(a)
15 Jul 2022
15 Jul 2022
Determined Allegation 1: a resident eloped from the home without staff knowledge and was later located by law enforcement; Allegation 2: staff did not have required medication training after starting; Allegation 3: chipped and peeling drywall in the kitchen area indicated disrepair, with a civil penalty assessed.
§ 1569.312(d)
§ 1569.69(a)(8)
§ 87303(a)
29 Jun 2023
29 Jun 2023
Identified concerns regarding care and supervision, incidental medical care, personal rights, maintenance and operation, and managed incontinence in the care setting.
05 Apr 2024
05 Apr 2024
Found that two residents argued, causing a fall when one pulled the other from a wheelchair; staff separated them and called 911, but both refused treatment, and all reports were completed with responsible parties notified. No deficiencies were observed.
29 Aug 2022
29 Aug 2022
Identified ongoing concerns across reporting of incidents, resident safety related to elopements, staffing, training, infection control, and maintenance. No citations were issued today.
08 Jun 2023
08 Jun 2023
Identified inconsistencies in medication records: service plans were updated and MARs signed, but narcotics logs were unsigned and unaccounted for on multiple nights, with several medication errors noted. Conducted an exit interview.
15 Jul 2022
15 Jul 2022
Identified that the addendum shortened the required 30-day notice to vacate, leaving a resident with an inappropriate eviction notice.
§ 87224(a)(1)
06 Apr 2021
06 Apr 2021
Identified medication administration errors, including giving other residents' medicines to the wrong resident and improper storage with medications left in a disposable cup on top of the MAR.
Identified failure to follow discharge orders for a resident, resulting in an ER return for vomiting, diarrhea, and unresponsiveness, and inconsistent administration of gabapentin that worsened neuropathy and impacted independence.
§ 87465(a)(5)
§ 80078(a)
§ 80072(a)(9)
04 May 2023
04 May 2023
Found health and safety concerns including mold around a shower pan and hallway drywall, a leaking HVAC system, a malodorous smell, a non-working signal system in two resident rooms, and missing lamps in several rooms. Identified licensing and documentation issues such as 19 non-ambulatory residents—well above the licensed 9—and missing documents in some resident files, plus a lack of extra sheets.
§ 87202(a)(1)
§ 87303(i)(1)
§ 87465(a)(1)
§ 87303(a)(1)
§ 87303(e)(6)
§ 87307(a)(3)
§ 87307(a)(3)
§ 87307(d)(2)
13 Sept 2022
13 Sept 2022
Identified an AWOL incident on 8-7-22 linked to lack of supervision. Found that medications were not given as prescribed to a resident, based on August 2022 logs and earlier findings.
10 Nov 2022
10 Nov 2022
Found that an unannounced POC visit occurred; deficiencies were cleared and the licensee complied with the POC terms. A clearance letter was provided and an exit interview was conducted.
12 Aug 2022
12 Aug 2022
Identified that a resident left without assistance on 8/7/2022, and that medical documents stated the resident cannot leave unassisted and were outdated, leading to a $500 civil penalty for a repeat violation within 12 months.
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§ 87705(c)(5)
05 Mar 2024
05 Mar 2024
Confirmed that an individual of immediate exclusion from all facilities was not currently working at the site. Noted that the exclusion letter was received and copies of the discharge letter for the excluded individual were taken; the individual has not been at the site since 03/07/2023.
14 Sept 2022
14 Sept 2022
Delivered amended documents related to a specific complaint and civil penalty materials to the site administrator, explained the purpose of the visit, and conducted an exit interview.
13 Sept 2022
13 Sept 2022
Identified Allegation 1 that medications and blood sugar checks for a resident lacked staff signatures indicating administration. Allegation 2 found no documentation of physician notification after high blood sugar readings, and Allegation 3 found linen shortages with beds lacking proper linen.
