Admission, assessment, and eviction
Cited in 5 reports, with 5 deficiencies in total.
Jul 23, 2026Jun 19, 2026Mar 17, 2026Dec 19, 2025Sep 11, 2025
YORKSHIRE VILLAGE
26933 CORNELL ST, Hemet CA 92544
100 bedsLatest official report Aug 20, 2026Licensed
Additional info
- Telephone
- (951) 658-1068
- Licensee
- DORTEN ENTERPRISES
- Administrator
- TERESA MAPILIS
- Contact
- TERESA MAPILIS
- License first date
- May 18, 2018
- License effective date
- May 18, 2018
- District office
- RIVERSIDE ASC · (951) 248-2222
- Regional office
- 18
- Clients served
- 983 - RCFE / DEMENTIA
Summary
The available records show 7 Type A and 16 Type B deficiencies for this facility.
- Most recent inspection
- Aug 20, 2026
- Most recent deficiency
- Aug 7, 2026
4 later reports, from Aug 10, 2026 through Aug 20, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 54 Riverside County facilities licensed for 50 or more beds.
In the available public five-year record, CCLD published 101 reports for this facility: 46 inspections, 55 complaint investigations, and 0 licensing or administrative records.
Those records contain 7 Type A and 16 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 46
- Recorded deficiencies
- 23
- Type A deficiencies
- 7
- Type B deficiencies
- 16
- Substantiated complaints
- 12
- Repeated topics
- 5
More than the typical 7
39 in the last 12 months
Well above the typical 3
20 in the last 12 months
Well above the typical 1
7 in the last 12 months
Well above the typical 2
13 in the last 12 months
Well above the typical 1
9 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Incident reporting
Cited in 4 reports, with 4 deficiencies in total.
Resident rights
Cited in 4 reports, with 4 deficiencies in total.
Basic services and supervision
Cited in 2 reports, with 2 deficiencies in total.
Hazardous items and storage
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Inspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Complaint
Allegations1 substantiated · 7 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(2)
- Regulation authority
- CCR
What the official deficiency says
Personal Rights of Residents in All Facilities, (a) (a) Residents in all residential care facilities for the elderly shall have... personal rights: (2) To be accorded safe, healthful and comfortable...furnishings and equipment. Above requirements were not met as evidenced by: Based on observation and interviews conducted, one (1) shower chair has torn back cushion that can cause discomfort for residents. This poses potential person rights risk to residents in care.
Official plan of correction
Business office manager agreed to discuss this matter with the administrator and the licensees and send photo proof of replacement or repair via email by the POC due date.
Deadline recorded: Sep 7, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 7, 2026
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items... This requirement was not met as evidenced by: Based on observations, two laundry rooms located in building " B " (Memory Care) were found unlocked with detergent and bleach, as well as scissors were observed unattended and accessible. This posed an immediate health risk to residents in care.
Official plan of correction
Facility will ensure hazardous items and sharp objects are inaccessible to residents by making sure that laundry doors stay locked and that scissors are picked up and put away as soon as the resident is finished using them. Medtechs will have meetings during each shift to remind care staff to keep the laundry doors locked and to keep scissors put away when not in use by the resident who is authorized to have scissors. Written proof of refresher training will be proved to the department by the POC date of 7/30/26.
Deadline recorded: Jul 30, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jul 30, 2026
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
87463 Reappraisals, (a)The pre-admission appraisal, as specified in Section 87457..., shall be updated in writing as frequently as necessary..., the updated pre-admission..., the reappraisal. This requirement was not met as evidenced by: Based on records review, staff did not conduct reassessment on Resident #1 after multiple falls occurred in one month in 2025. This posed potential health and safety risks to residents in care.
Official plan of correction
Medtech manager agreed to discuss the matter with the licensee and the administrator and send meeting notes involving resident wellness coordinator who is responsible for reassessment to LPA by the POC due date.
Deadline recorded: Aug 6, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 6, 2026
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 6 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Allegations1 substantiated · 3 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.1(a)(1)
- Regulation authority
- CCR
What the official deficiency says
(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met with evidence by (3) three out of (3) three residents were not accorded dignity in their personal relationship with staff.
