Jasmin Terrace at Yucca Valley

    55425 Santa Fe Trail, Yucca Valley, CA, 92284
    2.1 · 16 reviews
    • Assisted living
    AnonymousLoved one of resident
    1.0

    Caring staff but dangerous neglect

    I chose this affordable, home-like place because the admin was attentive and many caregivers were caring and friendly - my dad made friends and we have some happy memories. Unfortunately medical communication and attention were minimal, feeding was often neglected (food frequently inedible or left without assistance), and belongings were lost or mishandled. His room had a roof leak and a horrible smell. Staff sometimes didn't wear masks or disclose vaccination status, and a COVID outbreak tied to employee exposure led to hospitalization and long-term consequences, so I had to remove him. I appreciate the kind staff and accommodating management, but overall safety and care were unacceptable, so I can't fully recommend it.

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    Amenities

    2.06 · 16 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      2.5
    • Staff

      3.0
    • Meals

      1.0
    • Amenities

      1.0
    • Value

      2.1

    Location

    Map showing location of Jasmin Terrace at Yucca Valley

    About Jasmin Terrace at Yucca Valley

    Jasmin Terrace at Yucca Valley sits at 55425 Santa Fe Trail, right in the heart of Yucca Valley, California, and the building itself is a large place with enough room for up to 85 seniors who need assisted living, skilled nursing, or memory care, and as you walk around you'll see there are a lot of studio apartments and single or semi-private rooms, some with kitchenettes, so folks can settle in the way they like and still have their independence. Michael Garcia oversees the care management here, and the staff provide round-the-clock supervision and help with daily tasks like bathing, dressing, and giving out medicine, and the nursing care goes for 12 to 16 hours a day, with a call system running 24 hours for extra peace of mind, so there's always someone around if something happens. You'll find a mix of private suites and shared spaces, all furnished and wheelchair accessible, and even though it's a big place, you can bring along pets and there's a no smoking rule in all the indoor spaces, which helps keep things clean.

    This facility's got separate areas for memory care, offering secure living and specialized plans for Alzheimer's and dementia, and the staff pay attention to each person, giving support and activities that help keep the mind sharp and the days a little brighter. For those who like to be outside, you'll see walking paths, a garden to relax in, and some outdoor common spaces, and when the weather's nice, a bit of sun or fresh air is never too far away. They've also got a library, arts and game rooms, and a fitness area for folks who want to stay active, and there are planned group activities, movie nights, music, and programs to keep people social and feeling part of a community, and if someone wants devotional time or needs spiritual support, those services happen onsite.

    Meal services come three times a day, cooked to order, and you'll find a variety of menu options, including vegetarian and kosher, so different needs get met, and if anyone has special diets, the kitchen staff try to help with that too. If you need help with laundry or housekeeping, that's taken care of, and there's even a beautician onsite for haircuts and grooming, which makes things a bit easier for those who can't get out much. They do things like offsite trips using their own transportation, and there's a constant effort to keep people moving and involved in wellness programs, which does help health a bit. These rooms have air-conditioning, telephones, cable TV, and internet access, which makes things feel a bit more like home, and the environment's quiet, surrounded by the California landscape, so it feels set apart but not isolated, and there's a secure setting for people with memory needs so families can feel comfortable about safety.

    Jasmin Terrace provides assisted living services, skilled nursing, and memory care, and it's state licensed under license number 361880801, but it isn't accredited by the Better Business Bureau, and there is an entry fee to move in. Management and staff deliver as much personal care as needed, from medication administration to incontinence care or hospice support at the end of life. The community allows folks to bring a little of themselves, with space for their own things, and plenty of chances to engage, be social, or just enjoy quiet if that's what's wanted.

    People often ask...