§ 87465(a)(4)
§ 87465(a)(1)
§ 87468.1(a)(2)
13 Sept 2022
13 Sept 2022
Identified discrepancies in a resident's medication records, including insulin administration timing with missing initials and a transcription error for Levetiracetam (800 mg 2 tabs twice daily) versus the order (500 mg 2 tabs twice daily) after reviewing logs and interviewing staff. Conducted an exit interview with the administrator.
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15 Nov 2023
15 Nov 2023
Found the complaint unfounded following interviews and record review, with no deficiencies noted.
09 May 2025
09 May 2025
Investigated an incident alleging that a resident was hospitalized for a foot issue, and later fell resulting in a broken femur; the resident moved to a skilled nursing facility on 04/22/2025.
§ 9058
01 Dec 2022
01 Dec 2022
Reviewed records and notes from two incidents on 11/13/22 and 11/15/22, during which the resident requested hospital care for pain and the responsible party and physician were informed. Found the resident being treated for impetigo, a pruritic rash, and pneumonia, currently quarantined, with new medications prescribed and the physician notified; no deficiencies observed.
20 Jun 2023
20 Jun 2023
Investigated three incidents that led to hospitalizations on 06/10/23 and 06/13/2023; reviewed medical records and discharge orders, noting updated needs and services plans and new medications being administered. One resident remained hospitalized awaiting biopsy; no deficiencies observed; exit interview with the administrator completed.
23 Jun 2023
23 Jun 2023
Delivered immediate-exclusion orders to the administrator and to staff; both left immediately, and no citations were issued.
24 Jun 2022
24 Jun 2022
Investigated found that on May 15, 2022, a resident with dementia left the care home without staff knowledge and was later taken to the hospital after reportedly falling while unsupervised. Determined that there was not enough evidence to prove that the responsible party was not notified, and no deficiencies were cited.
§ 87458(b)(4)
§ 87211
29 Sept 2022
29 Sept 2022
Identified concerns from a follow-up on AWOL and falls incident reports, including an unattended front desk and six residents with missing or outdated needs and service plans; no approved dementia program plan was found and an old dementia plan from another facility number was on file. One resident was no longer at the site.
§ 87463(c)
§ 87705(c)(5)
13 Aug 2024
13 Aug 2024
Found that the allegations that staff did not distribute residents' medications as prescribed and that staff did not ensure a resident's blood pressure was taken were unsubstantiated.
11 Dec 2024
11 Dec 2024
Investigated a case-management follow-up for an incident on 11/27/24 involving a leak in a colostomy bag that sent a resident to hospital and later discharged back with weekly home health. Notified all parties within the required time frame, colostomy care training was provided, and no deficiencies were observed.
11 Oct 2024
11 Oct 2024
Found that the allegations that staff denied a resident access to medical treatment, refused to assist with food, and used the resident’s money were unsubstantiated.
13 Dec 2022
13 Dec 2022
Found missing information in records, medication errors involving a resident, unsigned narcotics logs on multiple days, and outdated needs and services plans with missing medical assessments.
§
§ 87463(c)
§ 87705(c)(5)
04 Mar 2022
04 Mar 2022
Identified that a resident had a positive test result and that it was not reported to Licensing as required; a case management deficiency for failure to report as required was issued.
§ 87211(a)(2)
03 Aug 2022
03 Aug 2022
Found that four residents eloped multiple times between May 7 and July 15, 2022, and that licensing did not receive incident reports for several of these episodes. Deficiencies were cited and a $250 civil penalty was assessed.
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§
18 Mar 2022
18 Mar 2022
Found no deficiencies at this site; safety and care practices were in place, including locked medications, appropriate water temperatures, accessible bathrooms, adequate food supplies, and functioning fire safety devices.
21 Mar 2023
21 Mar 2023
Identified multiple medication errors for one resident and an outdated needs and services plan, and found incident reports were not sent to the department.
§
§ 87463(c)
§
§
§
26 Apr 2024
26 Apr 2024
Verified compliance with Title 22 requirements during an unannounced visit, noting hot water at 109°F, locked chemicals and medications, adequate seven-day non-perishable and two-day perishable food supplies, posted notices, and sanitary resident rooms with required furnishings.
