Westmont at San Miguel Ranch.
Westmont at San Miguel Ranch is Ranked in the top 44% of California memory care with 6 CDSS citations on record; last inspected Feb 2026.
A large home, reviewed on public record.
Compared to 123 California facilities with a similar number of beds.
RCFE · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
among peers to rank.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
FACILITY WATCH · FREE
Westmont at San Miguel Ranch has 6 citations on record. Know the moment anything changes.
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Citation history, plotted month by month.
6 deficiencies on record. Each bar is a month with a citation.
Finding distribution
6 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour
“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Westmont at San Miguel Ranch's record and state requirements.
This facility holds a 105-bed license but operates without a formal memory-care designation from CDSS — what dementia-specific programming and staff training do you provide to residents with cognitive impairment, and can you provide written documentation of that program?
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No state inspection reports appear on file with CDSS for this facility — can you provide the date of your most recent licensing inspection and a copy of the inspection report for prospective families to review?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Zero complaints have been filed with CDSS for this location — what internal incident-reporting and quality-assurance processes do you use to track and address resident or family concerns before they escalate to state complaints?
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Every inspection visit, verbatim.
27 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-02-25Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that staff handled a resident roughly during toileting assistance, causing injury. An investigation on February 11, 2026 found no corroborating evidence: the resident reported staff were respectful and trying to help, other residents and staff denied any rough handling occurred, no injury was visible, and care records contained no documentation of an incident. The allegation was unsubstantiated.
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(Continue from LIC9099) A review of facility and resident records revealed that R1 has a documented diagnosis of mild cognitive impairment. R1 was unable to recall specific details of the alleged incident. However, during interviews, R1 stated that staff were nice, treated them with respect, and did not intentionally hurt them, but were attempting to assist with incontinent care. Interviews conducted with residents, staff, and outside sources did not disclose any corroborating evidence to support the allegation. Residents and outside sources did not express concerns regarding staff mishandling residents in an inappropriate manner. Staff interviews consistently indicated that direct care staff receive appropriate training, including proper techniques for assisting with transfers and activities of daily living, to ensure the health and safety of residents. Staff reported that care is provided in accordance with residents’ individualized service plans. Staff denied the allegation and stated they were not aware of any incidents involving residents reporting pain or sustaining injury following toileting assistance. During a visit to the facility on February 11, 2026, R1 was observed with no visible signs of abuse or neglect. Additionally, a review of R1’s daily notes for the relevant time period did not reveal any documentation supporting the allegation. Based on observations, record reviews, and interviews conducted with staff, residents, and outside sources, there was insufficient evidence to support the allegation that staff handled R1 in a rough manner causing injury. The preponderance of evidence standard was not met; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted with Executive Director, Jessica Zepeda. A copy of this report and the Licensee Appeal Rights (LIC 9058, 03/22) and LIC811, were provided at the conclusion of the visit.
2026-02-12Annual Compliance VisitType A · 1 finding
Plain-language summary
This routine inspection found that the facility failed to promptly send a resident to the hospital when an abscess on the resident's buttock began draining; the resident later developed sepsis and cellulitis from the wound. Staff noticed the drainage on March 11 but did not send the resident to the hospital until March 15, four days later, which was too long to wait given the infection risk from an open wound. The facility received a $500 penalty and was required to develop a plan to correct this issue, while a separate allegation about bathing frequency was found unsubstantiated.
“Based on interviews and records review, the facility did not meet the needs of R1 as R1s condition had changed due to the abscess having some kind of discharge. Even though staff did provide the required care the facility should have sent R1 out of the facility immediately, as the discharge from the open wound was now a portal for an infection as R1 had sepsis, which poses an immediate health and safety risk to residents in care.”
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(Continue from LIC9099) On 03/11/2025, it was noticed by the caregivers, that R1s abscess had some kind of drainage, but R1 was not complaining of pain or discomfort, the facility attempted to contact the hospital but there was no contact made. On 03/14/2025, a caregiver let a staff, S1, know there were two spots on R1s coccyx area, and one was open, but R1 had no complaints of pain or discomfort. An ointment was put on the area for comfort and the facility was observing the area. That same day S1 left a message for R1s doctor regarding the abscess discharge on R1s right buttock. Later that evening R1s doctor wanted to see R1, an appointment was scheduled for 03/15/2025, at 11:10 a.m. The facility contacted R1s family member but the appointment was cancelled for 11:10 a.m. On 03/15/2025, S1, then made arrangement for R1 to be sent out as a non-emergency transport, arriving at hospital at approximately 4:00 p.m. Records stated that R1s abscess looked quite large with possible extension to the muscle tissue, however on further evaluation the abscess did not extend into the muscle tissue and did not require operating room surgical intervention. The report stated there was no evidence of necrotic or infected tissue, however, R1 did have sepsis due to right gluteal abscess and cellulitis. Based on the information and evidence obtained, the facility did not meet the needs of R1 as R1s condition had changed due to the abscess having some kind of discharge. Even though staff did provide the required care the facility should have sent R1 out of the facility immediately, as the discharge from the open wound was now a portal for an infection as R1 had sepsis. Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Business Office Director, Ellen Arguello. (Continue at LIC9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continue from LIC9099C) An immediate civil penalty of $500 was assessed today. In accordance with Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Community Care Licensing Division. An exit interview was conducted with Business Office Director, Ellen Arguello who was provided with a copy of this report, the LIC 9099-D Deficiency Report, LIC411 IM, the LIC 811 Confidential Names List, and the LIC 9058 Licensee Appeal Rights. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continue from LIC9099A) For the allegation of Staff did not meet resident's bathing needs, RP stated that R1 is only bathed 2x per week. S3 stated that R1s Service Plan says two times a week for showers. S8 added that R1 didn’t like showers, so R1 would have bed baths. Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Business Office Director, Ellen Arguello, who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continue from LIC9099A) Based on interviews and records review, the department has determined that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegation is UNFOUNDED. An exit interview was conducted with Business Office Director, who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights.