    State of California Inspection Reports

    141

    Inspections

    37

    Type A Citations

    39

    Type B Citations

    6

    Years of reports

    14 Jul 2025
    Identified deficiencies due on 07/09/25 not addressed as of 07/14/25, with missing bed bug treatment/inspection documentation from an outside extermination company; civil penalties of $500 were assessed today and $100 per day will accrue until proof of correction is received; an exit interview was conducted.
    • § 9058
    03 Jul 2025
    Investigated two specific allegations: that staff did not properly relocate a resident, and that staff withheld the resident’s personal belongings. Found insufficient evidence to prove either allegation.
    19 May 2025
    Found that staff financially abused a resident: one staff member attempted to open a store credit account in the resident’s name and borrowed money, while another used the resident’s bank card for off-duty purchases, including transactions in Mexico.
    • § 87468.2(a)(8)
    19 May 2025
    Investigated a follow-up related to a complaint, meeting with the administrator, touring the site, and conducting interviews. Concluded with an exit discussion.
    • § 9058
    09 May 2025
    Identified that the resident's file could not be located and that the resident had been discharged in early 2024. A deficiency resulted in a $250 civil penalty for repeating the same violation within 12 months.
    • § 87506(e)
    • § 9058
    17 Apr 2025
    Found the odor-related allegation unsubstantiated; mild cleaning-solution scents were present in entryways, hallways, visitor bathrooms, and activity and dining areas, and four of five residents did not observe malodors while staff said areas are cleaned daily. Found the air-conditioning allegation unsubstantiated; air conditioning was operating during the visit and all residents reported proper operation with comfortable temperatures.
    11 Mar 2025
    Investigated a resident's death, collected pertinent documents, and interviewed staff, noting that no official death certificate had been issued yet and that the preliminary cause was believed to be heart failure.
    19 Feb 2025
    Reviewed a complaint-related issue; one resident had not resided since January 2025, and their records were temporarily removed for corporate review.
    • § 87506(e)
    22 Jan 2025
    Found insufficient evidence to prove the allegation that staff did not meet residents' care plan needs; staff arranged outside assistance to repair a catheter leak for a resident. Found insufficient evidence to prove the allegation that food was not served healthfully; meals were kept covered during tray distribution and served at appropriate temperatures in the dining area, with four of five residents reporting proper temperatures.
    17 Jan 2025
    Found that inadequate supervision allowed a resident to leave and be found outside, later hospitalized for cold exposure. Found no evidence that a wheelchair was not secured causing a fall or that residents’ hygiene needs were not met.
    • § 87468.2(a)(4)
    21 Oct 2024
    Identified that staff did not submit written incident reports to licensing about incidents affecting residents' health and safety, including ambulance transports and a physical altercation with injuries; observed a strong hallway odor and a sticky floor in a resident's room during a tour.
    • § 87303(a)
    • § 87211(a)(1)
    21 Oct 2024
    Found that staff allowed a resident to leave unassisted on December 21, 2022, despite forgetfulness and the need for supervision. The resident was struck by a vehicle while crossing a highway and died later that evening.
    • § 1569.269(a)(6)
    23 Aug 2024
    Identified deficiencies in the care setting, including missing admissions agreements for several residents and an unsigned physician's report. Also found health and safety concerns such as roaches in a bathroom, inconsistent hot water temperatures, an outdated activity plan, a missing chair in one resident room, and no current disaster drill on file.
    23 Aug 2024
    Reviewed conditions of the residential care setting, identifying various health and safety deficiencies including incomplete resident records, unmaintained outdoor areas, inconsistent hot water temperatures, presence of pests, and lack of current staff training and emergency drills.
    • § 87303(e)(2)
    • § 1569.695(c)
    • § 87506(a)
    • § 87219(f)
    • § 87507(d)
    • § 87303(a)
    • § 87307(a)(3)
    21 Aug 2024
    Identified a deficiency after finding a Raid insecticide spray on a tray beside a non-ambulatory resident's bed. Staff removed the spray after being alerted, and it was noted that a relative may have brought it.
    • § 87309(a)
    21 Aug 2024
    Found that the allegation that staff did not transport residents to appointments was not supported, as seven residents reported transportation to appointments and outside transportation was arranged for one resident’s past appointments with unclear communication about an 8/12 appointment. Found that the allegation of stealing a resident’s phone lacked sufficient corroborating evidence, and identified a non-working hallway light with insufficient closet lighting that maintenance repaired during the visit.
    21 Aug 2024