13 Aug 2024
13 Aug 2024
Found that the resident did not reside at this site but at a skilled nursing location on the same property; no investigation was conducted; the allegation was unfounded.
11 Oct 2024
11 Oct 2024
Investigated the allegation of an unexplained fracture in a resident and found it to be unsubstantiated.
28 Sept 2020
28 Sept 2020
Conducted an unannounced case management visit, explained to the administrator that the purpose was to interview staff about three open complaints, interviewed four staff across shifts, found no deficiencies, and conducted an exit interview with the administrator.
17 May 2021
17 May 2021
Identified compliance with safety and infection-control measures, including hard-wired smoke alarms, serviced fire extinguishers, and a recent fire inspection; PPE supplies were adequate and required postings were visible. Noted that certain forms must be submitted within 30 days, and an exit interview was conducted.
17 Aug 2023
17 Aug 2023
Investigated a complaint alleging the administrator called police on a resident; the resident said police involvement occurred, while the administrator stated the maintenance team called police after trying a health and safety check with no answer. No deficiencies observed.
05 Apr 2024
05 Apr 2024
Reviewed maintenance logs, medication log sheets, AWOL procedures, incident reports, random resident medical assessments, training records, and observations; found updated service plans and signed MARs, daily signing of the medication room narcotics log from April through January, and a notable improvement in documentation.
02 Nov 2021
02 Nov 2021
Identified that a resident did not receive proper medication assistance, with one medication not ordered or filled and several days not documented on the MAR. Found that air conditioning was operable, temperatures were within the required range, the home was not malodorous, meals met nutritional needs, and there was insufficient evidence to prove staff did not respond to residents’ calls or failed to provide services listed in admission agreements.
§ 87465(c)(2)
10 Dec 2021
10 Dec 2021
Determined there was insufficient evidence to confirm that the resident did not receive proper meal assistance. Observations and interviews showed conflicting information among staff and administrators.
18 Nov 2021
18 Nov 2021
Found that residents contracted scabies and/or bed bugs, based on interviews and reviews of medical and incident records.
§ 87468.1(a)(2)
05 Jul 2023
05 Jul 2023
Identified Allegation 1 about staff pressuring for confidential information as unfounded and Allegation 2 about the yard in disrepair as unfounded; Allegations 3-5 substantiated.
22 Jan 2025
22 Jan 2025
Found that staff did not provide adequate assistance to residents and spoke to residents inappropriately, and that one staff member was terminated for inappropriate conduct. Found insufficient evidence to prove the medication mismanagement allegation; records showed the resident received all medications to be given unless they refused, from November 2024 through January 22, 2025.
§ 80072(a)(1)
§ 87464(f)(4)
23 Apr 2025
23 Apr 2025
Identified a resident who was hospitalized for a foot issue and later after a fall that caused a broken femur. Found that all incident reports were submitted on time, the resident moved to a skilled nursing facility, and the matter remains under investigation with no deficiencies observed.
§ 9058
21 Sept 2021
21 Sept 2021
Investigated incident-report follow-up and found that a positive infectious-disease result on 9/2/21 was not reported to the department, with local health department information indicating prior positives. The location maintained no recent positives since 8/16/21 and cited possible confusion with a nearby similarly named site, while the lab never notified the site of the positive result. No deficiencies were issued.
25 Sept 2023
25 Sept 2023
Identified a lock damaged by a resident that posed a fire hazard; no deficiencies observed.
19 Apr 2024
19 Apr 2024
Found staff fingerprint-cleared and associated, with current First Aid or CPR certifications on file, and ongoing training documented. Found twenty resident files, the COVID-19 Plan, and survey binder in order; due to time restraints, a return visit was scheduled, and an exit interview was conducted with staff.
02 Nov 2023
02 Nov 2023
Found that one resident pushed another to the ground in front of staff; staff intervened, separated them, and notified the involved parties, and police were contacted. The resident who pushed refused medical attention. No deficiencies found.