Official plan of correction
Business Office Manager Nicole Anguiano agreed to hold an in-service training for staff pertaining to Section 87468.1 Resident Personal Rights. Proof of training completion will be submitted to LPA by Close of Business on 7/16/2026. Licensee shall forward an email informing the contents
Deadline recorded: Jul 3, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jul 3, 2026
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Complaint
Allegations2 substantiated · 3 unsubstantiated · 0 unfounded · 2 cited · investigated over 3 visits
Not classified in the sourceType B
- Official classification
- Type B
- Official code
- 87469(c)(3)
- Regulation authority
- CCR
What the official deficiency says
(c)If a resident who has an advance directive… facility staff shall do one of the following: (3) is experiencing a life-threatening emergency …directly related to the expected course of the resident’s terminal illness, the facility may immediately notify the resident’s hospice agency in lieu of calling emergency response (9-1-1). For emergencies not directly related … staff shall immediately telephone emergency response (9-1-1). This requirement was not met with evidence by: Emergency services were not contacted for R1 after R1 sustained a hematoma as a result of a fall.
Official plan of correction
All staff will complete an outside vendor training will be conducted covering how to determine a life threatening emergency requiring emegency response (9-1-1). Proof will be submitted to LPA via email by Close of Business on 7/14/2026.
Deadline recorded: Jul 14, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jul 14, 2026
Correction not verified in available records
Complaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 7 unsubstantiated · 0 unfounded · investigated over 3 visits
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87224(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph(5) (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not comply with the section cited above. Licensee did not follow the eviction procedure, which posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
Licensee agreed to conduct a training on eviction procedure by an outside vendor and submit proof of completion by POC due date.
Deadline recorded: Jul 20, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jul 20, 2026
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Complaint
Part of the complaint whose outcome is recorded on Jun 30, 2026 · Control 18-AS-20260528162825
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Jun 24, 2026 · Control 18-AS-20240206101016
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 10 unsubstantiated · 0 unfounded · investigated over 2 visits
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Part of the complaint whose outcome is recorded on Jun 16, 2026 · Control 18-AS-20220531102055
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Allegations2 substantiated · 4 unsubstantiated · 0 unfounded · 2 cited
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87625(b)(3)
- Regulation authority
- CCR
What the official deficiency says
(b)…the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry…This requirement was not met as evidenced by: Based on interviews and records review staff did not ensure that R1 was clean and dry, and was observed soiled in urine on different dates and different times. This poses a potential health saftey or personal rights risk for residents in care.
Official plan of correction
The POC is to conduct outside resource training regarding incontinence care and reporting/documenting resident self neglect. Proof of training for staff and administration is due by the POC due date. *The deficiency is part of an amended report.
Deadline recorded: Jul 10, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jul 10, 2026
Correction not verified in available records
Basic services and supervisionType B
- Official classification
- Type B
- Official code
- 87464(f)(4)
- Regulation authority
- CCR
What the official deficiency says
(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident…with those activities of daily living such as…bathing and assistance…This requirement was not met as evidenced by: Based on interviews and records review facility did not ensure R1 was assisted in bathing for a week. This poses a potential health saftey or personal rights risk for residents in care.
Official plan of correction
The POC is to conduct outside resource training regarding resident bathing and reporting/documenting resident self neglect. Proof of training for staff and administration is due by the POC due date. *The deficiency is part of an amended report.
Deadline recorded: Aug 26, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 26, 2026
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Jun 30, 2026 · Control 18-AS-20260528162825
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)(D)
- Regulation authority
- CCR
What the official deficiency says
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.. (D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met with evidence: Facility not maintaining proof of FAX transmittal receipt verifying the UIR was forwarded to CCL and CCL not having proof of receipt of the incident on 5/27/2026.
Official plan of correction
Upper management is to review Reporting Requirements, Section 87211, and provide the department with a signed affidavit confirming that the section was read. The facility will maintain copies of FAX transmittal receipts and/or email copies of any incident reports sent to the Department.
Deadline recorded: Jun 25, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jun 25, 2026
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.1(a)(3)
- Regulation authority
- CCR
What the official deficiency says
Personal Rights of Residents in All Facilities, (a) Residents in all residential care facilities for the elderly.... (3) To be free from punishment...such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on observations, Residents 1, 2, 3, & 4 did not know how to release themselves from geriatric chair. This posed immediate personal rights risk to residents in care.
