I moved my mom here and have mixed feelings. The grounds, pleasant entrance and location (near shopping and freeway) are great, and staff are generally friendly, attentive and run lots of activities - the dementia unit is separate and some caregivers are experienced. Rooms are small and often shared with a shared bathroom; linens and vacuuming are weekly. Food is hit-or-miss (some days okay, often poor), and maintenance/organization is inconsistent - broken AC, shower scheduling problems, buzzer/entry delays and reports of pest and cleanliness issues. Staffing shortages and admin disorganization have caused safety and care concerns, so I'm glad we moved but would recommend this place only cautiously and with close monitoring.
San Dimas Retirement sits at 834-844 W Arrow Hwy in San Dimas, California, right at the base of the San Gabriel Mountains, in a spot that's close to medical facilities like Healthcare Partners and Rowland Convalescent Hospital. The community offers assisted living, independent living, and memory care for seniors, including a special South Garden memory care unit for those with Alzheimer's disease and related dementia, providing 24/7 support and nursing as an alternative to nursing home placement. You'll find options for private suites, shared suites, studio apartments, and rooms fitted with modern basics like individual heating, air conditioning, telephone connections, kitchenettes, and cable readiness, and many rooms have access to garden patios or balconies. People can bring small pets, like cats and dogs, and there's underground parking, easy access common areas, walking paths, a small library, outdoor spaces, and a beauty and barber shop on-site, plus a cozy atmosphere that some call home-like, especially in the small-size South Garden area.
San Dimas Retirement has a dining room for restaurant-style meals that chefs and meal planners prepare with a focus on taste and nutrition. Housekeeping, personal laundry, and linen care are included, and staff offer daily help with medication management, bathing, dressing, grooming, as well as escorting residents to meals and activities. Trained aides and live-in caregivers are available around the clock for both companionship and non-medical assistance. Residents can pick from many activities, like walking or book clubs, fitness classes, creative art clubs, religious activities, outings, memory care enhancement programs, educational sessions, and both on-site and offsite events aimed at keeping minds, bodies, and spirits active.
Devotional times, social events, a game room, a fitness room, business room, library, and recreation rooms round out community life. The facility is licensed by the state, with special legal protections in place for LGBTQ residents and staff. There's a 24-hour call system and supervision, and nurses are on hand 12 to 16 hours a day. Rental policies, fees, and interior details such as floor types aren't spelled out, but tours are available for those wanting a closer look. Residents can find a comfortable, safe place here, with care tailored to changing needs, and amenities designed to make life easier and a little bit brighter, with a focus on personal choice and comfort for every stage of senior living.
People often ask...
San Dimas Retirement offers competitive pricing, with rates starting at a cost of $5,824 per month.
San Dimas Retirement offers independent living, assisted living, memory care, and skilled nursing.
Yes, San Dimas Retirement allows residents to age in place and adjust their level of care as needed.
The full address for this community is 834 Arrow Hwy, San Dimas, CA, 91773.
Yes, San Dimas Retirement 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
127
Inspections
14
Type A Citations
21
Type B Citations
5
Years of reports
24 Jul 2025
24 Jul 2025
Found that the allegations included unlawful eviction, harassment by residents, safeguarding citizenship documents, delayed response to call buttons, opening mail, inadequate food service, and transportation coordination. There was not a preponderance of evidence to prove these alleged violations, so the allegations were UNSUBSTANTIATED.
22 Jul 2025
22 Jul 2025
Investigated the allegation that staff did not seek timely medical care for a resident; found that 911 was called within minutes during the event and most residents reported timely assistance, though one resident described longer delays. Investigated the allegation about equipment maintenance; found a loaner breathing machine was provided after the breakdown, and residents indicated staff generally assisted with medication needs, with varying experiences about replacement of equipment.
14 Jul 2025
14 Jul 2025
Investigated the allegation that staff did not prevent a resident from harassing other residents. Found that the resident displayed inappropriate behavior and staff intervened; however, there was not a preponderance of evidence to prove the allegation, thus UNSUBSTANTIATED.