    Determined that staff provided transportation for residents' appointments, with one resident’s outside transportation arranged by a POA for specific dates, while evidence did not support stealing of a resident’s phone. Identified that inadequate lighting in a resident's bedroom was valid, as a hallway light was broken and took days to fix.
    • § 87303(d)
    02 Mar 2024
    Found insufficient evidence to support moving a resident to memory care without consent and insufficient evidence to support concerns that personal belongings were not safeguarded. Verified that staff background clearance was properly completed, and identified deficiencies in resident records, including a missing physician signature and incomplete medical assessments.
    02 Mar 2024
    Reviewed allegations found that staff moved a resident to memory care without proper consent and failed to safeguard residents’ belongings, but evidence was insufficient to confirm these concerns. Additionally, it was confirmed that staff worked with proper background clearances, resident records were incomplete, and these issues require correction.
    • § 87506(a)
    11 Jan 2024
    Found insufficient evidence to prove the allegation that staff did not assist with incontinence needs. Found evidence supporting the allegation that a resident was not bathed, with care logs showing missing baths.
    11 Jan 2024
    Found that staff did not assist a resident with their incontinence needs, while other residents reported staff helped them, and confirmed that a resident did not receive scheduled baths over a several-week period.
    • § 87464(f)(4)
    28 Dec 2023
    Investigated the allegation in the complaint and found that the administrator signed an amended document.
    25 Sept 2023
    Found no evidence to support that a resident sustained injuries due to lack of care and supervision by staff, and no evidence that staff failed to provide fluids to prevent dehydration per the written care plan.
    28 Dec 2023
    Confirmed that an administrator signed an amended complaint investigation document related to a specific allegation from September 2023.
    21 Dec 2023
    Found allegation 1 unsubstantiated; medications were generally sufficient per observations and resident interviews. Found allegation 2 and allegation 3 unsubstantiated; linen and toiletries were adequately supplied per observations and resident interviews.
    21 Dec 2023
    Found that staff provided residents with sufficient medication, linen, and toiletries, and therefore the allegations regarding shortages were unsubstantiated.
    09 Dec 2023
    Identified corrections to an earlier complaint during an unannounced visit, with the administrator signing the amended forms. An exit interview was conducted to discuss the matter.
    23 Aug 2023
    Found unsubstantiated the allegations that a resident was left in soiled linen and diapers for an extended period and that staff bribed residents. Interviews, documents, and observations showed residents are checked regularly, receive needed assistance, the environment is clean, pest control is in place, and repairs and staffing improvements are underway.
    23 Aug 2023
    Found no evidence to support the allegations that air conditioning failed, memory care doors were unsecured, or that an altercation was mishandled; air conditioning was repaired and cool air circulated, memory care doors remained secure and opened only about 10 inches. Noted sufficient meals and supplies, with residents observed eating a balanced lunch.
    09 Dec 2023
    Found that the licensee did not file a special incident report about a 6/2/2023 altercation between residents that led to one resident going to the hospital and returning with stitches.
    • § 87211(a)(1)
    09 Dec 2023
    Reviewed an unannounced visit to amend a prior complaint related to the facility, with necessary corrections discussed and documented.
    21 Nov 2023
    Found no evidence that a resident developed food poisoning while in care; menus showed a variety of nutritious meals and most residents stated meals were nutritious. Maintained pest control with the last treatment recently, and residents did not report roaches in bedrooms.
    21 Nov 2023
    Investigated allegations that a resident developed food poisoning, staff did not ensure nutritious meals, and pests were present; found no evidence to support these claims after review of records, facility tour, and interviews.
    04 Oct 2023
    Found mishandling of a resident's medications. Found that staff did not ensure the resident was transported to a scheduled medical appointment.
    04 Oct 2023
    Found that staff mishandled resident's medications by not locating prescribed medication for about seven days, and also failed to ensure the resident attended a scheduled medical appointment due to miscommunication.
    • § 87465(a)(1)
    • § 87465(e)
    25 Sept 2023
    Investigated the allegation that resident injuries resulted from lack of staff care and supervision, and that staff failed to provide fluids to prevent dehydration; found insufficient evidence to support these claims.
    19 Sept 2023
    Investigated findings showed no proof that staff stole medications or failed to provide proper shower assistance; however, two residents' medications were missing and there were no activities because staff were on medical leave.
    19 Sept 2023