04 Oct 2023
04 Oct 2023
Reviewed records during an unannounced quarterly visit, including maintenance logs, medication log sheets, updated AWOL procedures, incident reports, random resident medical assessments, training records, and safety observations; found that service plans were updated and MARs and the medication room narcotics log were signed, and an exit interview was conducted.
04 Oct 2023
04 Oct 2023
Found Allegation 1 that staff stole items from a resident's room and Allegation 2 that staff did not maintain a comfortable temperature to be unsubstantiated.
11 Sept 2023
11 Sept 2023
Found that the allegation that staff illegally evicted a resident was unfounded. No deficiencies were found.
03 Mar 2025
03 Mar 2025
Found that the allegation that it is in disrepair was not supported by enough evidence. A heating unit broke and was replaced within one week after staff were notified.
07 May 2025
07 May 2025
Found staff were on site with the administrator arriving later; safety measures were in place, including 112 F hot water, locked chemicals/meds, and functioning detectors, with posted rights and policies. Found fifteen staff files fingerprint-cleared with current First Aid/CPR and ongoing training; twenty resident files and the COVID-19 plan were in order.
§ 9058
§ 87203
§ 87618(b)(3)
§ 87202(1)
06 Apr 2021
06 Apr 2021
Identified improper medication administration, including meds given to the wrong residents, missed doses, and medications left unattended on top of the med chart in a disposable cup. Found no on-duty intoxication among staff; training records exist but do not prove proper training, and some residents ran out of medications with no incident reports filed; claims about forged documents were not confirmed.
§ 87465(a)(5)
§ 87211(a)(2)
03 Dec 2021
03 Dec 2021
Found insufficient overnight staffing on the shift, with two staff for 54 residents, leading to a resident falling and requiring lift assistance. Identified no evidence that a resident's postural support was in disrepair.
§ 87415(a)(2)
05 Jan 2022
05 Jan 2022
Found bathroom laminate flooring separated near the toilet, with the floor lifted and not secured.
§ 87303
15 Nov 2023
15 Nov 2023
Identified that staff illegally evicted a resident by not notifying the responsible party of the 30-day eviction notice. Allegations that staff did not provide a safe environment and that staff interfered with the resident's mail were not supported by the evidence.
§ 87224(b)(3)
09 May 2025
09 May 2025
Found compliance with safety and care standards during an unannounced visit, with chemicals and medications secured, a 7-day supply of nonperishable food and 2 days of perishables, all resident medications accounted for with narcotics logs signed, and call buttons on both sides tested and found functioning; no bodies of water observed.
§ 9058
10 Jan 2024
10 Jan 2024
Found Allegation 1 through 5 unsubstantial.
21 Apr 2021
21 Apr 2021
Found that the mail-tampering allegation and the wound-bandages issue were unfounded, with prescriptions and bandages secured and provided per policy. Found that the allegation of leaving a resident unattended in the shower was unfounded, with staff supervising to manage behavior and maintain safety and dignity.
18 May 2022
18 May 2022
Found staffing shortages on the morning of May 2, 2022 that delayed the morning medication pass. Determined there was no scheduled time for the resident’s medication and no evidence meds were not given as ordered, and no deficiencies were cited.
§ 87411(a)
10 Jan 2024
10 Jan 2024
Identified missing signatures in the medication room narcotics log for 01/01/2024 and 01/07/2024, while noting overall improvement in documentation and updated MARs.
§ 87465
17 Jan 2024
17 Jan 2024
Found ongoing issues with narcotics logs lacking signatures and multiple complaints in 2023, while improvements were noted in resident service plans and MARs.
14 Dec 2020
14 Dec 2020
Identified that an updated COVID-positive resident list was requested with date of birth and symptoms, and that additional fields for current location and ethnicity were requested; mass testing was completed and results awaited.
Noted an allegation that incident reports for two ER visits on 12/4/2020 and 12/7/2020 were not submitted.