2026-02-12Complaint InvestigationMixedType A · 1 finding
Plain-language summary
A complaint investigation found that a resident wearing an alarm sensor was able to leave the facility without supervision on September 14, 2024, walked to a nearby bus stop, and sustained an unwitnessed fall that resulted in a knee wound; the facility was cited for inadequate supervision and assessed a $500 penalty. Allegations about how the facility handled the resident's medical care after the fall and claims about unlawful eviction were either unsubstantiated or unfounded based on medical records and discharge planning documentation.
“Based on interviews and records review, R1 was able to elope from the facility on 09/14/2024 due to lack of care and supervision which poses an immediate Health, Safety, or Personal Rights risk to persons in care.”
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(Continue from LIC9099) According to R1s records, facility staff will support the resident with orientation, redirection, and wayfinding. It is also noted R1 cannot leave the facility unassisted. The facility utilizes a system that activates alarmed doors when the sensor the resident is wearing is in close proximity to exiting the area. S1 stated R1 had this sensor and staff would watch R1 sit outside the front of the facility. S2 stated he/she saw R1 walk outside through the computer screen and called for staff assistance. From S2s vantage point behind the concierge’s desk, there is no line of sight to the bench in front of the facility. S3 responded to S2s call for assistance. While outside of the facility, S2 and S3 called out for R1. S3 stated, “We found R1 by the bus stop on the public street corner.” S2 and S3 did not see R1, nor did R1 say he/she fell or was injured. However, on initial assessment, S2 stated that S2 saw a wound on R1s right knee. R1 was able to elope from the facility on 09/14/2024. No supervision was being provided to R1 which allowed R1 to make his/her way to the bus stop and sustain an unwitnessed fall that resulted in serious injury. Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Business Office Director, Ellen Arguello. An immediate civil penalty of $500 was assessed today. In accordance with Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Community Care Licensing Division. An exit interview was conducted with Business Office Director, Ellen Arguello, who was provided with a copy of this report, the LIC 9099-D Deficiency Report, the LIC 811 Confidential Names List, and the LIC 9058 Licensee Appeal Rights. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continue from LIC9099A) The facility staff denied R1 exhibited signs and symptoms of serious injury upon return to the facility, and the days following the unwitnessed fall. The facility staff also denied R1 requested for emergency medical services as well. R1 received day care center services offsite. On 09/16/2024, a Licensed Vocational Nurse (LVN) assessed R1 right knee as it was scraped and swollen. A Registered Nurse (RN) documented the R1s fall at the facility on 09/14/2024. Basic wound care was provided for knee abrasion and complaints of right knee pain. During the interview with health care provider, Director of Quality and Compliance (DQC), stated R1 was seen each day at the clinic from 09/16/2024 to 09/19/2024, and the scrapes to the knee were cleansed. Documentation shows facility staff provided first aid to R1s knee on 09/14/2024, and the resident was also assessed by licensed medical professionals on 09/16/2024. Based on interviews and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Business Office Director, Ellen Arguello, who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (continue from LIC9099A) Also on the records, it was noted that an RN from the hospital reviewed the care plan for R1 with the facility resident services director (RSD) and reported the services delivered are consistent with the care plan. For the allegation of Staff did not follow reporting requirements, the facility submitted an incident report to Licensing and also to R1s doctor. Responsible parties were also contacted. Regarding the allegation of Unlawful eviction, records show that upon discharge to the hospital, R1 hasn’t come back to the facility. Transition of care (TOC) team met with RSD on 9/25/24 and noted that RSD understands R1 needs to be discharged from skilled nursing facility and they are willing to accept R1 back temporarily while a new facility is found for her, due to R1 having a higher level of care needed. Per facility, R1, will have to move from the assisted living side and go to memory care side. On the same day, RSD noted that a call from a family member regarding expediting R1s discharge from skilled nursing, RSD educated family member regarding discharge process and resident's care. On 9/26/24, an inter disciplinary team (IDT) contacted responsible party to discuss the recommendation of memory care placement. Responsible party agreed with the plan to move R1. Based on records review, the department has determined that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. An exit interview was conducted with Business Office Director, Ellen Arguello , who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights.