    Found that staff did not steal resident medications or fail to provide proper shower assistance, based on interviews and record reviews; however, there was evidence of medication mismanagement due to missing medications for residents, and residents reported no available activities because staff responsible for activities were on medical leave.
    • § 87464(f)(7)
    • § 87464(f)(2)
    29 Aug 2023
    Identified that the allegation of water damage occurring from 8/19/2023 to 8/21/2023 and related repairs was unsubstantiated. Repairs were completed in some rooms, no active leaks were observed, and residents were relocated as needed.
    29 Aug 2023
    Investigated water damage related to leaks from August 19 to 21, 2023, finding repairs completed and no ongoing issues; resident relocation and overall facility conditions appeared appropriate.
    23 Aug 2023
    Investigated allegations of residents being left in soiled linens and diapers for extended periods and staff inappropriately bribing residents, and found no evidence to support these claims; residents reported feeling comfortable and receiving appropriate care.
    09 Aug 2023
    Identified a deficiency for not providing timely follow-up medical care to a resident. The administrator said the follow-up occurred and proof would be provided by the deadline; by 8/09/23 the deficiency was cleared, and a civil penalty was assessed for not addressing it by the deadline.
    09 Aug 2023
    Identified a delay in refilling a resident's medication, with the order dated 6/26/23 not received until 7/13/23. No documentation showed follow-up with the hospital or doctor to ensure timely receipt, and staff indicated hospital delays could exceed 10 days.
    09 Aug 2023
    Found that staff did not refill a resident’s medication in a timely manner, with the medication delayed from 6/26/23 to 7/13/23 without documented follow-up, and the reason for the delay could not be confirmed.
    • § 87464(f)(6)
    01 Aug 2023
    Identified deficiencies during an unannounced annual inspection, including pest activity in the kitchen and central bathroom, and an outdoor area for dementia residents that is not fully enclosed. Found gaps in staff health screenings, missing admissions agreements for residents, and an incomplete physician's report for another resident.
    01 Aug 2023
    Found several safety and health deficiencies, including incomplete resident and staff records, pest issues in the kitchen and bathrooms, and an outdoor space accessible to dementia residents that was not fully enclosed.
    • § 87705(h)
    • § 87555(b)(27)
    • § 87506(b)(15)
    • § 87507(c)
    • § 87411(f)
    31 Jul 2023
    Identified a staff member working without a required background clearance during an incident on 4/28/23, with a prior similar deficiency noted on 1/12/23. Found failures to arrange medical care for injuries and to report incidents to licensing agency within seven days, resulting in two immediate civil penalties for repeat violations.
    • § 87211(a)(1)
    • § 87355(e)(1)
    • § 87465(a)(1)
    31 Jul 2023
    Found not enough evidence to prove the allegation that staff hit a resident. Found not enough evidence to prove the allegation that residents were left in soiled diapers for extended periods.
    31 Jul 2023
    Investigated the allegation that staff hit a resident and left residents in soiled diapers for extended periods; found insufficient evidence to support either claim.
    07 Jul 2023
    Found insufficient evidence to prove Allegations 1 through 6, including claims of communication barriers, inadequate food quantities, lack of transportation assistance, leaving residents in soiled diapers, leaving a resident on the floor, and staff speaking inappropriately to residents.
    07 Jul 2023
    Investigated six allegations, including communication barriers, food adequacy, transportation assistance, residents left in soiled diapers, residents left on the floor, and staff speaking inappropriately; found no evidence to support these claims.
    28 Jun 2023
    Found that the allegation that staff withheld a resident's personal funds occurred; a staff member gave the resident $20 and then $80 of their own money on two consecutive days while the administrator was out of state.
    28 Jun 2023
    Investigated the allegation that staff withheld residents' personal funds, found that staff provided residents with money out of their own pockets while the administrator was out of state, and confirmed the allegation.
    • § 87468.1(a)(3)
    27 Jun 2023
    Investigated three allegations and found them unsubstantiated: a resident sustained injuries, a resident was left on the floor for an extended period, and staff slept on residents' beds during shifts.
    27 Jun 2023
    Investigated allegations of resident injury, being left on the floor, and staff sleeping on residents' beds; found no conclusive evidence to confirm any of the claims.
    22 May 2023
    Confirmed signatures on the amended complaint investigation and the related evaluation after explaining the allegation to the nutritionist; copies remained at the site.
    12 Jul 2022
    Determined there was no evidence that staff engaged in inappropriate interactions with residents, smoked marijuana in the presence of residents, treated residents without dignity, failed to administer medications as prescribed, or that uncleared staff remained on site.