09 Jul 2025
09 Jul 2025
Found no evidence to prove the allegation that staff did not prevent an altercation between residents; interviews indicated staff intervene to de-escalate verbal clashes and encourage residents to report concerns.
10 Jun 2025
10 Jun 2025
Found three of six smoke detectors on the second floor were not functioning at the time, while residents reported no issues.
§ 87303(a)
29 May 2025
29 May 2025
Found no evidence to support the allegation that staff failed to prevent a resident from harassing other residents.
21 Mar 2025
21 Mar 2025
Investigated the allegation that staff did not safeguard residents’ personal belongings and found insufficient evidence to corroborate it.
20 Feb 2025
20 Feb 2025
Found living areas clean and safe, with bedrooms furnished, bathrooms equipped with grab bars and non-skid mats, hot water within 105-120 degrees, cleaning supplies inaccessible, and exits unobstructed. Reviewed ten resident and ten staff records, confirming up-to-date emergency contacts, health screenings, and that medications are documented and stored securely; no deficiencies observed.
§ 87309(a)
07 Jan 2025
07 Jan 2025
Investigated the allegation that staff did not distribute a resident’s medications as prescribed; found that on 12/31/24 two PRN medications were given within less than eight hours without a documented reason, and several residents reported requesting PRN medications but not always receiving them.
§ 87465(a)(4)
03 Jan 2025
03 Jan 2025
Found no evidence to support the allegation that staff left residents in urine-soaked clothing for an extended period; residents and staff denied this claim. Found no evidence to support the allegation that staff did not provide residents with clean linens; residents and staff denied this claim.
12 Dec 2024
12 Dec 2024
Found three allegations—refusing access to personal belongings, failing to safeguard personal belongings, and not accord privacy—unsubstantiated after interviews, observations, and records were reviewed.
10 Dec 2024
10 Dec 2024
Found insufficient evidence to support the allegation that residents were prevented from participating in planning their care or that a second psychiatric medication was prescribed against a resident’s wishes; interviews indicated resident involvement and that the medication in question was discontinued by the physician after clarification.
01 Oct 2024
01 Oct 2024
Found that a resident was left unattended after a fall on 7/17/24, with no timely checks overnight and a wrist pendant that was inoperable. Found that staff did not promptly notify the authorized representative or physician after the fall, that extra personal care charges were added without proper discharge paperwork (despite a signed addendum and partial refund), and that the resident sustained a hip dislocation requiring another surgery with bruising not documented.
17 Sept 2024
17 Sept 2024
Found staffing shortages over several months, supported by interviews and rosters, with staff reporting stress and some shift delays. Found no clear evidence of violations in medication administration, hygiene, room cleaning, laundry, mold, pests, or persistent urine odors at this home.
23 Jul 2024
23 Jul 2024
Identified concerns about medication management after a resident, not oriented to time or day, could not recall prescribed medicines or their dosages; three pill bottles were found on a side table. Staff removed the medications and notified the responsible party, with coordination planned with the primary care physician regarding a change in condition.
23 Jul 2024
23 Jul 2024
Identified deficiencies in medication management were found during the visit, prompting action by the licensing program analyst.
20 Jun 2024
20 Jun 2024
Determined that the illegal eviction allegation—discharging a resident to a hospital without a 30-day eviction notice and refusing readmission—had insufficient evidence to prove it occurred. Interviews with staff and record reviews did not corroborate the claim.
20 Jun 2024
20 Jun 2024
Investigated alleged illegal eviction and found insufficient evidence to support the claim.
30 Apr 2024
30 Apr 2024
Investigated an allegation that a resident’s transportation for medical appointments was not met. Found no evidence to prove this issue as alleged; staff indicated rides were arranged with a preference for a larger vehicle, but the available vehicle sometimes differed and the resident could decline a smaller van.
30 Apr 2024
30 Apr 2024
Confirmed that there was no evidence to support the allegation of transportation needs not being met for a resident.
§ 87465(h)(1)
04 Apr 2024
04 Apr 2024
Found no evidence to support the allegation that staff did not address residents' healthcare needs, left residents in soiled clothing for extended periods, or failed to provide fresh linens. Interviews, records, and observations showed staff performed skin assessments, addressed medical needs, changed clothes and bedsheets as needed, and residents appeared clean and well cared for.