2026-02-11Complaint InvestigationNo findings
Plain-language summary
This was the facility's required annual inspection, conducted without advance notice. The inspector found the facility clean and well-maintained, with adequate staffing records, food supplies, emergency equipment, and safety measures in place, and no violations were cited.
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified herself upon arrival and was greeted by Executive Director Jessica Zepeda. The purpose of the visit was discussed with Executive Director Zepeda and Business Office Director Ellen Arguello. According to the facility license, the approved capacity is 105 residents, all non-ambulatory, with up to seven bedridden residents permitted on the first floor only. At the time of inspection, facility records indicated 89 residents in care, including 45 non-ambulatory residents and 23 residents in the memory care unit. No residents were bedridden. During the visit, the LPA toured the interior and exterior of the facility with Executive Director Zepeda, inspected common areas and a sample of resident bedrooms, reviewed staff and resident records, and conducted private interviews with staff and residents. All reviewed records contained the required documentation. The facility was clean, sanitary, and in good repair. Pathways were clear of obstructions and slip hazards. Resident bedrooms contained required furnishings. Doors, windows, screens, toilets, and showers were in working order. Adequate linens, hygiene supplies, and personal protective equipment were available. (Continue at LIC809C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (continue from LIC809) The facility had sufficient space and equipment to support dining, laundry, visitation, meetings, and resident activities. Confidential records and centrally stored medications were secured in locked areas. Food supplies met regulatory requirements, including at least two days of perishable food and seven days of nonperishable food. Cooking and dining utensils were sufficient for meal service. The walk-in refrigerator temperature measured 40°F and the walk-in freezer measured 0°F, both within required ranges. Emergency food and water supplies sufficient for three days for 110 persons were maintained. The facility’s ambient indoor temperature measured between 72°F and 74°F. Hot water temperatures in resident-use taps were within the compliant range. No sharp objects, toxic chemicals, poisons, fireplaces, or open-faced heaters were accessible to residents with dementia. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are stored at the facility. Smoke detectors, fire alarms, carbon monoxide detectors, emergency lighting, and the facility telephone were operational. Fire extinguishers were serviced within the past 12 months. A complete first aid kit was present and readily accessible. Proof of current business liability insurance was provided. Required licensing postings were observed in visible areas. Based on LPA observation and staff interview, the facility utilizes delayed-egress doors in the secured memory care unit. No deficiencies were cited during today’s visit. An exit interview was conducted with Business Office Director Ellen Arguello. A copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) was provided during the visit.
2026-01-30Other VisitNo findings
Plain-language summary
A resident accused a staff member of theft, but an investigation found no evidence to support the claim. The resident has a documented history of accusing people of stealing items that are later found, and their family confirmed this pattern has affected their personal relationships; the family expressed confidence in the facility and staff. No violations were found.
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[CONTINUED FROM LIC9099] S2 corroborated what was told by S1, and explained the fixation that AV had with them is due to AV’s mental state and the fact that when the resident first started with the facility, they were friendly with each other. On one occasion, AV mentioned that they lost money in their room and S2 offered to help, after which the accusations started. Resident 1 (R1), was familiar with AV and explained that AV had made accusations of stolen items in the past. R1 did not report the incidents due to doubts of the accusations being real, and due to AVs memory loss. LPA attempted to interview AV, however they were disoriented and not able to qualify for an interview, as they were not aware of the day nor were they able to confirm approximately how long they had lived in the facility. AV said they had no complaints against the facility at first, but after a while they stated that their objects and money was stolen and accused S2 of theft. On January 28, 2026, LPA interviewed AV’s responsible party (RS). RS stated that AV has a history of continuously reporting lost or stolen items and then finding them back. Per RS, that behavior has been repeated constantly affecting AV’s personal life due to accusing people close to them and loved ones. AV had also accused family members of stealing the same items for which they now accuse S2. RS was confident the items were not stolen. RS had no complaints about the facility or any of the staff and felt that AV could not be in a better place. On a visit on January 30, 2026, LPA interviewed the facility administrator (ADM) who provided records of the resident complaint as well as notes of the meeting held with AV and RS which corroborated that RS was aware of the situation and the proper actions were taken. Based on records reviewed, LPA observations, and interviews conducted with the victim, the victim’s POA, clients, and staff, the preponderance of evidence standard has not been met, and the allegation is deemed unsubstantiated. No deficiencies were cited in accordance with the California Code of Regulations. An exit interview was conducted with Facility Administrator Jessica Zepeda. A copy of this report and the Licensee Appeal Rights (LIC 9058, 03/22) were provided.
2025-11-10Complaint InvestigationUnsubstantiatedNo findings
2025-03-10Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that the facility charged a resident for a higher level of care on December 20, 2023, without a documented change in the resident's medical condition. However, the investigation found that the resident's medical records showed a steady decline in condition starting months earlier, with each care level increase documented in assessments signed by the resident's family member, and billing records confirmed the charges matched the care actually provided. The complaint was unsubstantiated.
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(Continue from LIC9099) It was specifically alleged that R1 was charged for a level of care increase on December 20, 2023, despite no documented change in R1’s medical condition per R1’s attending physician. However, a detailed review conducted on June 4, 2024, of R1’s medical records, health and service evaluations, and service care plans from May 16, 2022, through June 1, 2024, indicated a significant decline in R1’s medical condition (see details of the change in R1’s condition below). Additionally, a comprehensive review of R1’s account summaries and billing statements for the period in question (October 24, 2023, through June 1, 2024) confirmed that the charges accurately reflected the level of care provided by facility staff (see details of the billing statements below). Lastly, interviews with staff and with external sources did not corroborate the claim that R1’s level of care remained unchanged. Details of R1’s change in condition: The physician's report at the time of admission, dated July 6, 2022, indicated that R1 was diagnosed with Alzheimer’s disease, secondary diagnosis dementia with behavioral disturbance, hypertension, (high blood pressure), hyperlipidemia (abnormally high levels of cholesterol, triglycerides or other lipids in the blood), DYNA (group of serious and complex conditions that are caused by malfunction of the autonomic nervous system), CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), A-fib atrial fibrillation (irregular and rapid beating of the ventricles. On May 16, 2022, when R1 moved into the facility under the Memory Care level 2 service care plan. R1's responsible party reviewed and signed the service care plan on July 12, 2022. On September 27, 2022, R1’s assessment indicated a change in condition and an increase in level of care due to increased checks to 4x additional checks per shift. The prior assessment showed that R1 did not need additional checks. The service care plan was signed by R1’s responsible party on October 1, 2022. (Continue at LIC9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continue from LIC9099C) On March 24, 2023, R1’s assessment indicated a significant change in condition. R1's level of care increased to MC- level 3. The main contributing factor for the increase in the level of care was due to incontinence care increased to maximum assistance. R1’s prior assessment showed that R1 was independent in this category. In addition, R1 required daily assistance with special medications (creams and hydrocortisone cream). In the earlier assessment, R1 did not require any special medications. The service care plan was reviewed and signed by R1’s responsible party on March 24, 2023. On June 8, 2023, R1’s assessment showed a significant change in condition. R1's level of care increased to MC - Level 5, R1 required a higher level of care due to several medical condition changes. R1 required maximum assistance with special care needs, and R1 required daily assistance with oxygen use. The care team assisted in meeting R1's care needs with oxygen use to improve R1's quality of life. In addition, R1's change in condition required moderate assistance to provide frequent help due to disorientation, memory loss, difficulty completing tasks, increased episodes of memory, and/or cognitive impairment. Moderate assistance with wandering to other residents' rooms and R1 attempting to leave the building. R1 required daily intervention due to disruptive, aggressive, or socially inappropriate behavior. R1 care team was required to intervene due to R1's uncooperative and resistance to care, R1 had significantly increased levels of depression, anxiety, and/or mood disorder. The assessment and service care plan were reviewed with R1’s responsible party on June 8, 2023. On December 20, 2023, R1’s assessment showed a significant change in condition. R1's level of care increased to MC Level 7 (highest level of care). R1 required maximum assistance in all areas of care to meet R1’s needs. R1’s level of care increased with transfers from 0 to 60 maximum assistance due to requiring 2-person assistance due to R1 becoming non-weight-bearing. Assistance with mobility increased from 0 to 65 maximum assistance requiring 2-person assistance with observation and fall management. R1’s meals and nutrition needs increased from 0 to 30 maximum assistance requiring special cutting/preparing food (mechanically soft) and/or prompting throughout the meal. R1’s responsible party reviewed and signed the assessment and service plan on April 13, 2024. (Continue at LIC9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continue from LIC9099C) On 2/16/2025 LPA Garcia-Centeno reviewed the invoice billings from October 24, 2023, to June 2024. The allegation was that the resident was charged for services not rendered for this period. Statement period Payment due date MC Level Rent MC Charge Net Due 10/24/23 - 11/22/23 12/1/2023 MC Level 3 $4,476.15 $2,000 $2,000 11/22/23 - 12/22/23 01/01/24 MC Level 3 prorated 12/20 - 12/31/23 (credit) $ 4,4745 $2,000 - $774.19 $1,225.81 MC Level 7 prorated 12/20 - 12/31/23 $3,900 $$3,900- $2,390 $$1,509.68 $2,735.49 12/22/2023 - 1/22/24 02/01/24 Care - MC 7 2/1/24 to 2/29/24 $4,745 $3,900 $3,900 1/22/24 - 2/21/24 3/1/24 Care - MC 7 3/1/24 to 3/31/24 $4,745 $3,900 $3,900 2/21/24 - 3/18/24 4/1/24 MC Level 7 4/1/24 to4/30/24 $4,745 $3,500 Care - MC 4/1/24 to 4/30/24 $400 $3,900 3/18/24 - 4/23/24 5/1/24 MC Level 7 5/1/24 to 5/31/24 $4,745 $3,500 Care - MC 5/1/24 to 5/31/24 $400 $3,900 4/23/24 - 5/21/24 6/1/2024 MC Level 7 6/1/24 to 6/30/24 $4,745 $3,500 Care - MC 6/1/24 to 6/30/24 $400 $3,900 (Continue to LIC9099C) Statement period Payment due date MC Level Rent MC Charge Net Due 10/24/23 - 11/22/23 12/1/2023 MC Level 3 $4,476.15 $2,000 $2,000 11/22/23 - 12/22/23 01/01/24 MC Level 3 prorated 12/20 - 12/31/23 (credit) $ 4,4745 $2,000 - $774.19 $1,225.81 MC Level 7 prorated 12/20 - 12/31/23 $3,900 $$3,900- $2,390 $$1,509.68 $2,735.49 12/22/2023 - 1/22/24 02/01/24 Care - MC 7 2/1/24 to 2/29/24 $4,745 $3,900 $3,900 1/22/24 - 2/21/24 3/1/24 Care - MC 7 3/1/24 to 3/31/24 $4,745 $3,900 $3,900 2/21/24 - 3/18/24 4/1/24 MC Level 7 4/1/24 to4/30/24 $4,745 $3,500 Care - MC 4/1/24 to 4/30/24 $400 $3,900 3/18/24 - 4/23/24 5/1/24 MC Level 7 5/1/24 to 5/31/24 $4,745 $3,500 Care - MC 5/1/24 to 5/31/24 $400 $3,900 4/23/24 - 5/21/24 6/1/2024 MC Level 7 6/1/24 to 6/30/24 $4,745 $3,500 Care - MC 6/1/24 to 6/30/24 $400 $3,900 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (Continue from LIC9099C) Based on the review of R1's billing statements and account summaries from October 24, 2023, through May 21, 2024, R1 was billed correctly according to R1's level of care as indicated on service care plans. Based on observations, interviews with key staff and outside sources, and a review of pertinent records there was insufficient evidence found to support the allegation that R1 was charged for services not rendered. Due to a lack of evidence, the allegation is deemed to be unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence that the alleged violation occurred. An exit interview was conducted with Business Office Director, Ellen Arguello to whom a copy of this report, LIC 811, and Licensee Appeal Rights (9058 03/22) were provided at the conclusion of the visit.
2025-02-20Other VisitNo findings
Plain-language summary
This was the facility's required annual inspection on an unannounced visit, where the inspector found the building clean and well-maintained, with proper food storage, working safety equipment, secured medications, and all required records in order. The facility was operating at 80 of its 105 licensed capacity with no violations cited. Hot water temperature, emergency lighting, fire extinguishers, and first aid kits were all compliant.
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Licensing Program Analyst’s (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Jessica Zepeda. According to the facility’s license, the facility has a maximum capacity of 105 residents, all which will be non-ambulatory and twelve may be bedridden, approved for delayed egress. During today’s inspection, according to records, there were a total of 80 residents in care, LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected a sample of resident rooms. The facility was clean, sanitary, and in good repair. Hot water temperature was compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Smoke alarms, carbon monoxide detectors, emergency lighting, facility telephone, fire extinguisher and first aid kit were present. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Required licensing postings were observed in visible areas of the facility. No deficiencies were cited during today's annual inspection. An exit interview was conducted with Administrator to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
2024-10-17Other VisitNo findings
Plain-language summary
The facility reported the death of a resident on September 9, 2024, and this was an unannounced follow-up visit to investigate. The inspector conducted a health and safety check, reviewed care records, and interviewed staff, and found no safety violations or deficiencies.
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Jessica Zepeda. Today's visit was in response to Licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 9/20/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 9/9/2024. During today’s visit, LPA conducted health and safety check, finding no safety concerns. LPA also collected copies of and reviewed pertinent care records, and interviewed staff. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Zepeda, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
2024-10-17Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that a staff member smelled of alcohol and was yelling unprofessionally at the front desk. The investigation found that this person works in sales and does not provide resident care, and interviews with staff, residents, and an outside source found no evidence supporting the allegation—staff gave conflicting accounts about whether the person appeared intoxicated, no one witnessed alcohol consumption, and one staff member noted the person generally speaks in a high-pitched voice and was upset about a personal matter on the day in question. No violations were found.
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Regarding the allegation, it was alleged that facility staff (S1) smelled of alcohol and was seen yelling loudly and not being professional at the front desk. Records review revealed that S1 is in the sales department and job description does not include any caring for or supervising of residents. Interviews with facility staff confirmed that S1 does not provide care or supervision of residents. Interviews with staff revealed conflicting statements on whether or not S1 appeared to be under the influence of alcohol while at the facility. Staff interviews revealed there was a day when S1 showed up at the facility and was upset about a personal matter and was seen speaking loud due to being upset. Interviews with staff availed no witnesses to S1 consuming alcohol. Some staff interviews revealed that S1 generally speaks in a high pitch. Interview with outside source revealed no accounts of witnessing facility staff under the influence of alcohol while at the facility. Interviews with residents revealed no concern for staff being under the influence of alcohol at the facility. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Zepeda. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Zepeda whose signature below verifies receipt of these rights.