    22 May 2023
    Reviewed the amended complaint investigation related to staff signing a specific report, with staff present and documentation completed during the visit.
    03 Apr 2023
    Found that a Special Incident Report was not submitted for a resident's fall on 1/23/23, creating a potential health and safety risk. Identified that staff health screening records were incomplete, with evaluation details blank, no physician stamp or signature, and no date.
    • § 87412
    • § 87211
    26 Apr 2023
    Found no evidence to support that staff did not ensure safe personal hygiene in the kitchen. Observations showed staff wearing masks, gloves, and hair nets; the kitchen was clean with no food left out, and most residents did not report hygiene concerns.
    26 Apr 2023
    Investigated the allegation that staff do not ensure safe personal hygiene in the kitchen and found no evidence to support the claim, as staff were observed following safety protocols and interviews confirmed proper hygiene practices.
    03 Apr 2023
    Determined that the medication mismanagement allegation is unsubstantiated, supported by MAR records, locked storage, and interviews indicating proper handling. Determined that the allegations of an unsafe environment and untrained staff are unsubstantiated, based on interviews and training records.
    03 Apr 2023
    Found no evidence to support the allegation that staff hit a resident. Interviews and records showed no witness to such conduct, and one resident had an unwitnessed fall resulting in a cut above the left eye, with first aid provided and family notified.
    03 Apr 2023
    Investigated the allegation that staff hit a resident, with interviews and document review revealing no evidence to support that staff physically hit residents; an unwitnessed fall resulting in an injury was documented but not linked to abuse.
    13 Mar 2023
    Found bed bug issues being addressed, with measures underway to manage the situation. Five residents and staff were interviewed, all denying bed bugs and reporting clean, sanitary conditions.
    13 Mar 2023
    Reviewed that there was a bed bug incident and concerns about cleanliness; found evidence of pest control efforts, and observed the facility to be clean and sanitary with no bed bugs present during visits.
    17 Feb 2023
    Found no clear evidence to prove or disprove the allegation of staff abuse toward residents; video showed a resident tripping on a blanket while walking, and staff and resident interviews did not support abuse claims.
    17 Feb 2023
    Investigated the allegation that staff physically abused a resident and found no evidence to support the claim, with the resident’s fall on 2/12/23 attributed to tripping over a blanket rather than abuse or neglect.
    26 Jan 2023
    Found roaches throughout the location, and records showed pest control recommendations from earlier visits were not addressed.
    26 Jan 2023
    Found five allegations unsubstantiated after reviewing statements and records.
    26 Jan 2023
    Found that there were roaches throughout the facility, and previous pest control visits had not been effective in addressing the problem. The conditions confirmed the complaint regarding pests were valid.
    • § 87303(a)(c)
    12 Jan 2023
    Identified that a staff member worked at the home since June 2021 without criminal background clearance, despite records showing the clearance was still in progress. This posed an immediate health, safety, and personal rights risk to residents and repeated a similar violation from the previous year.
    • § 87355
    12 Jan 2023
    Identified that a staff member with criminal background clearance was not properly associated to the site until recently, with a $500 civil penalty assessed for that failure. Identified that another staff member’s clearance record was misencoded in the system and that residents did not receive annual medical assessments or dementia-related reappraisals, posing health and safety risks.
    12 Jan 2023
    Found staff neglect during a night shift left the memory care unit unsupervised, allowing one resident to injure another with a walking boot, resulting in a nasal fracture and a 1 cm laceration on the right side of the forehead, with prior aggressive behavior by the aggressor noted.
    • § 87468.1(a)(3)
    12 Jan 2023
    Reviewed documentation and interviews revealed failure to properly associate staff with the facility and to conduct required resident reappraisals and assessments, resulting in identified health and safety risks.
    • § 87705
    • § 87355
    09 Jan 2023
    Found no deficiencies noted; kitchen was clean with adequate food supplies and bed bug treatment used a heat machine, while staff were updating medication administration records and the central medication log.
    09 Jan 2023
    Reviewed health and safety concerns, including kitchen cleanliness and food supplies, along with medication records and pest control treatments; no deficiencies were identified during the visit.
    23 Dec 2022
    Found no health or safety hazards inside or around the home and observed sufficient staff to provide care. Noted a three-day supply of perishable food and a seven-day supply of non-perishable food, with residents' needs appearing met.
    23 Dec 2022