04 Apr 2024
04 Apr 2024
Investigated allegations that staff did not address resident healthcare needs, allowed residents to remain in soiled clothing, and failed to provide fresh linens; no substantial evidence found to support these claims.
§ 87507(f)
§ 87468.2(a)(4)
§ 87303(i)(1)
§ 87468.1(a)(8)
§ 87466
26 Mar 2024
26 Mar 2024
Investigated the allegation that staff did not provide adequate supervision resulting in a resident speaking to another resident in an inappropriate manner; interviews and records did not establish a preponderance of evidence that the incident occurred as described.
26 Mar 2024
26 Mar 2024
Investigated an allegation about inadequate supervision leading to a verbal altercation between two residents playing loud music, but insufficient evidence found to confirm if supervision was inadequate.
§ 87411(a)
22 Feb 2024
22 Feb 2024
Found no deficiencies after reviewing seven resident files, seven medications, and four staff files, and observing living areas, food service, safety systems, and care practices.
22 Feb 2024
22 Feb 2024
Identified no deficiencies during the inspection.
19 Jan 2024
19 Jan 2024
Found no preponderance of evidence to prove or disprove the allegations that staff did not provide adequate food service or that food quality was poor; most residents reported adequate meals and good quality, and the food supply appeared sufficient.
Found staffing levels sufficient to meet residents' needs, and all residents reported medications were given as prescribed with staff assisting for hygiene as needed.
19 Jan 2024
19 Jan 2024
Reviewed allegations of inadequate food service, poor quality food, insufficient staffing, medication administration issues, and inadequate hygiene care at the facility. Insufficient evidence to support the claims.
12 Dec 2023
12 Dec 2023
Found that a resident sustained an unexplained injury on 09/25/2022, with conflicting staff explanations and a delay in medical assessment and hospital transport. Found that authorized representatives were denied access to the resident's records, records were not provided within 24 hours as required, and two incidents were not reported to the Ombudsman in a timely manner.
12 Dec 2023
12 Dec 2023
Found that the fall occurred when a wheelchair brake was broken, and the resident stated there was no staff negligence. Found that there was insufficient evidence to prove delays in medical attention or a late response to the call light.
12 Dec 2023
12 Dec 2023
Confirmed that a resident sustained an unexplained injury without proper assessment or timely medical attention, authorized representatives were denied access to records, and incidents were not reported to appropriate parties in accordance with regulations.
04 Dec 2023
04 Dec 2023
Found insufficient evidence to prove that a clean mattress was not provided to a resident when moving rooms, with staff denying the allegation and several residents unable to corroborate; also found insufficient evidence to prove the resident’s toilet was in disrepair, as accounts varied.
04 Dec 2023
04 Dec 2023
Investigated allegations of staff not providing a clean mattress and the resident's toilet being in disrepair, but found insufficient evidence to support these claims, with interviews and observations contradicting the allegations.
28 Nov 2023
28 Nov 2023
Found insufficient evidence to prove the four allegations—staff behavior posing risk to a resident, inadequate food service, unfair treatment, and retaliation. Most residents and staff described interactions as respectful, with meals generally adequate and no retaliation observed.
28 Nov 2023
28 Nov 2023
Investigated allegations regarding staff behavior, food service, fair treatment, and retaliation against a resident. Found insufficient evidence to support any of these claims.
07 Nov 2023
07 Nov 2023
Investigated the allegation that a staff member claimed a resident on their taxes as a dependent; interviews with staff and residents and file reviews found no evidence to support the claim, and no staff tax filings were on file.
07 Nov 2023
07 Nov 2023
Investigated the allegation of staff committing tax identity theft using residents' personal information; found insufficient evidence to prove or disprove the claim, resulting in the allegation being unsubstantiated.
03 Nov 2023
03 Nov 2023
Found insufficient evidence to prove that staff stole residents’ belongings. Found insufficient evidence to prove that staff failed to change urine-soaked bedding, though a strong odor in one resident’s room indicated care deficiencies in that area.
