I love how the staff treated my loved one like family - compassionate, attentive, great memory-care focus, home-like atmosphere, good meals, activities, and clear communication made our transition smooth. That said, I noticed chronic understaffing and some serious cleanliness and safety issues (cockroaches reported, occasional urine on the floor, overcrowded rooms and rough residents), so I'd recommend touring in person, asking about current staffing/management, and watching how they handle those concerns before deciding.
Pacifica Senior Living Modesto offers a warm, home-like atmosphere with cozy private and shared studio apartments in carefully designed neighborhoods, and you'll find that the rooms feel comfortable, plus common areas include indoor and outdoor spaces like walking paths and patios, so residents can spend time where they're most comfortable. The staff remains onsite 24 hours a day to help with daily activities, and trained caregivers know how to support those with Alzheimer's, dementia, or more difficult behaviors, even using bracelets and alarms for those who might wander or need extra supervision, and there's a nurse available, along with medical staff who can check on health needs as they change. Legacies Memory Care is the community's dedicated memory care program focused just on residents with memory loss, with a secure building designed specifically so residents who need more support remain safe, and here the community offers services ranging from Memory Care, Respite and Short-Term Care, Assisted Living, even Home Health and Hospice. Residents get personalized care plans made after a full assessment of health and lifestyle, and staff can help with all kinds of needs, whether it's getting out of bed (including with mechanical lifts or with two-person help), taking medicine, moving around safely, or help with everyday tasks.
Meals are prepared by a professional chef and include vegetarian, low-sodium, and sugar-free options for different needs, with family-style dining for connection and comfort. The activity director offers plenty of programs for the body and mind like stretching, Tai Chi, brain fitness, arts and crafts, cooking, gardening, and even karaoke and music, while the Coro Health music program and pet therapy focus on holistic well-being. Residents can join in on faith-based activities, social gatherings, trivia, outings, and intergenerational programs, so there's something for most everyone, whether indoors in the activity center, relaxing outside, or enjoying movie and game nights. Housekeeping and laundry services are provided, transportation is arranged for errands and appointments, and there's an in-house beauty salon and wheelchair accessible showers for convenience and comfort. Residents can also keep a dog or cat if they wish, since pets are welcome. The community supports residents with a focus on dignity and respect, treating everyone as an extension of family, and staff often use redirection to make things easier for those who have memory trouble.
Pacifica Senior Living Modesto has 73 memory care suites, and the different living arrangements and levels of care let many people remain as their needs increase, so those with early memory problems through those needing more intense care can often stay in one place. The property is secure for safety, but it's also designed to feel relaxed and welcoming, with plenty of gathering spaces to encourage a sense of community. With full-time compassionate assistance, brain fitness and social activities, transportation, meals, medical staff onsite, and a range of senior living services, the community tries to offer a practical, supportive environment that's comfortable yet secure for older adults who need help or supervision, especially those dealing with memory loss or dementia.
People often ask...
Pacifica Senior Living Modesto offers competitive pricing, with rates starting at a cost of $4,628 per month.
Pacifica Senior Living Modesto offers assisted living.
There are 14 photos of Pacifica Senior Living Modesto on Mirador.
The full address for this community is 2325 St Pauls Way, Modesto, CA, 95355.
Yes, Pacifica Senior Living Modesto 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
135
Inspections
46
Type A Citations
23
Type B Citations
6
Years of reports
06 Jun 2025
06 Jun 2025
Found no violations cited during this visit. Discussed civil penalties under the stipulation, noting payments were due within 90 days and only a partial payment had been received, with remaining invoices to be provided.
§ 9058
26 Oct 2022
26 Oct 2022
Determined that a resident did not receive timely medical attention after unwitnessed falls, resulting in serious bodily injuries and extended pain, and that a civil penalty totaling $9,500 was issued after an earlier $500 penalty.
26 Oct 2022
26 Oct 2022
Investigated the failure to provide timely medical attention after an unwitnessed fall resulting in a rib fracture, leading to a civil penalty due to the resident experiencing prolonged pain and serious injuries while under care.
01 Sept 2022
01 Sept 2022
Found health and safety satisfactory, with residents clean and in good health, renovations underway, adequate food supply, sanitary conditions, and 14 staff on duty; no deficiencies cited.
01 Sept 2022
01 Sept 2022
Reviewed the health and safety conditions during an unannounced visit, noting residents appeared healthy and well-groomed, food supplies were adequate, and no deficiencies were observed.