2024-09-30Complaint InvestigationMixedType A · 1 finding
Plain-language summary
This was a complaint investigation into a resident's repeated falls over 19 months. The facility did not implement fall prevention measures such as bed rails or frequent checks until after the resident suffered a head laceration requiring stitches on January 31, 2019, despite assessments showing the resident was at high risk for falls; the investigation found the facility failed to protect the resident from injury. Allegations that the resident developed pneumonia due to neglect and that staff over-medicated the resident were found to be unsubstantiated.
“Based on review of records, and interviews, the licensee did not ensure R1 was free of neglect, which resulted in R1 sustaining injuries, this posed an immediate health, safety, and personal rights risk to 1 of 89 residents in care.”
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Throughout R1 residing at the facility, interviews with staff and R1’s family revealed R1’s health declined from being ambulatory with the use of a walker, to eventually wheelchair bound. Assessments conducted by the facility for R1 on 1/4/18, 2/6/18, 8/1/18, 1/31/19, 8/16/19, 2/15/20, and 6/24/20, consistently revealed R1 was at high risk for falls. Narrative charting records documented on June 3rd, 2018, R1 sustained a witnessed fall, R1 hit a wall, and staff summoned medical attention due to R1 sustaining a skin tear to the head. On January 31st, 2019, during the overnight shift, staff found R1 on the floor next to R1’s bed with a laceration to the head, and staff summoned medical attention. R1 was transported to the hospital on both occasions, with the fall on 1/31/2019 requiring stitches. Review of photographs obtained from R1’s medical provider, confirmed R1 suffered lacerations on both occasions. From approximately March 24th, 2018, to October 11th, 2019, R1 sustained approximately twelve (12) witnessed and unwitnessed falls. On at least seven of the twelve noted falls, R1’s falls were unwitnessed. A Service Plan for R1 dated January 31st,2019, did not reveal any measures addressing R1's falls. On subsequent visits the Department requested records, but the facility was not able to produce such records, including service plans addressing R1’s falls. Although staff reported checking in on R1 every two hours, the facility did not implement any fall prevention measures for R1 until after the fall on January 31st, 2019, which resulted in a hospital visit and R1 sustaining a laceration requiring stitches. By January 31st, 2019, review of records revealed R1 had sustained approximately ten (10) falls with no severe injuries. Interviews with multiple staff and R1’s family corroborated the facility implemented fall prevention measures after January 31st, 2019. The measures included placing bed rails and lowering of the bed. An Outside Agency Form dated January 31st, 2019, revealed fall prevention measures were discussed with staff on that date. The measures discussed with the external agency included lowering R1’s bed, conducting frequent checks and cleaning R1’s room to minimize trip hazards. During the investigation the facility produced assessments and service plans for R1, but these did not indicate what fall mitigating measures were implemented, nor what staff actions were implemented to mitigate R1’s falls. (See additional LIC 9099C form for continuation of report.) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 R1’s diagnoses included Hypernatremia (High Concentration of sodium in blood) due to Hypovolemia (decreased volume of circulating blood). There were no diagnoses related to, nor suspecting lack of fluid intake noted in the discharge summary. At the time of discharge form the hospital, R1’s diet had changed to nothing by mouth, until R1 was “more awake, and passes swallow eval”. The hospital's progress notes dated June 25th, 2020, noted R1 was hospitalized from June 22nd, 2020, to June 24th, 2020, with bilateral pneumonia and hypernatremia. Although Hypernatremia was noted as a admitting diagnoses, there were mentions of dehydration being a diagnosis. Additional interviews with multiple residents did not reveal there were concerns with lack of assistance with food, nor with lack of fluids available to residents. It was alleged neglect resulted in pneumonia. A source reported R1 was hospitalized and diagnosed with Pneumonia. The reporting party questioned how R1 suddenly developed Pneumonia as it could not happen overnight. Records obtained from R1’s medical care providers, including a hospital discharge summary and progress notes dated June 25th, 2020, and a hospice agency revealed the Pneumonia was likely bacterial and the suspected cause was aspiration (inhalation of foreign object or substance into the airways). Interviews with staff revealed R1 was assisted and seated at 90 degrees, as there was concerns of aspiration due to R1’s difficulty swallowing. Interviews with staff also revealed R1 had developed a cough for approximately a week prior to being hospitalized on June 20th, 2020. Staff notified R1’s family and R1’s primary care physician. On June 205th,/20, emergency medical services were summoned as R1 presented low oxygen levels and was congestion. It was alleged staff did not administer medication as prescribed. A source alleged the facility staff over medicated R1, as R1 seemed to sleep more and was less responsive. Interviews with residents, staff, resident’s responsible parties, and the Long-Term Care Ombudsman office did not reveal any concerns with staff over medicating residents. The LPA reviewed the Department’s Guardian system to locate the staff who was mentioned, but contact attempts were not successful. Additionally, the LPA requested additional records for review, but the facility was not able to produce such records. Based on the investigation, there was not enough evidence to prove the alleged violations occurred, therefore, the allegations were Unsubstantiated. An exit interview was conducted with Zepeda, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on evidence obtained, the allegation of staff neglect resulting in resident sustaining injury, was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D form. An immediate $500 civil penalty was assessed, and a plan of correction was jointly formulated with Executive Director Jessica Zepeda. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Zepeda, to whom a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058), were provided.