25 Feb 2021
25 Feb 2021
Found illegal eviction allegation unsubstantiated after reviewing interviews and records.
01 Oct 2020
01 Oct 2020
Found there was not enough evidence to prove that staff did not administer medications as prescribed by a physician. Found there was not enough evidence to prove that staff did not follow the resident’s pre-admission appraisal regarding body transfers or modified diet prescribed by a physician.
10 May 2022
10 May 2022
Found the urine odor and allegations about unauthorized residents leaving unfounded. Found the screen door and mini-blinds in good repair.
03 Nov 2020
03 Nov 2020
Identified ongoing problems with the phone line, with calls ringing busy and not transferring to voicemail during checks on several dates. Evidence supports the claim that the phone system did not function properly.
§ 87468.1(a)(9)
13 Apr 2022
13 Apr 2022
Determined that COVID-19 procedures were not followed and visitors were not screened, and that required Resident's Rights and Ombudsman posters were missing.
§ 87468.1(a)(2)
§ 87468(c)
11 Oct 2024
11 Oct 2024
Found a concern from a local fire department about residents being left unattended, with guidance provided on lifting residents. Noted room temperature at 75 degrees, sanitary resident rooms with required furniture, clean common areas, detectors in good repair, toxins and medications locked, an emergency food and water kit available, and exit interview completed.
27 Aug 2020
27 Aug 2020
Found that the temperature allegation did not have enough evidence, with thermostat readings ranging from 71 to 78 degrees and most residents reporting no temperature issues. Found that the insect allegation did not have enough evidence, as a few residents reported occasional insects and extermination services were performed; no deficiencies cited.
05 Oct 2020
05 Oct 2020
Investigated two specific allegations: that staff did not arrange medical care appropriate to the resident's conditions and needs, and that staff did not provide proper sleeping arrangements for the resident; both were unfounded.
06 Apr 2022
06 Apr 2022
Investigated a possible eviction of a resident and discussed options with the site administrator. Coordinated with the Ombudsman and the resident's family, reviewed eviction requirements, and no deficiencies were found.
10 Mar 2022
10 Mar 2022
Found medications were administered as prescribed and recorded, meals and menus met nutritional requirements, and there was not enough information to prove laundry service listed in admission agreements was not provided.
06 Apr 2021
06 Apr 2021
Identified medication management problems, including giving medications to the wrong resident, missed doses, incomplete MAR documentation, and meds left unsecured. Found delays in incontinence care, failure to follow discharge orders causing an ER return, gabapentin delays affecting dignity and independence, and ADL charting that may overstate assistance.
16 Feb 2022
16 Feb 2022
Determined that there was insufficient evidence to prove a leak or mold in the resident's room, with no leaks or mold observed. Found insufficient evidence to support the allegation that the resident's property was not safeguarded.
08 Jul 2024
08 Jul 2024
Confirmed a follow-up on a prior citation addressing care and supervision, medication logging, and maintenance and operation; found substantial compliance over the past 12 months.
27 Apr 2022
27 Apr 2022
Reviewed the proposed 30-day notice for a resident and licensing requirements. Confirmed that signage was posted after a recent citation; no deficiencies observed.
02 Jul 2024
02 Jul 2024
Found six incident reports past the 10-day deadline, and training logs were up to date.
18 Oct 2021
18 Oct 2021
Investigated findings identified that one resident left the care home unassisted despite a physician’s note restricting departures, and that another resident was assaulted by a roommate and treated in the hospital. A third resident was admitted directly from the hospital without a required pre-placement appraisal, with incomplete history documented prior to admission, and there were reports of unknown individuals soliciting funds from a resident.
§ 87458(b)(4)
§ 87457(a)(1)
02 Jul 2024
02 Jul 2024
Found that a random records review showed updated service plans and signed MARs, the medication room narcotics log was signed for all days from May through July, the latest incident reports were sent on 06/21/2024, and an exit interview was conducted.