11 Aug 2022
11 Aug 2022
Found health and safety measures satisfactory, with a sanitary setting, adequate food supply, and no deficiencies observed during the tour.
11 Aug 2022
11 Aug 2022
Found the facility to be safe, sanitary, with adequate food supplies and no observed deficiencies during the visit.
28 Jul 2022
28 Jul 2022
Found an unannounced health and safety check showed residents and staff present, the site was sanitary, and no deficiencies were observed. Found a resident-related incident led to moving the resident to another area within the site, with the resident expected to move out by month’s end, and several documents were requested for review.
28 Jul 2022
28 Jul 2022
Reviewed the safety and health conditions during an unannounced visit; observed the environment was sanitary, residents appeared safe, and no deficiencies were found related to staffing, food, or physical plant.
14 Jul 2022
14 Jul 2022
Conducted a case management visit, met with staff to explain its purpose, returned documents, and conducted an exit interview.
14 Jul 2022
14 Jul 2022
Investigated a case management visit at the facility with unannounced arrival, where documents were reviewed and an exit interview was conducted.
11 Jul 2022
11 Jul 2022
Found an unannounced health and safety visit, during which documents were reviewed, the kitchen was inspected, and residents appeared clean. Noted PPE was available, one Covid-19 case identified, Norovirus cleared, unusual incident reports reviewed, documents for residents provided, and an exit interview conducted.
11 Jul 2022
11 Jul 2022
Reviewed the facility's safety measures, including food supply, infection control, and resident care, and collected relevant incident documentation during an unannounced visit.
27 Jun 2022
27 Jun 2022
Found no deficiencies after an unannounced health and safety check conducted on 06/27/2022 at 10:30 AM.
Observed residents and 13 staff onsite, with the premises sanitary and no safety concerns identified.
27 Jun 2022
27 Jun 2022
Confirmed that the facility was safe and clean during a health and safety review, with no deficiencies observed and residents properly cared for.
08 Jun 2022
08 Jun 2022
Reviewed the stipulation and next steps with management and found that no violations were cited during the visit.
08 Jun 2022
08 Jun 2022
Reviewed a stipulation related to compliance and licensing terms, with representatives agreeing to abide by its conditions; no violations were cited during the visit.
01 Jun 2022
01 Jun 2022
Identified COVID-19 positive cases and completed a health and safety check after an unannounced visit, including a phone interview and a virtual tour. Found a 30-day PPE supply, an isolation room with a PPE station outside, a lid-equipped trash can, ongoing response testing, and limited resident visitation; no citations were issued.
01 Jun 2022
01 Jun 2022
Confirmed there were COVID-19 positive cases, with responses including testing, limited visitation, and the use of an isolation room equipped with PPE. No citations were issued during the visit.
19 May 2022
19 May 2022
Found the allegations supported by evidence: no sound financial plan, ongoing net losses with inadequate cash reserves and income insufficient to cover operating costs, failure to provide requested documents, and lack of general supervision over the licensed operation.
§ 87205(a)
17 May 2022
17 May 2022
Found specific allegations of financial concerns, including a lack of a sound financial plan, ongoing net losses with inadequate cash reserves, and income insufficient to cover operating costs. Also found that not all requested documents were provided, financial records were inadequate, and the licensee did not exercise general supervision over its affairs.
19 May 2022
19 May 2022
Investigated financial issues revealed that the facility operated at a net loss, lacked a compliant financial plan, and did not maintain adequate records, confirming concerns about financial stability and oversight.
§ 87205(a)
17 May 2022
17 May 2022
Found that the facility lacked a sound financial plan, operated at a net loss without sufficient cash reserves, failed to generate enough income to cover costs, and did not maintain adequate financial records.
23 Mar 2022
23 Mar 2022
Identified an unannounced case-management visit to follow up on reported scabies cases; infection control remained in place, residents were being treated, screenings for scabies continued, and the line list was emailed daily to the licensing department. Conducted an exit interview; no deficiencies found.
23 Mar 2022
23 Mar 2022
Investigated the allegation that a resident was not provided medical attention in a timely manner after multiple falls, resulting in serious injuries and pain. Found that hospital discharge instructions and fall-prevention guidance were not followed, and that timely emergency or medical care was not sought when the resident reported severe pain.