§ 87625(b)(3)
03 Nov 2023
03 Nov 2023
Confirmed allegations of odor, but unsubstantiated allegations of stolen belongings, inadequate bedding changes, and lack of fall risk measures.
06 Sept 2023
06 Sept 2023
Found that in 2021 Covid infections caused staff to isolate, leading to use of cross-trained staff and registry help to cover shifts. Found that Covid safety protocols were followed and requests for assistance were answered promptly, with no clear evidence to support the allegation of insufficient staffing, unsafe Covid-19 practices, or delayed responses.
06 Sept 2023
06 Sept 2023
Confirmed allegations of insufficient staff and failure to follow Covid-19 safety protocols were unsubstantiated. Residents' requests for assistance were generally responded to in a timely manner.
17 Aug 2023
17 Aug 2023
Found that notices of rate increases were provided to SSI recipients, that annual increases occur automatically via COLA and are not set by the site, and that the allegation that the site raised SSI rates did not have enough evidence to prove.
17 Aug 2023
17 Aug 2023
Investigated allegations of improper rate increase notifications and rent increases for SSI residents; determined no substantial evidence to confirm alleged violations occurred.
11 Aug 2023
11 Aug 2023
Found that carpets were replaced with laminate about eight months ago and both residents and staff reported regular cleaning. Found that call buttons were responded to promptly, meals were nutritionally adequate, and residents received incontinence care with checks every two hours; there wasn’t enough evidence to prove the reported concerns occurred.
11 Aug 2023
11 Aug 2023
Investigated allegations regarding disrepair of carpets, untimely assistance, nutritional quality of food, and soiled diapers. Determined insufficient evidence to support claims; most residents and staff reported satisfaction with current conditions and service response times.
§ 87468.1(a)(8)
§ 87211(a)(1)
§ 87468.1(2)
22 Jun 2023
22 Jun 2023
Found most residents reported snacks were available throughout the day, while one resident claimed bread was denied to make a sandwich, and staff responses varied between redirecting to snacks and fulfilling requests. Concluded there was not enough evidence to prove that the bread denial occurred.
22 Jun 2023
22 Jun 2023
Reviewed an allegation that staff denied a resident a snack between meals but found insufficient evidence to prove the claim, as most residents and some staff indicated snacks were available throughout the day.
16 May 2023
16 May 2023
Investigated allegation that staff hit a resident; video showed staff reaching toward the resident for cookies but not striking, and interviews with residents plus local law enforcement records indicated no hitting. Investigated allegations that staff did not provide adequate food service and did not serve meals; video showed meals were delivered (sandwich after a request and breakfast/lunch delivered to the resident), and residents stated they received meals.
16 May 2023
16 May 2023
Reviewed Allegations of staff mistreatment and inadequate food service, but evidence did not substantiate the claims.
24 Mar 2023
24 Mar 2023
Found no evidence that staff hit the resident; video showed staff reaching toward the resident for cookies but not striking. Found that a sandwich was provided after a request, and breakfast and lunch were delivered to the resident's bedroom.
24 Mar 2023
24 Mar 2023
Reviewed video footage, conducted interviews, and examined documentation to investigate allegations of staff hitting a resident, not providing adequate food service, and not ensuring food was served, ultimately finding the allegations unsubstantiated.
10 Mar 2023
10 Mar 2023
Found that the allegation that staff did not prevent verbal abuse between residents could not be proven or disproven. Found that the allegation that staff failed to report incidents to appropriate agencies could not be proven or disproven; the incident was reported to the appropriate agencies within the required time frame.
10 Mar 2023
10 Mar 2023
Investigated allegations of verbal abuse and failure to report incidents, finding insufficient evidence to confirm complaints regarding residents' interactions. Confirmed reports submitted to appropriate agencies within required time frame, and no prior incidents were reported by involved parties.
26 Jan 2023
26 Jan 2023
Found deficiencies after an unannounced visit; infection-control practices were reviewed, resident and staff records checked, medications inspected, and supplies observed, with PPE available at entry and in hallways, cleaning products secured, resident rooms meeting safety standards, and an exit interview conducted.