13 Aug 2024
13 Aug 2024
Reviewed allegations regarding medication distribution and monitoring of residents' blood pressure, found no evidence to support the claims.
08 Jul 2024
08 Jul 2024
Confirmed compliance with care and supervision, medication logging and signing, and maintenance and operation requirements during the follow-up meeting. No further quarterly visits required at this time.
02 Jul 2024
02 Jul 2024
Reviewed maintenance, medication, AWOL procedures, incident reports, medical assessments, training records, and facility observation to ensure compliance and safety.
26 Apr 2024
26 Apr 2024
Inspection confirmed compliance with regulations including proper documentation, resident care, and facility cleanliness.
19 Apr 2024
19 Apr 2024
Inspection found all necessary safety equipment in compliance, staff files were reviewed, and resident files and documents were in order. Compliance with regulations was noted during the visit.
05 Apr 2024
05 Apr 2024
Reviewed maintenance logs, medication log sheets, AWOL procedures, incident reports, resident medical assessments, and training records to ensure compliance and safety. Significant improvement in documentation noted.
05 Mar 2024
05 Mar 2024
Confirmed that the excluded individual was not working at the facility as of the date of the inspection. No citations were issued.
17 Jan 2024
17 Jan 2024
Identified issues with medication management and documentation during recent inspections. Ongoing monitoring and training required for improvement.
10 Jan 2024
10 Jan 2024
Allegations of staff not meeting resident's hygiene, grooming, cleanliness, linens, and training needs were investigated and found to be unsubstantiated.
15 Nov 2023
15 Nov 2023
Confirmed an allegation regarding illegal eviction, while allegations related to staff behavior were not substantiated.
§ 87224(b)(3)
02 Nov 2023
02 Nov 2023
No deficiencies were observed during the inspection and the allegations of physical harm were unfounded.
04 Oct 2023
04 Oct 2023
Confirmed that allegations of staff stealing items from a resident's room and staff not providing a comfortable temperature for residents were unsubstantiated.
25 Sept 2023
25 Sept 2023
Conducted unannounced visit, no deficiencies observed. Advised administrator to change lock, which was damaged by resident. Follow-up with resident pending.
11 Sept 2023
11 Sept 2023
Investigated allegations of illegal eviction and personal rights violations; determined both allegations were unfounded with no evidence or reasonable basis.
17 Aug 2023
17 Aug 2023
Visited the facility to follow up on a resident complaint. No deficiencies were observed during the visit.
05 Jul 2023
05 Jul 2023
Conducted an unannounced visit to follow up on incidents where the facility lost power for several hours but found no deficiencies.
29 Jun 2023
29 Jun 2023
Identified deficiencies in care and supervision, medical care, personal rights, maintenance, and incontinence management during a recent inspection.
23 Jun 2023
23 Jun 2023
Confirmed immediate exclusion of staff and individual from facility following a case management visit. No citations issued during the visit.
20 Jun 2023
20 Jun 2023
Confirmed no deficiencies found during the follow-up visit after incidents involving residents being sent to the hospital.
08 Jun 2023
08 Jun 2023
Reviewed maintenance logs, medication log sheets, AWOL procedures, incident reports, resident assessments, training records, and facility observation to ensure compliance and safety. Identified multiple medication errors and unsigned medication room narcotics logs during night shift changes.
04 May 2023
04 May 2023
Identified deficiencies in resident care, sanitation, and safety during inspection visit.
§ 87303(i)(1)
§ 87303(e)(6)
§ 87303(a)(1)
§ 87307(d)(2)
§ 87465(a)(1)
§ 87202(a)(1)
§ 87307(a)(3)
§ 87307(a)(3)
04 Apr 2023
04 Apr 2023
Conducted an unannounced visit to follow up on incidents of residents leaving the facility without permission. No deficiencies were observed during the visit.
21 Mar 2023
21 Mar 2023
Identified multiple medication errors and an outdated needs and services plan during the visit. The facility also failed to send required incident reports to the department.
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§ 87463(c)
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§
13 Dec 2022
13 Dec 2022
Identified deficiencies and medication errors during the inspection.