    Found no health or safety hazards inside or outside, adequate staffing present, and sufficient food supplies available during an unannounced health and safety check.
    16 Nov 2022
    Found Allegation 1: no marijuana given to residents by staff; Allegation 2: staff did not yell at residents; Allegation 3: food stored safely; Allegation 4: proper incontinence care provided; all four unsubstantiated.
    16 Nov 2022
    Found no evidence to support that staff gave residents marijuana, yelled at residents, stored food improperly, or failed to provide proper incontinence care.
    07 Sept 2022
    Identified that temperatures were not kept comfortable because the air conditioning in common areas and the main kitchen was inoperable, with residents and staff reporting no cooling in these areas.
    07 Sept 2022
    Found that the allegation about the licensee not maintaining a comfortable temperature was true, as the air conditioning was inoperable in common areas, leading to uncomfortable indoor temperatures reported by residents and staff.
    • § 87468.1(a)(2)
    26 Aug 2022
    Found that the allegation that activities were not provided to residents was supported by interviews and observations. Found insufficient evidence to confirm bruises occurred or that residents' nutritional needs were not met.
    26 Aug 2022
    Found that the allegation that residents did not receive activities was valid, while the claim that residents sustained bruises and that nutritional needs were unmet could not be confirmed.
    • § 87705(c)(7)
    09 Aug 2022
    Identified two deficiencies: not maintaining a full 30-day supply of N95 masks and expired food in the pantry.
    09 Aug 2022
    Found the allegation that staff do not treat residents with dignity unsubstantiated, as interviews could not corroborate it and there was insufficient evidence to prove it occurred.
    09 Aug 2022
    Found that the facility was implementing COVID-19 safety protocols, had an incomplete supply of N95 masks, and allowed an employee to work without a criminal background clearance; also identified expired food items in the pantry.
    • § 87555(b)(9)
    • § 87355(e)(1)
    01 Aug 2022
    Identified an allegation concerning a case-management deficiency being amended from a prior deficiency dated 07/28/2022.
    01 Aug 2022
    Reviewed a recent visit to amend previous deficiencies and discussed the findings with the administrator.
    28 Jul 2022
    Found that staff did not properly report incidents involving residents. The other two allegations—interfering with ongoing investigations and unlawfully evicting residents—were not supported.
    • § 87705(b)(1)
    28 Jul 2022
    Identified a nonfunctional pull cord near a resident bed and a slow staff response to a bathroom call, creating an immediate risk to residents. Also identified that unwitnessed falls were not reported, posing potential risk to residents.
    25 Apr 2022
    Identified Allegation 1: Insufficient staffing to meet residents' needs, unsubstantiated. Identified Allegations 2 and 3: Call-button response delays and unwitnessed falls, unsubstantiated.
    28 Jul 2022
    Identified a non-functioning call button near a resident’s bed and uncovered that unwitnessed falls by a resident were not properly reported, posing potential safety risks.
    • § 87211
    • § 87303
    12 Jul 2022
    Found no evidence that staff engaged in inappropriate interactions with residents, treated residents with dignity, smoked marijuana on site, administered medications improperly, or created an uncomfortable environment; staff not presently employed or visiting the facility.
    25 Apr 2022
    Investigated five allegations about staff conduct and found insufficient evidence to prove or disprove each: staff do not treat residents with respect (#1); staff use derogatory terms (#2); staff create a hostile environment (#3); staff failed to assist residents after a fall (#4); and unclear staff working (#5).
    25 Apr 2022
    Reviewed records and interviewed staff and residents regarding various concerns, found no evidence to support the allegations that staffing was insufficient, call responses were delayed, resident deaths were questionable, toileting or bathing needs were unmet, or residents experienced unwitnessed falls.
    • § 87705(b)(1)
    • § 87705(c)(4)
    • § 87303(a)
    • § 87705(c)(4)
    • § 87705(c)(4)
    25 Mar 2022
    Investigated the death of a resident with an unannounced site visit, where licensing staff identified themselves to the administrator and explained the purpose. Requested documents included ID/emergency information, admission agreement, physician's report, psychiatric and medical notes/orders, resident appraisal, medication records, and weight records, and coroner's report, police report, and death certificate were requested when available; an exit interview was conducted.
    25 Mar 2022
    Reviewed documentation related to a resident’s death following an unannounced visit, and requested additional official records from the facility.
    25 Feb 2022
    Identified the first allegation that residents were locked in their rooms as having insufficient evidence to confirm. Found no evidence to support the second allegation that staff do not assist residents or sleep, since all interviewed staff stated they assist when help is needed.
    25 Feb 2022