§ 87465(j)
23 Mar 2022
23 Mar 2022
Determined that resident did not receive timely medical attention after multiple falls and injuries, including a rib fracture, despite hospital discharge instructions emphasizing the need for prompt care if conditions worsened; this led to serious bodily injury and a civil penalty assessment.
§ 87465(j)
02 Mar 2022
02 Mar 2022
Found that staff did not provide emergency medical care for a resident exhibiting signs of distress after multiple falls and arm injuries, delaying hospital evaluation until late September and October. Also found failure to notify the resident's responsible party of changes in condition and to follow reporting policies.
11 Mar 2022
11 Mar 2022
Investigated two new scabies cases during an unannounced visit; observed one resident with an ongoing rash and reviewed another resident’s medical file confirming a persistent rash. Requested an updated scabies line list for the two residents and that all residents in Central Valley be screened with documentation emailed by the stated deadline.
11 Mar 2022
11 Mar 2022
Identified that a resident at a senior care home lacked a fall prevention plan and inflatable lap buddy documentation in their service plan, despite being noted as a fall risk. Found that there were no post-fall tracking forms and that fall-management procedures were not followed, with several falls documented.
§ 87463(a)(3)
11 Mar 2022
11 Mar 2022
Identified that a resident at risk of falling lacked an appropriate fall prevention plan and related documentation, and observed that the facility did not follow proper fall management procedures after multiple falls occurred.
10 Mar 2022
10 Mar 2022
Found no deficiencies cited after a virtual discussion about new rash/scabies cases, infection control, PPE use, line lists, and staff/resident symptom monitoring, with an exit interview conducted.
10 Mar 2022
10 Mar 2022
Confirmed ongoing efforts to monitor and control rash and scabies cases through testing, infection control measures, and daily updates, with reporting to health authorities, without citing any deficiencies during the inspection.
02 Mar 2022
02 Mar 2022
Investigated and found that one resident had nine falls between September and November 2021, and that one-on-one staffing and safety equipment were not provided because the family could not pay. Identified issues safeguarding personal property, including an incomplete move-in inventory that did not document items later claimed missing and unclear details about what was taken, and confirmed the resident was diagnosed with head lice in October 2021 and treated.
§ 87464(d)
03 Mar 2022
03 Mar 2022
Identified ongoing concerns about compliance with regulations and resident rights based on prior actions, and no deficiencies cited during this visit; an exit interview was conducted via Microsoft Teams.
03 Mar 2022
03 Mar 2022
Found ongoing non-compliance with health and safety regulations despite prior efforts, with multiple citations issued and continued concerns about resident care and facility management.
02 Mar 2022
02 Mar 2022
Found four specific allegations—resident injury, an incontinent resident not kept clean and dry, a dining area that was unsanitary, and a lack of comfortable living accommodations—had insufficient evidence to prove or disprove. Noted inconsistent information and incomplete records that prevented a definitive determination on these items.
02 Mar 2022
02 Mar 2022
Determined that the facility failed to provide emergency medical care for resident after repeated falls and injuries, including a fracture, and did not follow proper reporting procedures, resulting in civil penalties.
§ 87211(a)(1)
§ 87465(a)(g)
§ 87466
25 Feb 2022
25 Feb 2022
Found that all smoke detectors and the fire alarm system were functioning, and the communication panel now properly signals the fire department. Fire department released the fire watch and accepted the newly installed devices; no deficiencies were found today; an exit interview was conducted.
25 Feb 2022
25 Feb 2022
Confirmed the fire alarm system was tested and is now functioning properly, allowing the fire watch to be released.
01 Feb 2022
01 Feb 2022
Identified deficiencies included a fire alarm system that did not function properly, failing to alert residents, staff, and visitors or notify the local fire department, and quarterly fire drills not conducted. An immediate civil penalty of $500 was assessed.
01 Feb 2022
01 Feb 2022
Found the allegation that a small electrical fire occurred due to a faulty wire in a resident's room and that it was not reported to licensing or the fire department.
01 Feb 2022
01 Feb 2022
Identified that the fire alarm system was not functioning properly and that fire drills were not being conducted quarterly, resulting in a citation and civil penalty for violations of safety regulations.
05 Jan 2022
05 Jan 2022
Identified concerns about a rash/scabies outbreak and Covid-19 in the care setting, with discussions on monitoring, reporting, and infection prevention measures.
05 Jan 2022
05 Jan 2022
Reviewed a virtual meeting discussing ongoing monitoring and infection control measures related to a rash/scabies outbreak and COVID-19, including line listing, screening, and testing protocols.