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§ 87463(c)
§ 87705(c)(5)
01 Dec 2022
01 Dec 2022
Visited facility and reviewed medical records for a resident who requested hospital visits due to pain. No deficiencies found during the visit.
10 Nov 2022
10 Nov 2022
Deficiency cited in the inspection have been cleared and the facility complied with the terms of the plan of correction.
29 Sept 2022
29 Sept 2022
Confirmed deficiencies in the operation of the facility, including missing or outdated resident plans and the lack of an approved dementia program plan.
§ 87463(c)
§ 87705(c)(5)
14 Sept 2022
14 Sept 2022
Reviewed visit findings and provided amended documents. Delivered civil penalty and explained appeal rights to the administrator.
13 Sept 2022
13 Sept 2022
Confirmed repeated elopements of a resident from the facility without staff supervision, resulting in a civil penalty issued by the Department of Social Services.
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06 Sept 2022
06 Sept 2022
Identified deficiencies related to resident safety and operational issues during the visit. A civil penalty was assessed for a maintenance violation.
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29 Aug 2022
29 Aug 2022
Identified multiple areas of concern during the meeting and issued citations for violations related to reporting, staffing, training, maintenance, and resident care. Ongoing monitoring and follow-up required to ensure compliance with regulations.
12 Aug 2022
12 Aug 2022
Reviewed the incident report related to a resident elopement and identified deficiencies that led to a civil penalty being assessed.
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§ 87705(c)(5)
03 Aug 2022
03 Aug 2022
Confirmed multiple elopement episodes, resulting in a civil penalty assessment for repeat violations.
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29 Jul 2022
29 Jul 2022
Confirmed that a 30-day eviction notice was issued to a resident but not sent to the licensing department as required by regulations.
§ 87224(f)
15 Jul 2022
15 Jul 2022
Determined improper notice given for resident eviction. Citations issued under Title 22, Division 6.
§ 87224(a)(1)
24 Jun 2022
24 Jun 2022
Found insufficient evidence of a staffing deficiency on a specific day. Identified a delay in medication pass due to lack of staff.
§ 87411(a)
18 May 2022
18 May 2022
Confirmed shortage of staff on a specific date, resulting in a delay in medication administration.
§ 87411(a)
10 May 2022
10 May 2022
Found no evidence of foul odors or unauthorized residents leaving without permission. The screen door and mini-blinds were in good repair.
27 Apr 2022
27 Apr 2022
Confirmed no deficiencies during the visit. Reviewed proposed notice for 30-day resident discharge and verified proper signage.
13 Apr 2022
13 Apr 2022
Allegations of not following COVID-19 and visitor screening procedures were substantiated. Deficiencies were cited per regulations.
§ 87468(c)
§ 87468.1(a)(2)
06 Apr 2022
06 Apr 2022
No deficiencies were cited during the visit, and discussions were held regarding a potential resident eviction.
18 Mar 2022
18 Mar 2022
Confirmed no deficiencies during the inspection of the facility.
10 Mar 2022
10 Mar 2022
Confirmed that medications were administered as prescribed and meals met nutritional requirements, but there was insufficient evidence to support lack of provided services listed.
04 Mar 2022
04 Mar 2022
Found a deficiency for failure to report a positive COVID-19 case as required by the Department.
§ 87211(a)(2)
16 Feb 2022
16 Feb 2022
Determined insufficient evidence to prove allegations of water leaks, mold, or mishandling of a resident's property; no leaks or mold observed, and property inventory was present in the resident's file.
05 Jan 2022
05 Jan 2022
Observed laminate flooring separating near toilet area, not secured. Deficiencies cited under Title 22, Division 6, Chapter 8.
§ 87303
10 Dec 2021
10 Dec 2021
Investigated the allegation that a resident did not receive proper meal assistance and found inadequate evidence to support the claim, resulting in it being unsubstantiated.