    Investigated allegations that residents were locked in their rooms and that staff did not assist or were sleeping; found insufficient evidence to confirm either violation.
    • § 87705(c)(7)
    02 Feb 2022
    Found no health or safety hazards inside or outside the residence; residents present, staffing adequate, and food supplies more than adequate in response to a health and safety complaint.
    02 Feb 2022
    Confirmed that during an unannounced visit, no health or safety hazards were observed inside or outside, sufficient staffing and supplies were available, and residents' needs appeared to be met.
    21 Jan 2022
    Found no health or safety concerns observed, and residents appeared well cared for with adequate staff and food. Addressed a health and safety complaint and confirmed there were no hazards present.
    21 Jan 2022
    Confirmed that during an unannounced visit, no health or safety hazards were observed inside or outside, sufficient staff and food supplies were present, and residents' needs were being met.
    18 Jan 2022
    Found no information indicating lack of care or supervision related to the resident's death after an unannounced visit following the incident where the resident was found unresponsive in the shower. Validated that medications and MARS matched, and that staff interviews supported the events surrounding the death, with the resident under home health care for ongoing conditions.
    18 Jan 2022
    Identified the specific allegation of lack of supervision resulting in a resident wandering away on 1/8/2022. Noted that the delayed egress door alarm sounded immediately when the handle bar was depressed and remained activated until a code was entered.
    18 Jan 2022
    Found that lack of supervision led to a resident wandering away from the facility, resulting in her leaving through a delayed egress door, falling, and sustaining minor injuries.
    • § 87705(k)(8)
    14 Dec 2021
    Found no evidence to support Allegation 1 that staff did not wear PPE; staff and residents reported PPE use, and supplies were ample. Found no evidence to support Allegation 2 about pests and Allegation 3 about cleanliness; pest control reports showed no infestation, residents and staff reported no pest sightings, and premises appeared clean.
    14 Dec 2021
    Found insufficient evidence to prove that staff did not wear masks or that there was a malodorous smell; observations showed entry screening, mask use, PPE, sanitizers, and no noticeable odor, though two residents were not oriented to answer questions.
    14 Dec 2021
    Investigated the allegations that staff did not wear masks and that the facility was malodorous; found no sufficient evidence to support either claim, observing proper mask use and a clean environment during the visit.
    28 Oct 2021
    Found that the allegation that staff failed to meet the resident’s needs during two falls in February 2020 was not proven.
    14 Jun 2021
    Found a strong urine odor in resident bedrooms and hallways, especially in memory care, with reports of residents using closets as toilets, and noted ongoing staffing shortages with overtime and days when only one memory care staff member was on duty. Determined that several incidents were not reported to the licensing agency, including two falls and a staff injury in 2020.
    28 Oct 2021
    Investigated the allegation that staff failed to meet Resident #1's needs after two falls; findings indicated the resident received appropriate care and the allegation was unsubstantiated.
    14 Oct 2021
    Found infection control measures in place, including a screening area, signage, adequate PPE, cleaning and hand hygiene supplies, and a designated lead tracking COVID-19 cases; staff trained in infection control, and no deficiencies were cited.
    14 Oct 2021
    Found insufficient evidence that staff did not follow proper COVID-19 protocols; observations showed entry screening, masks and PPE, training, hand sanitizers, social distancing, and isolation of residents with COVID, addressing the specific allegation.
    14 Oct 2021
    Reviewed evidence and interviews concluded there was insufficient proof that staff failed to follow COVID-19 protocols regarding masking, PPE, screening, and quarantine procedures.
    02 Aug 2021
    Determined that the administrator was not present on the premises as required. Identified that staff did not administer a resident’s medications as prescribed.
    02 Aug 2021
    Determined that the administrator was frequently absent from the premises and that staff failed to administer a resident’s medications as prescribed.
    • § 1569.618(a)
    • § 87564(a)
    16 Jul 2021
    Identified a cockroach problem, including a live roach and bait traps in the kitchen, with the kitchen not listed as serviced during a recent extermination visit. Found no evidence that staff mishandled residents' funds or failed to properly maintain the facility.
    16 Jul 2021
    Found that the allegation of a cockroach infestation was valid, with evidence of live cockroaches and live-in pests, while the allegations of staff neglecting proper maintenance and mishandling residents’ funds were unsubstantiated.
    • § 1569.256(a)(5)
    14 Jun 2021