Official plan of correction
Licensee agreed to stop using the geriatric chairs until updated physicians' orders for the residents are obtained by the licensee. Licensee will send proof of in-service training to LPA via email by the POC date.
Deadline recorded: Jun 9, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jun 9, 2026
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Complaint
Allegations3 substantiated · 1 unsubstantiated · 0 unfounded · 3 cited
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be..., (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Licensee did not ensure that staff dispense medication from correct resident's medication container. This posed potential health and safety risk to residents in care.
Official plan of correction
Licensee agreed to provide in-service traning on medication management and send proof to LPA via email by the POC due date.
Deadline recorded: May 14, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 14, 2026
Correction not verified in available records
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)(D)
- Regulation authority
- CCR
What the official deficiency says
87211 Reporting Requirements, (a) Each licensee shall furnish to the licensing agency such reports..., (1) A written report shall be submitted to the licensing agency..., (D) Any incident which threatens the welfare, safety or health of any resident.... This requirement was not met as evidenced by: Licensee did not report the incident involving medication error to all relevant parties. This posed potential health and safety and personal rights risk to residents in care.
Official plan of correction
Licensee agreed to provide in-service traning on reporting requiements and send proof to LPA via email by the POC due date.
Deadline recorded: May 14, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 14, 2026
Correction not verified in available records
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
87309 Storage Space and Access, (a) Except as specified in subsection (b), the licensee shall ensure that ... knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by: Licensee did not ensure knives were inaccessible to R3 who followed a staff member into kitchen and took a knife. This posed immediate health and safety risk to residents in care.
Official plan of correction
Licensee stated that in-service training was already conducted immediately after the incident and locked storage was purchased so that sharp and dangerous items are double locked along with locked kitchen door.
Deadline recorded: May 14, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 14, 2026
Correction not verified in available records
Complaint
Allegations0 substantiated · 4 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
Admission, assessment, and evictionType A
- Official classification
- Type A
- Official code
- 87463(j)
- Regulation authority
- CCR
What the official deficiency says
(j) The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements - General, to support each residents physical, social, emotional, safety and health care needs, as identified in their current appraisal. This requirement was not met as evidenced by: Observing staff schedule and interview with Executive Director. Staff was unable to redirect or prevent unnoticed elopement of R1. R1 Went unnoticed for over 2 hours.
Official plan of correction
Executive Director reported the facility will schedule an additional staff member for the noc shift to help monitor residents every 30 minutes and check facility exits. Training for elopement will be conducted with all staff. Proof of correction to be submitted to LPA by close of business on 03/18/2026.
Deadline recorded: Mar 17, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 17, 2026
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 3 unfounded · investigated over 2 visits
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Mar 5, 2026 · Control 18-AS-20250828112158
No deficiencies recorded in this reportInspection
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(b)(1)(C)
- Regulation authority
- CCR
What the official deficiency says
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. (1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to:(C)behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations, lacking in hazard awareness, or lacking in impulse control. This requirement was not met as evidenced by: LPA also reviewed Unusual Incident/Injury Reports (LIC 624s) reporting R1's unwitnessed incidents occurring on 06/01/2024, 06/13/2024, 06/14/2024, and 06/17/2024 where R1 was reportedly found on the floor inside and outside of the facility. BOM Anguiano reported she was unable to find documentation of an updated reappraisal noting a plan to address R1's change of condition related to the unwitnessed incidents noted above. This poses a potential health/safety risk to residents in care.
Official plan of correction
Wellness Director reported the facility will conduct an in-service staff training regarding resident reappraisals. Proof of correction to be submitted to LPA by close of business on 01/02/2026.
Deadline recorded: Jan 2, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jan 2, 2026
Correction not verified in available records
Complaint
Allegations0 substantiated · 9 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(a)(3)Fires or explosions which occur in or on the premises shall be reported immediately to the local fire authority; in areas not having organized fire services, within 24 hours to the State Fire Marshal; and no later than the next working day to the licensing agency. This was not met with evidence by: Facility staff did not report fire evacuation in Building B's of the (42) forty-two residents the next working day as required. The facility submitted an incident report of the fire evacuation of Building B's for (42) forty-two residents on 3/17/2025.