03 Dec 2021
03 Dec 2021
Found insufficient staffing during overnight shift and unsubstantiated claim of disrepair.
§ 87415(a)(2)
18 Nov 2021
18 Nov 2021
Confirmed allegations of residents contracting scabies and/or bed bugs. Deficiencies cited as per regulations.
§ 87468.1(a)(2)
02 Nov 2021
02 Nov 2021
Confirmed that a resident was not properly assisted with medication and found deficiencies in medication administration records. Identified no issues with air conditioning, odors, or meal quality.
§ 87465(c)(2)
18 Oct 2021
18 Oct 2021
Confirmed allegations of a resident leaving unassisted and being assaulted by another resident, while another resident was deceived into providing money to unknown individuals.
§ 87457(a)(1)
§ 87458(b)(4)
21 Sept 2021
21 Sept 2021
Confirmed positive case of an infectious disease in the facility, but communication issues with the lab led to a delay in notification.
17 May 2021
17 May 2021
Inspection identified compliance with safety and operational regulations, including proper documentation and emergency preparedness.
21 Apr 2021
21 Apr 2021
Confirmed unfounded allegations of staff tampering with resident mail and not providing necessary wound bandages. Additionally, determined staff did not leave resident unattended in the shower despite inappropriate behavior.
06 Apr 2021
06 Apr 2021
Found failure to administer medications correctly and run out of medication for residents. Staff not seen providing care while intoxicated. Staff training compliance unclear.Forgery of documents not proven.
§ 87465(a)(5)
§ 87211(a)(2)
25 Feb 2021
25 Feb 2021
Confirmed complaint of illegal eviction unsubstantiated; facility working with resident on unpaid rent and behavior challenges.
14 Dec 2020
14 Dec 2020
Identified deficiencies in reporting COVID-positive residents and incidents to the Department were addressed during a meeting with facility staff.
03 Nov 2020
03 Nov 2020
Confirmed that the phone line system was malfunctioning, leading to an inability to reach the facility by phone.
§ 87468.1(a)(9)
05 Oct 2020
05 Oct 2020
Interviews, records review, and observations showed that allegations of staff not assisting in arranging appropriate medical care and staff not providing proper sleeping arrangements for a resident were not substantiated.
01 Oct 2020
01 Oct 2020
Confirmed that staff administered medications as prescribed by the physician and followed the resident's pre-admission appraisal for body transfers and diet modifications.
28 Sept 2020
28 Sept 2020
Interviews with staff conducted and no deficiencies were found during the visit.
27 Aug 2020
27 Aug 2020
Confirmed that the facility was not operating at uncomfortable temperatures or harboring insects.
16 Jun 2020
16 Jun 2020
Investigated four allegations: residents falling due to lack of supervision, medications not properly stored or administered, insufficient staffing to meet residents' needs, and unqualified or improperly trained staff. Determined that none of the allegations could be substantiated due to insufficient evidence.
20 Apr 2020
20 Apr 2020
Confirmed complaint of unauthorized family member handling confidential records at the facility.
§ 87405(d)(2)
§ 87355(e)(1)
11 Mar 2020
11 Mar 2020
Confirmed no deficiencies found during the inspection and all requirements were met.
27 Jan 2020
27 Jan 2020
Visited facility unannounced for a case management visit in response to POC correction amend and print out. Conducted exit interview and provided 809 report and cleared POC report to the facility.
23 Jan 2020
23 Jan 2020
Confirmed previous issues were resolved during a follow-up visit, and deficiencies observed in December had been corrected.
12 Dec 2019
12 Dec 2019
Identified multiple deficiencies in the facility, including issues with light fixtures, ceilings, walls, vents, and appliances.
§ 87303(a)
09 Dec 2019
09 Dec 2019
Identified deficiencies in personnel records and fingerprint clearance for the facility's new Administrator.
§ 1569.17(b)
§ 1569.17(b)
21 Nov 2019
21 Nov 2019
Conducted case management visit, no deficiencies identified. New Executive Director/Administrator to start on 12/2/19.