    Found that the understaffing allegation reflected ongoing shortages and that staff from a sister location were borrowed to meet needs. Investigated the marijuana-use allegation; observed the designated smoking area, found no evidence of staff smoking or marijuana paraphernalia, and any odor appeared to come from an independent resident who leaves the site as they wish.
    • § 80065(a)
    14 Jun 2021
    Found Staff did not ensure resident is fed, unsubstantiated; diapering needs not met, unsubstantiated. Identified pests, cockroaches observed in bathrooms and around sinks, substantiated.
    • § 1569.256(a)(5)
    14 Jun 2021
    Found that the allegation that staff removed a resident's shower chair, preventing showers, was not supported by evidence; a replacement chair was provided and the original was located. Found that the allegation that residents were being fed rotten food was not supported by evidence; meals observed were fresh.
    14 Jun 2021
    Identified bed bugs at the site, including one on a resident's shirt and another inside a dryer. Noted that the allegation that staff do not provide adequate food service to residents was not supported, with observed lunch fresh and well-portioned.
    14 Jun 2021
    Identified that residents' personal records were not safeguarded, based on documents reviewed and interviews conducted.
    14 Jun 2021
    Identified disrepair in the kitchen and plumbing with sewage leaks and lengthy repair delays. Found that a staff member did not treat a resident with dignity or respect in an incident involving ethnic remarks.
    14 Jun 2021
    Found that the facility had a persistent foul odor, staff shortages that affected care, and failed to report resident falls and injuries to the appropriate authorities.
    • § 874119(a)
    • § 87705(a)(2)
    • § 87625(a)(3)
    • § 87211(a)(2)
    14 Jun 2021
    Investigated a reported bed bug presence, confirming the allegation as true after finding a bed bug inside a dryer and on a resident’s shirt; also reviewed food service quality and found no issues in that area.
    • § 1569.269(a)(5)
    23 Feb 2021
    Identified concerns included staffing turnover after a December 2019 fire with increased incidents; possible mold in ceilings, a non-functional heating and cooling system, bedrooms in poor condition, and bed bug and roach infestations, with delays attributed to COVID-19.
    23 Feb 2021
    Found issues with staffing stability and significant physical plant concerns, including mold, broken heating and cooling, damaged bedrooms, and widespread pest infestations, while also noting ongoing efforts to monitor residents' dietary needs.
    08 Oct 2020
    Investigated an allegation that an employee yelled at a resident and tipped them in a wheelchair; the resident said the employee is not nice and yells, while the employee denied intentional harm. Deficiencies were identified.
    08 Oct 2020
    Investigated an incident where a staff member was accused of tipping over a resident in a wheelchair, with interviews indicating that the staff member denied intentional harm and the resident reporting feeling unfairly treated.
    • § 80072
    27 Jul 2020
    Found adequate food and supplies for 50 residents, with meals prepared and stored properly and menus posted. Found clean, hazard-free rooms, a functioning emergency alert system with prompt responses, hot water around 110–113°F in three rooms, medications secured, and accessible fire extinguishers with shaded outdoor spaces in common areas.
    27 Jul 2020
    Confirmed that the facility was in compliance with licensing requirements, with proper safety measures, sufficient food supplies, and no immediate hazards observed during a scheduled virtual pre-licensing inspection.
    30 Apr 2020
    Found that staff and residents adhered to universal precautions such as wearing masks and gloves, taking temperatures, practicing social distancing, and using hand washing stations; the allegation that staff were not following these precautions was unsubstantiated.
    15 Apr 2020
    Confirmed that staff and residents were not consistently wearing masks, and a resident tested positive for COVID-19, with concerns about residents walking around sneezing and spreading the virus. Conducted a virtual inspection observing proper sanitation, posted signage, and staff adhering to PPE protocols.
    • § 87705(a)(2)
    • § 874119(a)
    • § 87211(a)(2)
    • § 87625(a)(3)
    09 Mar 2020
    Investigated a fire caused by faulty electrical wiring in the ceiling, which led to the building being deemed unsafe and residents being relocated to alternative care sites.
    • § 87468.1
    • § 80087(a)
    31 Jan 2020
    Investigated allegations that resident injuries were unexplained and staff failed to meet resident needs, both found unfounded; however, it was confirmed that staff did not administer medication as prescribed on a specific date.
    • § 87465(a)(5)
    27 Jan 2020
    Investigated the allegation that staff failed to administer medication and improperly managed resident behavior; found that staff ran out of medication, leaving a resident without prescribed medication for days, and also observed that staff appropriately monitored and attended to the resident's needs.
    24 Dec 2019
    Found that the facility failed to follow the admission agreement regarding a resident’s belongings and refund of unused rent money.
    • § 87506

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