27 Dec 2021
27 Dec 2021
Found that all deficiencies from a prior complaint were cleared during an unannounced visit after reviewing required documents.
27 Dec 2021
27 Dec 2021
Investigated allegations of a scabies outbreak and inadequate infection-control response; determined a scabies outbreak occurred among residents and containment was not timely.
Determined allegations of insufficient supervision and faulty fall-prevention planning leading to multiple falls and injuries; found gaps in the needs and service plan and supervision, with civil penalties pending.
§ 87466
§ 87468.2(a)(4)
§ 87464(f)(2)
§ 87468.1(a)(2)
§ 1569.312(a)(e)
27 Dec 2021
27 Dec 2021
Determined that the facility failed to recognize and timely address a widespread outbreak of scabies among residents, and also inadequately supervised residents who experienced multiple falls, resulting in injuries and related safety concerns.
15 Dec 2021
15 Dec 2021
Investigated the allegation that staff did not ensure the resident was fed; found the resident was fed, with a diet accommodated and no meal denial documented. Identified a fall during movement between areas, a resident pushed another causing injury, and staffing shortages that led to insufficient supervision and delays in assistance.
§ 87463(d)
§ 87705(c)(4)
§ 87705(b)(2)
15 Dec 2021
15 Dec 2021
Confirmed that staff ensured the resident was fed and offered alternatives, while also finding that the resident fell and was pushed by another resident. Identified staffing levels as inadequate to provide proper supervision and care.
09 Dec 2021
09 Dec 2021
Found that a resident did not elope, with supervision maintained and the resident assisted back. Found that falls among residents were linked to staffing shortages, with unwitnessed falls occurring, and two positive COVID-19 cases were not reported to the licensing agency or local health department.
09 Dec 2021
09 Dec 2021
Found no pests or mold. Found staffing shortages that forced caregivers to monitor two communities, causing delays in assistance and falls among residents; found no problems with records or medication administration.
§ 87411(a)
§ 87705(c)(4)
09 Dec 2021
09 Dec 2021
Identified an allegation that a resident went AWOL on 11/21/2021; noted inconsistencies in diagnosis and medical condition documentation and that updated physician information was not obtained. Observed alarms and cameras functioning during the visit; deficiencies cited on 12/09/2021.
09 Dec 2021
09 Dec 2021
Investigated an incident involving a resident who went AWOL in 2021, reviewed medical records and assessment procedures, and found that facility alarms and security systems were functioning properly. Noted deficiencies were cited regarding resident assessment documentation.
16 Nov 2021
16 Nov 2021
Determined neglect and lack of supervision led to a resident’s nine falls and a pressure injury, resulting in serious bodily injury and a civil penalty of ten thousand dollars.
16 Nov 2021
16 Nov 2021
Investigated serious neglect and lack of supervision that led to a resident developing multiple falls and a pressure injury, resulting in a civil penalty for causing serious bodily injury.
13 Aug 2021
13 Aug 2021
Found that two residents with dementia were not adequately supervised, allowing a sexual assault to occur. Noted that local law enforcement reporting requirements were not followed.
08 Nov 2021
08 Nov 2021
Found inadequate supervision on multiple shifts at the site, resulting in several unwitnessed falls, with some requiring medical attention. Found no evidence to support the refund issue after a resident's death, no failure to release medical records to a family member on request, and no failure to provide meals to residents.
§ 1569.652(c)
§ 87705(c)(4)
08 Nov 2021
08 Nov 2021
Investigated allegations related to medication disposal, health screenings for new hires, missing medications, laundry service, and staffing adequacy. Findings showed expired medications were disposed without documentation; all newly hired staff completed health screenings; medications were accounted for; laundry service was disrupted due to a broken washer and limited housekeeping; and staffing gaps contributed to care and supervision challenges, including unwitnessed falls.
§ 87411(a)
§ 87705(c)(4)
§ 87465(i)
08 Nov 2021
08 Nov 2021
Identified an incident of resident abuse by a staff member, where the staff member pushed a resident and held the resident's wrists; two staff witnessed the event, the resident was found without clothing from the waist down, and bruising was noted on both wrists with an injury to the left cheek. Deficiencies were cited under state regulations, and an exit interview with the administrator was conducted.
§
08 Nov 2021
08 Nov 2021
Investigated allegations showed that residents’ refunds were delayed after death, medical records were only released to the responsible party, residents received meals as documented, and staff inadequate supervision led to multiple unwitnessed falls.
§ 87211(a)(1)
§ 87466
§ 87465(a)(g)
12 Oct 2021
12 Oct 2021
Determined that serious bodily injury resulted from lack of care and supervision, tied to repeated resident falls and a resident leaving unsupervised through a secured door, leading to a civil penalty of $10,000.
12 Oct 2021
12 Oct 2021
Identified lack of timely medical attention after an unwitnessed fall and failure to observe and report health changes promptly, resulting in a serious bodily injury requiring hospitalization and surgery. Issued a civil penalty of $10,000.
12 Oct 2021
12 Oct 2021
Determined that the facility failed to provide timely medical care after a resident's fall and injuries, resulting in a serious bodily injury and a civil penalty of $10,000.
11 Oct 2021
11 Oct 2021
Confirmed receipt of the accusation and reviewed required notice procedures, including informing residents and the Local Ombudsman, posting notices, and sending copies to the licensing agency; advised that civil penalties could apply if requirements aren’t followed and to contact the Legal Division about the Notice of Defense. No deficiencies were cited during this visit.
11 Oct 2021
11 Oct 2021
Reviewed compliance with Health and Safety Code requirements regarding timely resident notifications and posting notices following an incident, and confirmed there were no safety hazards or deficiencies noted during the visit.
16 Aug 2021
16 Aug 2021
Identified a resident-on-resident sexual assault and inadequate supervision and failure to report to authorities. Issued a civil penalty of $10,000.
16 Aug 2021
16 Aug 2021
Confirmed a resident was sexually assaulted by another resident due to inadequate supervision and failure to follow mandated reporting requirements, resulting in a civil penalty for serious bodily injury.
§
§
13 Aug 2021
13 Aug 2021
Identified an allegation that there were not enough direct care staff to support residents' safety and health care needs, and that PPE was not stocked for 30 days. Observed PPE and hygiene supplies in secured areas and noted supervision gaps, including a resident waiting to be fed and another resident triggering door alarms.
§ 87705(c)(4)
13 Aug 2021
13 Aug 2021
Found the allegation that residents did not receive proper first aid and wound care not proven. Identified evidence supporting the allegation of inadequate laundry service, including a non-working dryer that was replaced.
13 Aug 2021
13 Aug 2021
Identified that residents received proper first aid and wound care for pressure injuries, but found that laundry services were inadequate due to a non-functioning dryer that had been replaced.
§ 87211(a)(3)
09 Aug 2021
09 Aug 2021
Found egress notification lighting functioning. Noted discussions with staff and the executive director indicating adequate staffing and availability of a medtech and support staff to assist residents as needed.
09 Aug 2021
09 Aug 2021
Found no deficiencies after an unannounced annual infection-control visit; 39 staff and 56 residents were vaccinated, with 4 residents choosing not to be vaccinated for personal reasons.
09 Aug 2021
09 Aug 2021
Reviewed a recent inspection, noting that safety systems were functioning properly and staff were adequately scheduled to meet residents' needs, including support staff and communication devices.
§ 87463
03 Aug 2021
03 Aug 2021
Found several health and safety concerns, including dirty rooms and bathrooms, broken blinds and screens, and expired milk with freezer-burned foods; improper chemical storage and an undated container were also noted. Observed egress doors and alarms not functioning, nonworking keypad, and delays in resident care, such as a resident waiting long to be fed and another in a soiled condition.
03 Aug 2021
03 Aug 2021
Identified a case management visit to amend a complaint-related citation. Found the related issue downgraded to a less serious category after appeal findings, and an exit interview was conducted.
03 Aug 2021
03 Aug 2021
Identified multiple regulatory violations, including unsanitary conditions, expired and spoiled food, broken blinds and screens, and malfunctioning egress doors, during an unannounced safety and infection control inspection.
25 Jun 2021
25 Jun 2021
Identified that residents were not weighed monthly per policy; several months in 2020 and January 2021 lacked weights due to COVID outbreaks and staff illness, and no designation or plan existed to ensure residents' needs were met and the program was followed.
24 Jun 2021
24 Jun 2021
Found that no exception was requested for a resident to sleep in a recliner. Beds were available, yet the resident slept in a recliner.