Official plan of correction
Wellness Director, Haley Logan, agreed to enroll in a training from an outside provider for all managing members regarding reporting requirement, section 87211. The POC will need all managing staff to submit proof of completion to LPA no later than close of business on 10/3/2025.
Deadline recorded: Oct 3, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 3, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 0 unsubstantiated · 5 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87464(f)(6)
- Regulation authority
- CCR
What the official deficiency says
87464 Basic Services: (f) Basic services shall at a minimum include:(6) Arrangements to meet health needs,... This requirement is not met as evidence by: Based on medication review and documents reviewed licensee did not ensure medications for R1,R2,R4,R6,R7,R8,R9 were available at the facility for the residents which poses an immediate risk to the health, safety, or personal rights of the persons in care.
Official plan of correction
Administrator will certify in writing that will provide training to staff, will obtain all missing medication, and ensure that medication list is current by POC due date: 9/17/25. Administrator will submit a copy of training provided, and picutres of medication missing for R1,R2,R4,R6,R7,R8,R9 by 9/23/25.
Deadline recorded: Sep 17, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 17, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they were aware of the disrepair of R1’s floor at least two months before 08/02/2023, but did not repair the floor, which posed an immediate health and safety risk to residents in care.
Official plan of correction
During today's visit, LPA observed the floor to have been repaired.
Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.
Corrective action observedRecorded in report dated Sep 11, 2025
Correction deadline recordedDeadline Oct 10, 2025
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they did not complete a reappraisal of R1 following R1’s hospitalizations for falls on 06/25/2021 and 03/19/2023, which posed a potential health and safety risk to residents in care
Official plan of correction
The licensee will conduct training on Reappraisals requirements and provide proof of training and materials used by POC due date
Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 10, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 2 unsubstantiated · 0 unfounded · 1 cited
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)(D)
- Regulation authority
- CCR
What the official deficiency says
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case (D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records review, Licensee only reported to the Department 2 out of 23 incidents that occurred with R1, which poses a potential health and safety risk to residents in care.
Official plan of correction
Licensee stated they will schedule training for themselves and all staff on mandated reporting requirements. Proof of training and materials used will be submitted to the Department by the POC due date
Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 10, 2025
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 0 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Jun 24, 2026 · Control 18-AS-20240206101016
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 0 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 1 unfounded · 1 cited · investigated over 2 visits
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(8)
- Regulation authority
- CCR
What the official deficiency says
Personal Rights of Residents in All Facilities: (a) Residents in all RCFEs shall have all of the following...rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services...This requirement was not met, as evidenced by: Based on interviews, the licensee did not ensure R1's right to have their representative informed of activities related to care was met. Admin. revealed the responsible party of R1 wasn't notified due to R1 receiving services from a hospice agency, who would have reached out to the responsible party for notification.
Official plan of correction
The Administrator stated in-service training will be provided to staff regarding notifying family members of hospice residents of any health changes.
Deadline recorded: Apr 29, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Apr 29, 2024
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Apr 22, 2024 · Control 18-AS-20240417082812
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(A)
- Regulation authority
- CCR
What the official deficiency says
87411 Personnel Requirements- General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure facility personnel to be sufficient in numbers and competent to provide the services necessary to meet resident needs.
Official plan of correction
Facility agrees to revisit the schedule for the assisted living building that may include increasing more staff or have more frequent checks to ensure there is consistent supervision, as well as provide additional training on supervision and safety of residents. Facility will provide training log and revised staffing schedule to the Department by POC date of 3/22/2024.
Deadline recorded: Mar 22, 2024. A deadline is not proof that correction was completed.
Citation dismissed - not a correctionOn Mar 22, 2024
Deficiency Dismissed Type B 03/22/2024 Section Cited CCR 87411(A)
Plan of correction recorded
Correction deadline recordedDeadline Mar 22, 2024
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1
- Regulation authority
- CCR
What the official deficiency says
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(11) To have their visitors....permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not being met as evidenced by: Based on interviews obtained, it was determined that this poses a potential health and safety risk to residents in care.
Official plan of correction
Licensee to self certify that they have reviewed the regulation, and send LPA an email detailing completion by 12/28/21.
Deadline recorded: Dec 28, 2021. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Dec 28, 2021
Correction not verified in available records
Complaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
No deficiencies recorded in this report
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology