Ivy Park At Cathedral Hill is a residential care home for the elderly (RCFE) in San Francisco, San Francisco County, California — state license #385600429, licensed for 210 residents, listed as licensed in the CDSS record we retrieved August 2, 2026. It does not appear on the DHCS Assisted Living Waiver participant list checked August 9, 2026 — that list covers the state waiver only, not a home's own payment arrangements. California has 40 dated inspection and complaint documents on file for this home going back to 2022, the most recent dated May 13, 2026 — published below in full, verbatim and unscored.

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Ivy Park At Cathedral Hill

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Residential care home for the elderly (RCFE) · Large community, 210 residents · San Francisco, CA · San Francisco County
LicensedWheelchairMemory careHospiceBedridden
No openings reportedBeds change hands in days ·
License #385600429, held since 2018 · read from the California state record on August 2, 2026 ·See on State Site →
1550 Sutter Street · San Francisco, San Francisco County
Phone
(415) 921-1552
from the state licensing roster · August 2, 2026
No Google listing is on file for this home.
Website
None on file
Many small homes have no website — that says nothing about the care inside.
Contact facts come from the state roster, a county Area Agency on Aging roster, the home’s Google listing, or the operator — each labelled, never blended. Operators: add or correct yours, free →
Print tour sheet →

Wheelchair / non-ambulatoryVerified in record
Dementia / memory careVerified in record
Hospice careApproved for 14 residents
Bedridden careApproved for 21 residents

“Not on file” is not a no — approvals can be bed- or room-specific, so confirm current scope with the home on a tour. Where a number is shown it is the state’s own wording for how many residents the approval covers, not how many places are open today; where none is shown, the record simply does not state one.

Specific medical needs — insulin, oxygen, a catheter, an ostomy — aren’t in the state license record; ask the home directly. A feeding tube, tracheostomy, or advanced wound care usually needs skilled nursing →

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What the state record says, word for word
AGE RANGE 60 AND OVER. 114 MAY BE NON-AMBULATORY. 21 MAY BE BEDRIDDEN IN ROOMS 201-211 AND 308-311. LICENSE IS SUBJECT TO TERMS AND CONDITIONS OF HOSPICE WAIVER FOR 14 RESIDENTS. NEW MGMT. CO, OAKMONT MANAGEMENT GROUP, LLC. EFFECTIVE DATE 7/1/22.State service designation983 - RCFE / DEMENTIAthe CDSS license record, verbatim · checked August 2, 2026

“RCFE / Dementia” is the state’s designation for a home with an approved Dementia Care Plan of Operation — it’s recorded separately from the comments above, which is why the memory-care approval may not appear in that text.

Since 2022, the state has visited this home 50 times and filed 40 documents. The most recent is a facility evaluation report, dated May 13, 2026.

Most recent state visit
July 9, 2026
Occupancy at the July 1, 2025 visit
86 of 210 beds

The state's published file for this home includes 15 documents with transcribed findings, dated April 12, 2022 to July 1, 2025. 15 of the 15 carry the state's recorded outcome word: “Substantiated” (9), “Unsubstantiated” (6). 15 include the transcribed allegation the state investigated, word for word.

Summary composed by computer from the 15 documents below — every count derives from them, and the documents themselves are the state's records, verbatim. We never grade, score, or color a record.

What the state’s words mean
Substantiatedthe state found the allegation more likely true than notUnsubstantiatedinvestigated, but couldn’t be confirmed either way — not a finding of wrongdoingUnfoundedthe state concluded it was false or couldn’t have happenedType A citationthe most serious: an immediate health-or-safety risk, usually fixed on the spot or on a short deadlineType B citationless serious, with a deadline to fix
The last 36 months — 27 of 40 documentsFull record on the state’s site →
20265 state visits · 5 documents
May 13, 2026Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Feb 26, 2026Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Feb 25, 2026Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Feb 18, 2026Complaint investigation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Jan 29, 2026Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

20256 state visits · 9 documents
Dec 23, 2025Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Dec 23, 2025Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Dec 18, 2025Complaint investigation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Dec 18, 2025Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Oct 13, 2025Complaint investigation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Oct 13, 2025Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Jul 1, 2025Complaint investigation reportUnsubstantiated

Allegation investigated: Licensee is not ensuring that resident has hot water while in care

On 7/1/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Fili Igafo. LPA toured the facility, interviewed facility staff, outside parties and made observations during the course of the investigation. Complaint alleges licensee is not ensuring that resident has hot water while in care. Upon tour of multiple resident bedrooms across several residential floors; LPA and staff tested water temperature dispensed from bathroom showers and found water temperature to be within approrpriate range. In addition, statement from reporting party provided contradicting information towards the allegation. Due to a lack of corroborating evidence the allegation is found to be unsubstantiated. Nothe state’s words, verbatim · CDSS document, Jul 1, 2025 · control 14-AS-20250602135433
Mar 26, 2025Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Feb 25, 2025Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

20248 state visits · 11 documents
Dec 27, 2024Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Nov 7, 2024Complaint investigation reportUnsubstantiated

Allegation investigated: Facility staff are locking residents in their bedrooms Facility staff are not conducting planned activities with residents

On 11/7/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Fili Igafo. LPA toured the facility, interviewed staff, gathered facility records and made observations during the course of the investigation. Complaint alleges facility staff are locking residents in their bedrooms. Based upon tours of the facility memory care unit and observations, LPA found that all resident door handles have been modified and requires a key to open from the outside of the bedroom. Complaint further alleges that residents are not able to exit due to diagnoses of dementia. Residents however are able to freely leave the bedroom as all bedroom doorknobs do not have a locking mechanism or any devices preventing residents exiting from inside the bedroom (photos taken). LPA attempted to contact Local San Francisco Fire Inspector for additional details on fire safety requirements but was unable to conductthe state’s words, verbatim · CDSS document, Nov 7, 2024 · control 14-AS-20240814165101
Nov 7, 2024Complaint investigation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Aug 28, 2024Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Aug 9, 2024Complaint investigation reportSubstantiated

Allegation investigated: Staff did not provide adequate supervision resulting in resident falling. Staff did not respond to resident's call button in a timely manner.

On August 9, 2024, Licensing Program Analysts(LPAs) John Calandra and Dominic Tobola, arrived at the facility at 9:20 AM to deliver findings for a complaint opened on March 12, 2024. LPAs Calandra and Tobola, were greeted by Tam Nguyen, Maintenance Director and explained the puprose of the visit. Fili Igafo, Executive Director arrived later during the visit. Regarding the allegation, that staff did not provide adequate supervision resulting in resident falling, the department interviewed multiple staff. Through these interviews, it was found that staff had knowledge of other staff who were preoccupied with other activities during working hours and not attending to resident’s needs. Furthermore, the LPAs learned that the there is a lapse in communication amongst staff resulting in staff, not being able to provide adequate care and supervision to persons in care. Therefore, the preponderance of evidence standard has been met and this allegation is SUBSTANTIATED. Substantiatedthe state’s words, verbatim · CDSS document, Aug 9, 2024 · control 14-AS-20240305161257
May 14, 2024Complaint investigation reportSubstantiated

Allegation investigated: Staff did not ensure emergency services were contacted in a timely manner

On May 14, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:00 AM to conduct an unnanounced Complaint Investigation. The purpose of the visit was to open a complaint received on May 9, 2024 and deliver conclusionary findings. LPA Calandra was greeted by Executive Director, Fili Igafo, and explained the purpose of the visit. LPA Calandra gathered relevant information to the above allegation, interviewed staff and collected documents. Regarding the allegation of a violation of resident’s personal right to medical services, it was found that there was at least one time that staff did not contact emergency personnel in a timely manner. Residents have medical and dental needs, and the Licensee shall provide assistance in meeting those necessary medical and dental needs. Staff have failed to do this based on information gathered. Substantiatedthe state’s words, verbatim · CDSS document, May 14, 2024 · control 14-AS-20240509102757
May 14, 2024Complaint investigation reportUnsubstantiated

Allegation investigated: Staff did not ensure they have records for new residents Facility has a pest infestation

On May 14, 2024, Licensing Program Analyst (LPA) John Calandra conducted a conclusionary complaint investigation at the facility and met with Fili Igafo, Executive Director. The purpose of the visit was to deliver conclusionary findings to the initial complaint investigation on January 4, 2024. LPA gathered information relevant to the above complaint allegation and conducted interviews with staff and residents. In regard to the allegation that the facility has a pest infestation, it was determined that while the facility had pests in the past, they had not had a pest infestation and have retained pest control services. Based on this information, the finding of this allegation is determined to be unsubstantiated. Regarding the allegation that staff did not ensure they have records for new residents, the LPA reviewed records and interviewed staff. It was determined that the facility did in fact have records for new residents. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 14, 2024 · control 14-AS-20231226123813
May 14, 2024Complaint investigation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Apr 23, 2024Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Feb 15, 2024Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Jan 4, 2024Complaint investigation reportUnsubstantiated

Allegation investigated: -Staff did not ensure they have records for new residents -Facility has a pest infestation -Staff did not keep residents personal information confidential

This report was Amended due to new information being found through the course of the investigation. Report was reviewed with Fili Igafo, Executive Director and a copy of the report left at the facility. On January 4, 2024, Licensing Program Analyst(LPA), John Calandra and Licensing Program Manager(LPM), Cara Smith arrived at the facility at 9:30 am to open a complaint with four allegations. LPA Calandra and LPM Smith met with Ella Frick, Executive Director and asked for the following documents: -Roster with apartment numbers and move-in dates. -Resident files -Pest Control Inspection Reports LPA Calandra and LPM Smith took a tour of the facility's common spaces including dining rooms and a cafe on the first, second, and fourth floors which were observed to be clean and orderly. LPA and LPM reviewed four resident records. Assessments were up to date. Newly admitted residents records were also observed to be complete. LPA and LPM collected resident documents and pest control inspection rthe state’s words, verbatim · CDSS document, Jan 4, 2024 · control 14-AS-20231226123813
20232 state visits · 2 documents
Dec 15, 2023Complaint investigation reportSubstantiated

Allegation investigated: -Staff did not administer resident's medication as prescribed -Staff do not answer resident's call button in a timely manner

On December 15, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Executive Director, Ella Frick and explained the purpose of the visit. Regarding the allegation, staff did not administer resident's medication as prescribed, according to the reporting party, Resident 1 (R1) should be receiving 200mgs of a prescribed medication daily. In addition, reporting party indicated that the prescribed medication comes in 100mg tablets so R1 should be receiving two tablets a day in the morning, the facility’s instructions were to provide one tablet a day. During the visit, LPA interviewed staff, observed R1's medications, reviewed R1's physician's orders and MAR. Based on documentation reviewed, LPA observed a discrepancy between the physician's order, the MAR system being used by the facility, and the prescription bottle that was given by the pharmacy. According to the physician's order anthe state’s words, verbatim · CDSS document, Dec 15, 2023 · control 14-AS-20231128101756
Sep 23, 2023Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Beside homes the same size
Type A citations8typical 1
Type B citations6typical 1
Substantiated complaints16typical 2
Total complaints17typical 7
State visits on file50typical 19
“Typical” is the statewide median across the 1,244 licensed larger communities (16+ beds) in the state record — larger, longer-licensed homes accumulate more visits and reports, so compare like with like. One complaint can contain several allegations. Counts cover this license since 2018.
Year-by-year trend
YearVisitsDocumentsSubstantiated202655020256902024811220237832022384
An “unsubstantiated” complaint is not a finding of wrongdoing — it means the state investigated and could not confirm the allegation. Outcome words are the state’s own; we never grade, score, or color a record.Operate this home? Respond to or correct any document here, free. Respond or correct →

See an error in these counts? Report it — free →

$6,000$9,000 /mo
our estimate — San Francisco County band, market research June 2026; not this home’s quoted price
$3,500 · statewide low$9,000 · statewide high
California’s public record holds no per-home price, so we never invent one. Ask the home for its rate sheet, or
Ways families pay here
Private pay — ask what the base rate includes and what’s billed separately.SSI/SSP — California’s board-and-care payment standard is $1,626.07/mo (2026): $1,444.07 to the home, $182 stays with the resident.Medi-Cal ALW — this home isn’t on the DHCS waiver list (checked August 9, 2026). Details →

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What dementia training does staff have, and is the area secured?
Non-ambulatory approval — whole home or specific rooms, and is a spot open?
How is medication handled and logged day to day?
What’s in the base monthly rate, and what’s billed separately?
Staff-to-resident ratio on day and night shifts?
How are medical emergencies handled after hours?

The first two come straight from this home’s record — a brochure won’t answer them.

Operate this home? This page is generated from CDSS public records — respond or correct it, free.
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Call (415) 921-1552

Is Ivy Park At Cathedral Hill licensed?

Yes — Ivy Park At Cathedral Hill is a licensed residential care home for the elderly (RCFE) in San Francisco (San Francisco County): California license #385600429, shown as licensed in the CDSS state record checked August 2, 2026, licensed for 210 residents. State records list 40 inspection and complaint documents since 2022; the most recent, a facility evaluation report dated May 13, 2026, appears in the inspection record on this page.

Can Ivy Park At Cathedral Hill care for dementia, hospice, bedridden, or non-ambulatory residents?

From the CDSS license record, checked August 2, 2026.

The CDSS license record checked August 2, 2026 lists Ivy Park At Cathedral Hill with clearances for wheelchair / non-ambulatory, dementia / memory care, hospice care, and bedridden. Clearances describe what the license permits, not day-to-day staffing — confirm current scope and availability with the home directly on a tour.

Wheelchair / non-ambulatoryDementia / memory careHospice careBedridden

From the California state record. Some approvals are bed- or room-specific — always confirm current scope with the facility.

What the state record says, word for word
Verbatim, from the CDSS license recordAGE RANGE 60 AND OVER. 114 MAY BE NON-AMBULATORY. 21 MAY BE BEDRIDDEN IN ROOMS 201-211 AND 308-311. LICENSE IS SUBJECT TO TERMS AND CONDITIONS OF HOSPICE WAIVER FOR 14 RESIDENTS. NEW MGMT. CO, OAKMONT MANAGEMENT GROUP, LLC. EFFECTIVE DATE 7/1/22.

How much does Ivy Park At Cathedral Hill cost?

California's public licensing record does not include Ivy Park At Cathedral Hill's monthly price, so we never show or estimate one for a specific home. As county-level context only, assisted living in San Francisco County typically runs $6,000–$9,000/mo and small board-and-care homes $5,000–$8,000/mo (market research compiled June 2026 — ranges, not quotes; California's 2026 SSI/SSP board-and-care payment standard is $1,626.07/month, of which $1,444.07 is the room-and-board portion paid to the home). Ask the home for its own rate sheet and what the base rate includes — or use the cost section at the top of this page.

Does Ivy Park At Cathedral Hill accept Medi-Cal or the Assisted Living Waiver?

Ivy Park At Cathedral Hill is not in the DHCS Assisted Living Waiver participant record we checked August 9, 2026 — that list covers only the state's ALW program, not a home's own payment policies, so ask the home directly about private Medi-Cal arrangements. The waiver pays for assisted-living care services (not room and board) at participating homes; every DHCS-listed home appears on our statewide Medi-Cal page.

Assisted living on Medi-Cal in California →See the DHCS list →

How full it was at the last state visit

86 of 210 beds occupied (41%) when the state visited on July 1, 2025. Availability changes constantly — confirm a current opening with the home.

What do state inspections show for Ivy Park At Cathedral Hill?

Verbatim from CDSS complaint-investigation reports — the state's own words, never summarized by us. Record checked August 2, 2026.

The CDSS state record checked August 2, 2026 lists 50 state visits and 40 dated documents since 2022 for Ivy Park At Cathedral Hill; 15 complaint-investigation narratives are transcribed verbatim below. The most recent, dated July 1, 2025, records an allegation the state marked “Unsubstantiated. Open any entry to read the state's full finding, word for word.

Most licensed homes receive some findings over 36 months; what matters is what was found and whether it was corrected. Counts here are shown compared with homes of similar size, and the state's own words appear in full below.

15 transcribed reports on file

2025

Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewedLicensee is not ensuring that resident has hot water while in care
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
On 7/1/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Fili Igafo. LPA toured the facility, interviewed facility staff, outside parties and made observations during the course of the investigation. Complaint alleges licensee is not ensuring that resident has hot water while in care. Upon tour of multiple resident bedrooms across several residential floors; LPA and staff tested water temperature dispensed from bathroom showers and found water temperature to be within approrpriate range. In addition, statement from reporting party provided contradicting information towards the allegation. Due to a lack of corroborating evidence the allegation is found to be unsubstantiated. NoCDSS inspection report, July 1, 2025 · control 14-AS-20250602135433

2024

Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewedFacility staff are locking residents in their bedrooms Facility staff are not conducting planned activities with residents
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
On 11/7/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Fili Igafo. LPA toured the facility, interviewed staff, gathered facility records and made observations during the course of the investigation. Complaint alleges facility staff are locking residents in their bedrooms. Based upon tours of the facility memory care unit and observations, LPA found that all resident door handles have been modified and requires a key to open from the outside of the bedroom. Complaint further alleges that residents are not able to exit due to diagnoses of dementia. Residents however are able to freely leave the bedroom as all bedroom doorknobs do not have a locking mechanism or any devices preventing residents exiting from inside the bedroom (photos taken). LPA attempted to contact Local San Francisco Fire Inspector for additional details on fire safety requirements but was unable to conductCDSS inspection report, November 7, 2024 · control 14-AS-20240814165101
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff did not provide adequate supervision resulting in resident falling. Staff did not respond to resident's call button in a timely manner.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
On August 9, 2024, Licensing Program Analysts(LPAs) John Calandra and Dominic Tobola, arrived at the facility at 9:20 AM to deliver findings for a complaint opened on March 12, 2024. LPAs Calandra and Tobola, were greeted by Tam Nguyen, Maintenance Director and explained the puprose of the visit. Fili Igafo, Executive Director arrived later during the visit. Regarding the allegation, that staff did not provide adequate supervision resulting in resident falling, the department interviewed multiple staff. Through these interviews, it was found that staff had knowledge of other staff who were preoccupied with other activities during working hours and not attending to resident’s needs. Furthermore, the LPAs learned that the there is a lapse in communication amongst staff resulting in staff, not being able to provide adequate care and supervision to persons in care. Therefore, the preponderance of evidence standard has been met and this allegation is SUBSTANTIATED. SubstantiatedCDSS inspection report, August 9, 2024 · control 14-AS-20240305161257
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff did not ensure emergency services were contacted in a timely manner
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
On May 14, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:00 AM to conduct an unnanounced Complaint Investigation. The purpose of the visit was to open a complaint received on May 9, 2024 and deliver conclusionary findings. LPA Calandra was greeted by Executive Director, Fili Igafo, and explained the purpose of the visit. LPA Calandra gathered relevant information to the above allegation, interviewed staff and collected documents. Regarding the allegation of a violation of resident’s personal right to medical services, it was found that there was at least one time that staff did not contact emergency personnel in a timely manner. Residents have medical and dental needs, and the Licensee shall provide assistance in meeting those necessary medical and dental needs. Staff have failed to do this based on information gathered. SubstantiatedCDSS inspection report, May 14, 2024 · control 14-AS-20240509102757
Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewedStaff did not ensure they have records for new residents Facility has a pest infestation
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
On May 14, 2024, Licensing Program Analyst (LPA) John Calandra conducted a conclusionary complaint investigation at the facility and met with Fili Igafo, Executive Director. The purpose of the visit was to deliver conclusionary findings to the initial complaint investigation on January 4, 2024. LPA gathered information relevant to the above complaint allegation and conducted interviews with staff and residents. In regard to the allegation that the facility has a pest infestation, it was determined that while the facility had pests in the past, they had not had a pest infestation and have retained pest control services. Based on this information, the finding of this allegation is determined to be unsubstantiated. Regarding the allegation that staff did not ensure they have records for new residents, the LPA reviewed records and interviewed staff. It was determined that the facility did in fact have records for new residents. UnsubstantiatedCDSS inspection report, May 14, 2024 · control 14-AS-20231226123813
Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewed-Staff did not ensure they have records for new residents -Facility has a pest infestation -Staff did not keep residents personal information confidential
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
This report was Amended due to new information being found through the course of the investigation. Report was reviewed with Fili Igafo, Executive Director and a copy of the report left at the facility. On January 4, 2024, Licensing Program Analyst(LPA), John Calandra and Licensing Program Manager(LPM), Cara Smith arrived at the facility at 9:30 am to open a complaint with four allegations. LPA Calandra and LPM Smith met with Ella Frick, Executive Director and asked for the following documents: -Roster with apartment numbers and move-in dates. -Resident files -Pest Control Inspection Reports LPA Calandra and LPM Smith took a tour of the facility's common spaces including dining rooms and a cafe on the first, second, and fourth floors which were observed to be clean and orderly. LPA and LPM reviewed four resident records. Assessments were up to date. Newly admitted residents records were also observed to be complete. LPA and LPM collected resident documents and pest control inspection rCDSS inspection report, January 4, 2024 · control 14-AS-20231226123813

2023

Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewed-Staff did not administer resident's medication as prescribed -Staff do not answer resident's call button in a timely manner
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
On December 15, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Executive Director, Ella Frick and explained the purpose of the visit. Regarding the allegation, staff did not administer resident's medication as prescribed, according to the reporting party, Resident 1 (R1) should be receiving 200mgs of a prescribed medication daily. In addition, reporting party indicated that the prescribed medication comes in 100mg tablets so R1 should be receiving two tablets a day in the morning, the facility’s instructions were to provide one tablet a day. During the visit, LPA interviewed staff, observed R1's medications, reviewed R1's physician's orders and MAR. Based on documentation reviewed, LPA observed a discrepancy between the physician's order, the MAR system being used by the facility, and the prescription bottle that was given by the pharmacy. According to the physician's order anCDSS inspection report, December 15, 2023 · control 14-AS-20231128101756
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedFacility is not meeting resident's dietary needs. Facility did not respond to resident's emergency cord.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
On July 5, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230425173240. LPA Han met with the administrator and explained the purpose of the visit. Regarding to allegation of facility is not meeting resident's dietary needs, there is no additional information forthcoming from the reporting party. However, resident-in-question (R1) stated that R1 likes the taste of the meals but R1 has chewing difficulties so R1 has requested for soft foods. However it was not honored despite several meetings with facility staff including directors. As part of the investigation, LPA reviewed documents provided by the facility, interviewed facility directors, and staff. SubstantiatedCDSS inspection report, July 5, 2023 · control 14-AS-20230425173240
Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewedResident sustained unexplained injuries while in care. Staff are not following resident's care plan. Staff are not meeting resident's showering needs. Staff do not assist resident with feeding. Facility does not provide a food menu to residents. Staff do not provide adequate laundry service. Resident's call button is not being answered in a timely manner. Authorized representative is not provided resident records in a timely manner. Staff speak to residents in an inappropriate manner. Staff are mismanaging resident's medications. Staff are not properly trained. Staff do not safe guard resident's personal items
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
On 4/24/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220701103915. LPA Han met with business office director, and explained the purpose of the visit. Regarding to allegation of resident sustained unexplained injuries while in care, the reporting party stated that R1's responsible party noted a large bruise and skin tear on R1's forearm. As part of the investigation, LPA interviewed facility staff and reviewed documents. According to facility staff, the responsible party did not report to them that R1 had a large bruise and skin tear on the forearm. However, during R1's stay, R1 was transferred to the hospital multiple times due to crying, hitting staff, and staff did not know what R1 wanted, therefore, they transferred R1 to the hospital. In addition, staff reported that there was one incident where R1 was screaming, crying, falling back on staff, repeated refusal for personal hygiene and combative througCDSS inspection report, April 24, 2023 · control 14-AS-20220701103915
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff are mismanaging resident's medications.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
On 2/21/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20221024090920 LPA Han met with the administrator and explained the purpose of the visit. Regarding to allegation of staff are mismanaging resident's medications- the reporting party stated that facility failed to administered 2 of resident #1 (R1)'s medications- medication #1 for 8 days and medication #2 for 2-3 days due to lack of medications as the facility staff did not properly follow through with the pharmacy and the physician for the refills. In addition, the reporting party stated that this matter was discovered by a former staff days later and he/she took actions by contacting the pharmacy and physician and the medications were delivered in 2 days with one of the two medications being on a higher dosage. SubstantiatedCDSS inspection report, February 21, 2023 · control 14-AS-20221024090920

Transcribed from CDSS complaint-investigation reports · record checked August 2, 2026.

What the state has logged

California has logged 50 state visits for this home as of August 2, 2026. These are the home's own counts, straight from that record — shown beside the statewide median for larger communities (16+ beds), computed across all 1,244 licensed homes of that size, because larger and longer-licensed homes naturally accumulate more visits and reports. They are facts, not a grade — a citation may be minor and since corrected, and an “unsubstantiated” complaint is not a finding of wrongdoing.

Type A citations
8
typical for this size: 1
Type B citations
6
typical for this size: 1
Substantiated complaints
16
typical for this size: 2
Total complaints
17
typical for this size: 7
State visits on file
50
typical for this size: 19
See the full inspection record on the state's site →
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