§ 87824(b)(2)
25 Jun 2021
25 Jun 2021
Found that the allegation of failing to report incidents to the responsible party was unfounded, since incidents were reported to the responsible parties.
25 Jun 2021
25 Jun 2021
Found no evidence to support the allegations that calls from families were not answered promptly and that furnishings were not comfortable.
25 Jun 2021
25 Jun 2021
Found the allegations that a resident was severely neglected and that incidents were not reported to the resident's responsible party to be unfounded.
25 Jun 2021
25 Jun 2021
Reviewed communication logs and conducted a physical inspection, finding no evidence that calls from families were not responded to promptly or that residents were not provided with comfortable furnishings.
24 Jun 2021
24 Jun 2021
Investigated the allegation that the facility did not request an exception for a resident to sleep in a recliner; found that the resident was permitted to do so without an approved exception and that beds were available but removed at the resident’s request.
11 Jun 2021
11 Jun 2021
Found that complaint findings and citations not delivered at the 05/27/2021 visit were later provided, and that those items were not added to the 05/27/2021 documentation. Found that the related allegations were reviewed with the involved person during this visit, that appeals rights were explained, and that an exit interview was conducted.
§ 87465(a)(i)
§ 87465(a)(5)
11 Jun 2021
11 Jun 2021
Found no evidence that residents did not receive their medications due to lack of staff; MARs showed morphine administered as prescribed and on time, and staff reported no concerns about medication administration.
11 Jun 2021
11 Jun 2021
Reviewed complaint findings and citations related to an incident on 06/11/2021, confirming that some citations were mistakenly omitted from earlier documentation. Provided explanation of the deficiencies and conducted an exit interview.
§ 87211(a)(2)
§ 87705(c)(4)
10 Jun 2021
10 Jun 2021
Found that the AWOL and elopement allegation involving a resident did not meet the preponderance of evidence to prove its occurrence.
10 Jun 2021
10 Jun 2021
Determined that the allegation of an AWOL was unsubstantiated based on interviews and records, despite indications that the incident may have occurred.
27 May 2021
27 May 2021
Investigated allegations that the power of attorney differed from the administrator and that the resident did not receive adequate care; reviewed chart notes showing multiple falls and hospice notifications. Found there is not a preponderance of evidence to prove violations occurred.
27 May 2021
27 May 2021
Identified that a resident did not receive daily Ensure Boost Plus 1 as ordered and that October through December 2020 MARs were left blank, despite staff being told to monitor administration.
27 May 2021
27 May 2021
Found that staff did not ensure residents received their prescribed Ensure Boost Plus 1 as ordered, despite documentation indicating it was available, leading to a violation of medication administration standards.
20 May 2021
20 May 2021
Identified an incident on 4/16/2021 in which a resident left without permission despite a physician's order restricting unsupervised exits. Noted alarms and a motion camera were functioning at key exit areas; deficiencies were cited and penalties assessed.
20 May 2021
20 May 2021
Reviewed the incident involving a resident leaving unassisted despite medical restrictions, and observed all safety alarms functioning properly; deficiencies were cited with civil penalties assessed.
14 May 2021
14 May 2021
Investigated the complaint alleging concerns about care; conducted interviews and a site tour, and requested documents; due to insufficient information, returned later to continue and complete the review.
14 May 2021
14 May 2021
Conducted interviews and toured the facility related to a complaint investigation, collecting documents; additional follow-up will be scheduled to complete the investigation.
09 Mar 2021
09 Mar 2021
Found no safety deficiencies after a health and safety check and follow-up via video call; exit interview completed.
29 Apr 2021
29 Apr 2021
Found that a resident had multiple falls starting in January 2020, resulting in a head injury and other injuries. Identified an allegation of inadequate care and supervision related to those falls, and that documentation and follow-up after falls were not completed.
§ 87466
§ 87463(a)(3)
29 Apr 2021
29 Apr 2021
Investigated falls and related injuries that occurred to a resident, finding that the facility did not properly implement fall prevention and post-fall procedures despite the resident being at high risk. Additionally, there was no evidence supporting the allegation that the resident's wedding ring was lost or stolen.
§ 87705
§ 87303
§ 87555
§ 1569.699
14 Apr 2021
14 Apr 2021
Found that inadequate staffing led to unsupervised resident care and a resident leaving through a secured door, resulting in a serious injury. Found the allegation of a resident-on-resident assault could not be proven due to a lack of witnesses and inconsistent statements.