02 Feb 2023
02 Feb 2023
Investigated complaints about food quality, respectful treatment, and medical care; most residents did not corroborate the claims, and evidence did not clearly prove or disprove the allegations.
02 Feb 2023
02 Feb 2023
Investigated allegations of inadequate food service, lack of respect towards residents, and failure to meet medical needs, but could not find enough evidence to confirm or deny the claims.
26 Jan 2023
26 Jan 2023
Identified deficiencies were observed during the inspection, including missing staff certifications and incomplete documentation of required training.
25 Jan 2023
25 Jan 2023
Investigated allegations that staff interfered with resident visits by requiring appointments and a 30-minute limit, and that privacy was not provided during visits, along with concerns about medication timing, call-button responses, staff conduct, meeting dietary needs, communication with responsible parties, room temperature control, and adherence to the bath schedule. Found insufficient evidence to establish violations.
25 Jan 2023
25 Jan 2023
Found allegations of staff interfering with resident visits, distributing medication, answering call buttons, speaking inappropriately, meeting dietary needs, communicating with responsible parties, and maintaining temperature to be unsubstantiated.
03 Jan 2023
03 Jan 2023
Found that the allegation that staff did not prevent a resident from wandering away could not be proven. Investigators noted that a resident repeatedly attempted to exit through gate controls, staff monitored closely, and the resident's responsible party moved the resident to another facility.
03 Jan 2023
03 Jan 2023
Unannounced visit conducted to investigate allegation of resident attempting to leave facility multiple times. Staff aware and taking measures to prevent resident from leaving.
28 Oct 2022
28 Oct 2022
Found insufficient evidence to prove that the elevator door injured anyone or that older units lacked motion sensors; tests showed doors detected a person and retracted, and most residents reported no issues.
28 Oct 2022
28 Oct 2022
Found insufficient evidence to prove the allegations of inadequate staffing, inadequate food service (cold foods and lack of variety), absence of activity schedules, and pest concerns; residents' experiences varied, with some noting improvements and others reporting ongoing issues.
28 Oct 2022
28 Oct 2022
Investigated an allegation regarding elevator safety, determining no substantial evidence found to indicate the elevators were malfunctioning or lacked proper sensors, based on interviews and operational tests.
25 Oct 2022
25 Oct 2022
Found that the two elevators have motion sensors and function as expected; the specific claim that a hand was crushed by a closing door could not be substantiated.
25 Oct 2022
25 Oct 2022
Confirmed the allegation regarding the elevator's condition as unsubstantiated after interviews and testing showed that the elevator had sensors to prevent injuries and was in good working order.
§ 87412(c)
24 Oct 2022
24 Oct 2022
Identified illegal eviction of a memory-care resident and staff failures to prevent the resident from leaving unassisted. Determined there was insufficient evidence to prove that incident reporting to licensing and the resident's family occurred as alleged.
§ 87705(k)(5)
§ 87224(a)(4)
24 Oct 2022
24 Oct 2022
Confirmed allegations of illegal eviction and failure to prevent a resident from leaving unassisted. Unsubstantiated claim of failure to promptly report incidents to regulatory authorities and family members.
06 Oct 2022
06 Oct 2022
Investigated allegations that staff do not treat residents with respect and that staff speak inappropriately in front of residents, as well as that staff are not properly trained. Interviews and records showed that some residents experienced disrespectful treatment by staff, seven of eight staff had not completed the required annual training hours, onboarding was provided, and there was no evidence that staff spoke inappropriately in front of residents.
§ 87468.1(a)(1)
06 Oct 2022
06 Oct 2022
Verified allegations of staff mistreatment towards residents, lack of required staff training, and unsubstantiated claims of staff speaking inappropriately in front of residents.
15 Sept 2022
15 Sept 2022
Found insufficient evidence to prove or disprove the allegation that residents were bitten by insects and that staff did not communicate to resolve it; most residents did not corroborate, no insects were observed during the visit, and pest-control reports showed no activity, though two residents reported bites with unclear photos.
15 Sept 2022
15 Sept 2022
Investigated the allegation of insects in the facility; not enough evidence found to confirm or deny the claim, as inspections and interviews did not reveal insect presence after pest control services.
14 Sept 2022
14 Sept 2022
Identified the allegation that the elevator could crush a hand if someone reaches in at the last moment to stop the doors, with sensors not reliably detecting a hand in time, based on tests and interviews.
14 Sept 2022
14 Sept 2022
Confirmed that the elevator sensor did not detect an object in the door, leading to a hand being caught in the closing elevator door.
05 Aug 2022
05 Aug 2022
Found no credible evidence to prove that staff lacked qualifications. Found no credible evidence to prove that residents were confined to rooms, that hydration was inadequate, that staffing was insufficient, that cleanliness was not maintained, or that residents needed help with oral hygiene.
05 Aug 2022
05 Aug 2022
Interviews with staff and residents did not support all of the allegations regarding staff qualifications, quality of food, hydration, room confinement, staffing levels, cleanliness, and oral hygiene assistance.
23 Jun 2022
23 Jun 2022
Investigated multiple complaints by interviewing residents and staff and reviewing records; found meals were improved and varied, no mail tampering reported, medications aligned with prescriptions, services billed as agreed, and meals served on schedule; found no evidence supporting these allegations.
23 Jun 2022
23 Jun 2022
Investigated complaints about inedible food, opened mail, unprescribed medication, overcharging for services, and untimely meal service; all allegations found unsubstantiated due to lack of evidence. Conducted interviews and reviewed documents to reach conclusions. Exit interview held.
12 May 2022
12 May 2022
Investigated the allegation that staff did not assist a resident in a timely manner and the allegation that equipment stored in the parking area posed a hazard; interviews and observations did not yield a clear preponderance of evidence to prove or disprove either claim.
12 May 2022
12 May 2022
Confirmed valid allegations of staff not assisting residents in a timely manner. Unsubstantiated claims of hazardous furniture in the parking structure.
§ 87303(a)
22 Mar 2022
22 Mar 2022
Investigated the allegation that staff retaliated against the resident and attempted eviction; there was no eviction notice, staff denied threats, and the resident reported no witnesses.
Investigated the allegations that staff falsely claimed the resident smoked in the room and that staff did not assist with medical care; findings showed past smoking but not recent, and transportation was provided so the resident could attend scheduled medical appointments.
22 Mar 2022
22 Mar 2022
Investigated allegations included staff retaliation against a resident, false statements about smoking in the room, and lack of medical care assistance; found no conclusive evidence to support these claims.
03 Mar 2022
03 Mar 2022
Investigated allegations that residents’ toileting needs were not met promptly and that residents were not treated with respect. Found that some residents experienced long waits for toileting assistance and that staff sometimes entered rooms without knocking or spoke to residents inappropriately.
03 Mar 2022
03 Mar 2022
Found incidents of long wait times for toileting assistance and lack of respect in interactions with residents.
23 Feb 2022
23 Feb 2022
Found all areas clean and well maintained, including resident bedrooms, bathrooms, kitchen, and common spaces. Health screenings, infection control practices, medication storage, and staff and resident records appeared up to date, with no deficiencies observed.
23 Feb 2022
23 Feb 2022
Investigated allegations of food quality and medication timing. Found that food had improved after kitchen changes, the kitchen was clean and well-stocked, and no issues were found with residents’ medications; not enough evidence to prove violations occurred.
23 Feb 2022
23 Feb 2022
Found that the complaint about a person being trapped in the dining-area elevator was unsubstantiated. Testing showed the elevator operated correctly, and staff and residents reported no trapping incidents.
23 Feb 2022
23 Feb 2022
Interviews and observations found no evidence to support allegations about food quality or medication administration at the facility.
§ 87468.2(a)(4)
01 Dec 2021
01 Dec 2021
Found two issues: delays in providing residents with their trust fund balances and failure to inform residents about positive COVID-19 results. Earlier concerns about a missing resident, staff harassment, and testing after exposures were not supported by the evidence.
01 Dec 2021
01 Dec 2021
Confirmed allegations of staff not providing residents with trust fund accounting and failing to notify residents of positive COVID cases.
17 Nov 2021
17 Nov 2021
Investigated allegations that a caregiver passed medications on 10/25/21 to about 20 residents without proper training and that residents experienced delays due to staffing shortages. Found that three medication technicians were sick that evening, residents reported wait times for as-needed meds, and interviews and records could not definitively prove the medication passing or training lapse occurred.
17 Nov 2021
17 Nov 2021
Confirmed that the staff member passed medication without proper training. Residents do not consistently receive their medication on time.
30 Sept 2021
30 Sept 2021
Investigated multiple allegations and found staffing shortages contributing to delayed medications and treatments, medication administration problems, concerns about meal quality and serving temperatures, and dirty conditions in the facility. Observed that activities were still being provided—by volunteers with a new activity director in place—and a driver assisting with medications had training documented.
30 Sept 2021
30 Sept 2021
Short-staffing, medication administration, dietary needs, food services, and cleanliness allegations at the facility were confirmed. Activities and staff training allegations were unsubstantiated.
§ 87468.1(a)(1)
§ 87411(c)(3)
17 Sept 2021
17 Sept 2021
Investigated the allegation that a resident’s air conditioner was not installed properly. The unit appeared properly installed and operating; maintenance added weather stripping after a recent move-in, and interviews with staff and residents did not support the allegation, with no evidence to prove it.
17 Sept 2021
17 Sept 2021
Confirmed that the air conditioning unit was properly installed and operational in the resident's room, based on interviews and inspections.
§ 87411(a)
§ 87465(a)(5)
§ 87555(a)
§ 87303(a)
21 Jul 2021
21 Jul 2021
Investigated complaints about staffing and care at a home; found that 12 of 16 residents reported being short-staffed and experiencing medication delays or slow responses to call lights. The following specific allegations were not supported: unwitnessed fall, intercoms in disrepair, bathing needs not met, and administrator not communicating with resident representatives.
21 Jul 2021
21 Jul 2021
Found that 5 of 11 residents experienced missed or late-administered medications, including pain medications, with waits of 1 to 2 hours. Staffing shortages and frequent double shifts, especially among med techs, contributed to delays and some residents did not receive required treatments.
21 Jul 2021
21 Jul 2021
Confirmed allegation of medication errors and staff shortages based on interviews with residents and staff.
16 Jul 2021
16 Jul 2021
Found concerns about food quality and nutrition: residents described meals as too salty, tough, and not well cooked, with drinks watered down. Staff noted numerous complaints and cost-cutting measures, such as removing yogurt and serving more processed meats.
16 Jul 2021
16 Jul 2021
Substantiated allegation of poor food quality based on interviews with residents and staff, along with observations in the kitchen.
19 Jun 2021
19 Jun 2021
Found a COVID-19 positive case on 4/8/21 and no record of reporting it.
19 Jun 2021
19 Jun 2021
Identified deficiencies in reporting COVID-19 positive case.
16 Jun 2021
16 Jun 2021
Found no evidence to support the allegation that staff did not prevent inappropriate interactions between residents. Found food service generally adequate with warm meals and a variety of options, and linens in good condition.
16 Jun 2021
16 Jun 2021
Investigated claims of inappropriate behavior between residents, inadequate food service, and insufficient linen supply; found no sufficient evidence to support these allegations.
§ 1569.69(a)(1)
09 Jun 2021
09 Jun 2021
Investigated two specific allegations and found insufficient evidence to prove or disprove either. For the refund allegation, the POA explained the SSI check was voided by law and a refund check was mailed to the family; for the personal items allegation, belongings were returned or made available for pickup, with some items still in the resident’s room.
09 Jun 2021
09 Jun 2021
Confirmed allegations of staff not issuing a refund were unsubstantiated after interviews with the Administrator and Power of Attorney. Allegations of staff taking residents' personal items were also unsubstantiated after interviews with residents and staff.
04 Jun 2021
04 Jun 2021
Found that in the dementia unit, staff used a rock or other object to crush medications and gave them mixed in soda to a resident. Found that a resident’s morning doses of two medications were not administered as prescribed, there was no record of an infection for another resident’s toe, podiatry visits were limited by COVID-19, and there was no evidence of falsifying medication administration.
§ 87465(a)
04 Jun 2021
04 Jun 2021
Confirmed documentation issues relating to medication administration and foot care, but did not find evidence of resident neglect or falsification of records.
§ 87468.1(a)(10)
§ 87468.2(a)(19)
14 Apr 2021
14 Apr 2021
Investigated complaints about staff responding to calls, assisting with doctor visits, baths, meals, medication, and hot water safety. Found the allegations unsubstantiated after interviews and checks.
14 Apr 2021
14 Apr 2021
Investigated multiple allegations including lack of staff assistance with calls for help, doctor visits, and baths, unsanitary food service practices, improper medication assistance, and bathing incidents; determined all allegations lacked sufficient evidence to be confirmed or denied.
§ 87465(a)
07 Apr 2021
07 Apr 2021
Investigated allegations that the resident sustained multiple pressure injuries, that the bed was in disrepair, and that nutrition was improper. Findings indicated only one stage II wound on the right buttock treated by home health; bed functioned normally; appetite improved with no notable weight change, and the resident reported comfort; these allegations are unsubstantiated.
07 Apr 2021
07 Apr 2021
Investigated three allegations related to resident care: no multiple pressure injuries found, bed not in disrepair, and resident receiving proper nutrition. Each allegation lacked sufficient evidence to be confirmed.
§ 87555(a)
01 Apr 2021
01 Apr 2021
Investigated by a licensing analyst via teleconference due to COVID-19, gathering details about a resident's death on 04/01/2021 and requesting several documents to be emailed by the end of the business day. The case remains open pending additional information.
01 Apr 2021
01 Apr 2021
Reviewed documents related to a death incident at the facility and conducted a telephonic interview with the administrator to gather additional information.
§
29 Jan 2021
29 Jan 2021
Found that the death claim was unfounded; the resident is alive and living there, and the rumor came from another resident.
29 Jan 2021
29 Jan 2021
Confirmed unfounded allegation of resident's death at facility.
§ 87411(a)
05 Jan 2021
05 Jan 2021
Found that the resident's original room was near a smoking area and cold; staff offered to move, the resident agreed, and is now comfortable in a new room. Found that staff and resident deny refusing to maintain a comfortable temperature, and there is not enough evidence to prove the temperature-related allegation.
05 Jan 2021
05 Jan 2021
Confirmed that a resident had issues with their room close to a smoking area and being cold, staff offered and moved the resident to a new room where they are now comfortable. Refusal to maintain a comfortable temperature in the room was denied.
16 Dec 2020
16 Dec 2020
Identified a medication mix-up where a pill meant for one resident was given to another with a similar name. Interviews and MAR review supported the occurrence of the error.
16 Dec 2020
16 Dec 2020
Investigated medication error with a resident, where one staff member mistakenly provided a pill intended for another resident. Identified and confirmed staff separated medications to prevent future confusion.
03 Dec 2020
03 Dec 2020
Identified a medication mix-up where a pill intended for one resident ended up with another resident with a similar name. Interviews and medication records supported that the error occurred.
03 Dec 2020
03 Dec 2020
Confirmed incident with medication error involving a resident.
14 May 2020
14 May 2020
Determined that there was insufficient evidence to prove the allegation that a resident with dementia wandered away from the facility, as the resident was confirmed to be capable of leaving unassisted and had no dementia diagnosis.
01 Apr 2020
01 Apr 2020
Investigated complaints about inadequate food service, poor quality food, and unsanitary conditions; found no evidence to support these allegations.
26 Feb 2020
26 Feb 2020
Confirmed no violations during inspection of the facility.
24 Feb 2020
24 Feb 2020
Confirmed unsubstantiated allegations of staff mistreatment, medication mismanagement, and lack of adequate training. One allegation of unqualified staff administering medication was substantiated.