§ 87464(f)(1)
§ 87405(h)(5)
14 Apr 2021
14 Apr 2021
Investigated allegations that staff failed to provide timely medical care after a resident fall, resulting in serious injuries including a hip fracture requiring surgery. Also found that the responsible party was not notified immediately as required by policy, and civil penalties are pending with a repeat violation noted within the last 12 months.
§ 87465
§ 87466
14 Apr 2021
14 Apr 2021
Determined that insufficient staffing led to a resident’s fall and serious injury, and confirmed that residents could leave secured doors unsupervised, contributing to the incident. Additionally, found no evidence to support that a resident was assaulted by another resident.
§ 87303(a)
13 Apr 2021
13 Apr 2021
Determined there was not a preponderance of evidence to prove or disprove the death-related allegation. Interviews and records supported that residents received appropriate care and medication management.
13 Apr 2021
13 Apr 2021
Identified a discrepancy in a resident's Lorazepam medication record after switching from pill to liquid, with inconsistent balance entries indicating the record was not properly maintained. Conducted a case management call to follow up on a learned deficiency from a prior complaint investigation.
13 Apr 2021
13 Apr 2021
Investigated the allegation of questionable death and found no evidence to support it, with residents and staff reporting satisfactory care and no issues with medication or supplies.
09 Mar 2021
09 Mar 2021
Reviewed a health and safety check via FaceTime, confirming the overall safety of the facility’s food, environment, and staffing with no issues observed. Conducted an exit interview at the conclusion.
29 Dec 2020
29 Dec 2020
Identified pest control problems with cockroach presence in resident bedrooms, bathrooms, and the kitchen. Staff reported they were never informed that an employee stole medication.
29 Dec 2020
29 Dec 2020
Found the following allegations were reviewed: residents not receiving care and supervision due to insufficient staff; egress door alarms not working; residents not allowed to go to the back patio because sidewalks are uneven; new employee training not conducted; and residents not taking medications and becoming aggressive. However, there was not a preponderance of evidence to prove these allegations occurred.
§ 87705(4)
§ 87307(5)
28 Dec 2020
28 Dec 2020
Found that rent increases were not provided with the required 60-day written notice, that the required resident personal property inventory was not completed, and that several prescribed medications were not administered as directed on multiple days; a civil penalty for a repeat violation within 12 months was noted.
28 Dec 2020
28 Dec 2020
Investigated six allegations about resident room changes, health-change notifications to authorized representatives, resident choice of hospice, potential overmedication, safeguarding of incontinence supplies, and safeguarding personal belongings. Identified unsanitary living conditions and unsafe mattress placement in May 2020, while evidence did not establish violations for the remaining allegations.
§ 87705(f)(1)
§ 87468.1(a)(2)
28 Dec 2020
28 Dec 2020
Identified two specific allegations: that a resident with a history of sexual and aggressive behavior was not supervised. Found that a resident had an unexplained bruise on her back.
29 Dec 2020
29 Dec 2020
Investigated concerns about insufficient staffing, non-functional alarms, residents being restricted from going to certain areas, inadequate staff training, and residents experiencing medication issues and behavioral changes, and found no conclusive evidence to confirm violations.
28 Dec 2020
28 Dec 2020
Identified violations related to failing to provide proper notice for rent increases, not completing a personal property inventory, and administering medications as prescribed, leading to citations and a civil penalty.
§ 87208
§ 87405
§ 87411(a)
01 Dec 2020
01 Dec 2020
Found several fire-safety deficiencies, including exposed electrical wiring in the riser room; delayed egress signs required on all doors with delayed egress; missing or inadequate smoke detectors; spacers required in the riser room; Knox Box keys needing replacement; sprinkler system not facing the street; and carbon monoxide detectors required in hallways leading to sleeping areas.
01 Dec 2020
01 Dec 2020
Identified several fire safety issues, including exposed electrical wiring, missing signage, and malfunctioning detectors, during a follow-up inspection. Will conduct further follow-up on these concerns.
§ 87465(a)(5)
09 Nov 2020
09 Nov 2020
Investigated the allegation that a family visitor video-recorded residents during a private visit; administrator stated she was unaware of the recording and it was shared on social media. Found insufficient evidence to prove the allegation occurred, and it was unsubstantiated.
09 Nov 2020
09 Nov 2020
Investigated a complaint about a family visitor recording residents during a private visit; found no conclusive evidence to prove the allegation.
22 Oct 2020
22 Oct 2020
Found that a resident sexually assaulted another and safeguards to protect the victim were not implemented, including failing to separate the involved resident and to notify local law enforcement as required.
30 Oct 2020
30 Oct 2020
Investigated the allegation that staff failed to monitor a resident, allowing the resident to leave unattended; the resident was later located by police after the incident was circulated on social media.
30 Oct 2020
30 Oct 2020
Determined the allegation that a resident left unattended due to inadequate monitoring, after which staff retrieved the resident from an off-site location and brought them back. Found during a tele-visit that egress door alarms sounded when doors were pushed open, and determined the allegation to be substantiated.
§ 1569.312(a)(e)
30 Oct 2020
30 Oct 2020
Determined that the facility did not properly monitor a resident, resulting in the resident leaving unattended and being reported missing by police after appearing on social media.
22 Oct 2020
22 Oct 2020
Identified privacy and dignity concerns around surveillance cameras due to a lack of a clear plan to protect residents’ privacy. Identified staffing shortages and inconsistent night-shift coverage, and reported that residents’ bedroom doors were sometimes locked.
22 Oct 2020
22 Oct 2020
Investigated a resident sexual assault incident, revealing that the facility failed to protect the resident and did not follow proper reporting and intervention procedures, although the evidence was insufficient to conclude the abuse occurred.
10 Sept 2020
10 Sept 2020
Found no deficiencies related to the allegation of accepting fire evacuee residents. A tour was conducted, and evacuee and staff rosters and a written plan for maintaining services and health and safety were reviewed.
10 Sept 2020
10 Sept 2020
Reviewed the facility’s response to accepting fire evacuee residents, including touring the premises and requesting relevant rosters and plans; no deficiencies were cited.
22 Jul 2020
22 Jul 2020
Confirmed that a licensing analyst conducted a Covid-19 preparedness check and provided technical guidance during a visit, accompanied by public health officials.
§ 87101(c)(3)
02 Jun 2020
02 Jun 2020
Investigated allegations that staff failed to address and notify about a resident’s change in care and that the resident developed a pressure injury, along with falls and inadequate response to health changes; findings showed deficiencies in care and documentation, but the resident’s death was not linked to neglect.
12 Mar 2020
12 Mar 2020
Investigated allegations of staff mishandling medication, resident altercations, resident left in soiled briefs, and a Norovirus outbreak; found no evidence to confirm these issues occurred.
07 Jan 2020
07 Jan 2020
Reviewed ongoing concerns over compliance with regulations, including management, supervision, medication handling, and safety issues, with multiple complaints and citations since 2016, and noted that no deficiencies were cited during today’s meeting.
26 Nov 2019
26 Nov 2019
Identified multiple safety and supervision concerns, including damaged window screens, a malfunctioning air conditioner, and unsupervised resident altercations, during a case management visit.
§ 1569.312(a)(e)
13 Nov 2019
13 Nov 2019
Found that staff failed to adequately reposition and provide incontinence care to a resident with pressure injuries, resulting in worsening skin conditions, and that staffing levels were insufficient to meet residents' needs, leading to safety and care concerns.
§ 87464(f)(1)
12 Nov 2019
12 Nov 2019
Reviewed various facility concerns including incident reporting, medication errors, falls, skin tears, elopements, case management, complaint closures, administrator certification, staffing schedules, and outside compliance consultation, with an administrator agreeing to send relevant documents and designate herself as administrator. An exit interview was conducted, and a summary was provided at the conclusion.
§ 87307(d)(2)
07 Nov 2019
07 Nov 2019
Reviewed the facility's resident and staff files, medication records, and met with the administrator during an unannounced visit. Conducted the inspection over several hours and completed an exit interview afterwards.
§ 87464(f)(1)
§ 87405(d)(2)
23 Oct 2019
23 Oct 2019
Reviewed a recent unannounced visit related to a previous report, during which updated documentation was provided and explained to the facility representative. Concluded with an exit interview and the appropriate documentation being given.
§ 87208
§ 87465
22 Oct 2019
22 Oct 2019
Determined that the facility failed to provide adequate care and supervision, resulting in multiple resident falls and delays in assistance due to staffing shortages.
§ 87465
10 Oct 2019
10 Oct 2019
Reviewed resident incident records and medical files, identifying missing incident reports and unreported multiple falls and injuries, including an elopement, highlighting violations related to reporting requirements and supervision.