2024-08-27Other VisitNo findings
Plain-language summary
A licensing analyst conducted an unannounced visit on August 26, 2024, following the facility's report of a resident death on August 19, 2024. The analyst reviewed health and safety conditions, checked care records, and found no deficiencies or safety concerns.
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Jessica Zepeda. Today's visit was in response to Licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 8/26/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 8/19/2024. During today’s visit, LPA conducted health and safety check, finding no safety concerns. LPA also collected copies of and reviewed pertinent care records. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Zepeda, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
2024-05-22Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A family member asked whether the facility was charging extra fees for services and whether care was properly documented for insurance reimbursement. The investigation found no evidence that the care plan was inaccurate or that the facility was not providing the services it said it would, so the complaint could not be substantiated.
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R1 was concerned about what care required an extra fee and what would be reimbursed. The primary concern raised in the investigation was what, and how services were written on the case plan to receive reimbursement form R1’s insurance company. The investigation did not reveal evidence that the care plan was not accurate regarding the services R1 was offered or received. The preponderance of evidence standard has not been met and this allegation is unsubstantiated. An exit interview was conducted with Ellen Argullo, Business Office Manager . A copy of this report along with Licensee Rights (LIC9058 01/2016) was left at the facility.
2024-05-21Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
An investigator looked into a complaint that a resident wasn't receiving medication because they spit it out and staff didn't try again later. The investigation found no violation: staff correctly documented when the resident refused or spit out medication, and medical orders did not require re-administering medication in those situations; staff also correctly understand that residents have the right to refuse medication.
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[Continued on LIC9099] Regarding the allegation, it was alleged that resident (R1) was not getting their medication due resident spitting medication out when being administered and staff not trying to dispense medication again at a later time. Interview with outside source (OS) revealed that they have witnessed staff dispense medication to R1, R1 spit medication out and staff wrote down that R1 refused medication. OS reported that staff stated they could not dispense the medication again due to R1 refusing medicine. Interviews with facility staff revealed that staff are aware that residents have the right to refuse medication and are not to be forced to take medication. Facility staff reported that when a resident spits medication out staff dispose of the medication and note it in Quick MAR. Records review revealed that the facility had documentation of incident where R1 spit medicine out. Records review revealed that none of R1’s medication orders state that the medication is to be administered multiple times in the event that R1 spits medication out. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Executive Director Jessica Zepeda . A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Zepeda whose signature below verifies receipt of these rights.
2024-05-15Other VisitNo findings
Plain-language summary
A licensing analyst made an unannounced visit to check on the facility's use of delayed-egress doors (doors that take a few seconds to open) in the memory care area. The facility had obtained written approval from the local fire marshal for these doors, and the inspector verified that the facility's floor plan matched the approved safety plan. No violations were found during the visit.
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Licensing Program Analyst (LPA) conducted an unannounced Case Management visit. LPA disclosed the purpose the visit to Mainentance Director George Hayes and was allowed entry into the facility. Executive Director Jessica Zepeda met with LPA shortly after. The facility presently uses delayed-egress doors in its secured memory care area and requested the local fire authority to grant approval in writing for the use of the delayed-egress doors. The Fire Safety Inspection Request (STD850) was completed by the local fire authority and received in the RO on May 9, 2024. The requested fire clearance has been approved by the local fire marshal, which includes the facility's updated floor plan and the use of delayed egress. LPA reviewed the facility’s updated floor plan, which matches the STD850. LPA also observed that the new floor plan was posted in a visible area. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Jessica Zepda, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
2024-04-26Complaint InvestigationSubstantiatedType B · 1 finding
Plain-language summary
A resident requested help after soiling themselves at 9:17 PM, but staff said they couldn't help because they were the only caregiver working and their shift was ending. The care need was not documented for the next shift, and the incoming caregiver never provided the assistance—the resident remained in soiled clothing until they called again at 3:26 AM, more than six hours later.
“Based on interviews and record review 1 of 63 residents did not receive basic services when care was not delivered to R1 for six hours which posed a potential risk to the health of persons in care.”
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The investigation revealed that R1 activated their call button at 9:17 PM to request care as they had defecated and needed to be cleaned. Staff 1 (S1) responded to the resident and informed them that they could not provide the care at that time as S1 was the only caregiver on duty at that time. S1 was near the end of their shift. S1 reported that they informed the relieving caregiver about R1’s need for care. The care need was not transferred to the next shift in writing violating facility policy. The relieving caregiver did not provide care to R1. R1 fell asleep without receiving care. R1 woke up about and called for care at 3:26 AM and the care staff provided the required care. R1 received care over six hours after their first request for assistance. R1 was left in soiled clothing for an excessive period of time. The preponderance of evidence standard has been met and this allegation is substantiated. A deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6 Chapter 8, and is listed on the 9099D. An exit interview was conducted with Jessica Zepeda, Executive Director and a copy of this report, LIC 811, LIC 9099 D and Licensee/Appeals Rights (LIC 9058 01/16) was provided.
2024-03-27Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that the facility increased care costs for a resident without notifying the responsible party, but the investigation found no violation—the facility did send written notice of the care level change and rate increase by email within the required timeframe, and the resident's assessment showed she did need more assistance with daily activities. The facility's admission agreement allows for immediate rate changes when care needs increase, with written notice to follow within two business days.
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[Continued from 9099] Regarding allegation, “staff did not communicate with responsible party of fee increases for resident’s care plan”, it was alleged that the facility increased cost in care level for R1 without having a meeting with responsible party. Interviews with facility staff revealed that they do not schedule a meeting every time there is a change in care level pricing. Review of admission’s agreement had no mention of required meetings when changes in care level costs. Admission’s agreement section “Change in Services” states “If Westmont at San Miguel Ranch determines through an assessment, that you require additional services or a different care program than the one in which you are participating , you agree to the new additional services or care program appropriate to your needs. The rate for the new service or care program shall apply immediately. The community will give you written notice of a care change and corresponding rate increase within two (2) business days after providing newly assessed services.” Interview’s with outside sources revealed that R1’s responsible party did not receive notification of increase in care level cost. Facility provided LPA documentation showing that changes to service plan was emailed to R1’s responsible party on 12/20/2023. Review of records revealed that R1 required more assistance with ADL’s on updated assessment dated 12/20/2023. Interview’s with outside sources revealed that R1 did require more assistance with ADL’s since the last assessment that was conducted in 6/9/2023. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Resident Services Director Eva Amorim . A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Resident Services Director Eva Amorim whose signature below verifies receipt of these rights.
2024-01-30Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
The Department investigated six complaints about care at this facility, including allegations about incontinence care, medication assistance, shower assistance, access to hazardous items in a salon room, temperature control, and staff communication. Interviews with staff and residents, along with the inspector's visit, did not support any of these allegations; the facility had addressed a salon door that wasn't locking properly by the time of the inspection. All complaints were unsubstantiated.
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It was alleged staff did not meet the needs of an incontinent resident. It was reported to the Department residents were found with soiled incontinence briefs. Interviews with internal and external sources did not reveal any concerns regarding staff not providing incontinence care. Interviews did reveal some of the residents may have experienced an increase in bowel movements and this may have contributed to staff encountering residents with soiled briefs, but there were no concerns with lack of care. Additionally, there were no concerns with skin irritation, nor breakage due to lack of incontinence care. It was alleged staff did not assist residents with prescribed medication and that staff falsified documents. It was reported to the Department facility staff had witnessed medications had been dispensed, documented as taken by resident, but instead placed in a medication cart. Interviews with internal sources did not recall witnessing any similar incidents, nor the staff not assisting residents with medication. External sources did not have any concerns with lack of medication assistance. The facility did not produce the records requested by the Department, as they were not readily available. It was alleged Staff were not following a resident's care plan. It was reported to the Department staff had not assisted residents with showers. Interviews with internal and external sources did not corroborate staff were not assisting residents with showers, nor did they reveal any concerns with lack of assistance from staff. Interviews did reveal that during the time period in question, there were staff disagreements that had led to staff blaming each other. Records requested from the facility were not readily available for review. It was alleged staff did not ensure hazardous items were inaccessible to residents. It was reported to the Department that a Salon in the Memory Care unit was not secured; therefore, chemicals and sharp items were accessible to residents. An interview with the Executive Director at the revealed the facility had addressed the concern about the door not locking properly. Interviews with internal and external sources did not corroborate chemicals, nor sharp items being accessible to residents. During a visit to the facility, the LPA witnessed the salon to be locked and used for Personal Protective Equipment storage. Additionally, the Reporting Party disclosed having photographs corroborating the door was unlocked. These photographs were not provided to the Department. (See additional LIC 9099-C for continuation of report.) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 It was alleged staff did not maintain a comfortable temperature for residents. It was reported to the Department staff left residents windows open at night. Interviews with internal and external sources did not reveal any concerns regarding staff leaving residents windows open. Staff would close windows at the residents’ requests. Additional interviews revealed residents had reported rooms may have been warm and management addressed this with the facility maintenance personnel. There was no evidence to corroborate windows were left open, nor that this resulted in residents having cold like symptoms. It was alleged facility staff failed to follow reporting requirements. It was reported to the Department facility staff did not follow the facility's internal process of reporting concerns. External sources revealed some staff would report concerns to management team and would expect management to follow up with them when follow up was not required, or necessary.. Interviews with internal and external sources, including third party providers, did not reveal any concerns with lack of communication from staff. Based on the evidenced obtained throughout the investigation, there was not a preponderance of evidenced to prove the alleged violations occurred, therefore, the allegations were unsubstantiated. An exit interview was conducted with Michael Sokoloswky, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.
2024-01-19Annual Compliance VisitType B · 1 finding
Plain-language summary
During a continued annual inspection on January 16, 2024, inspectors found the facility clean and well-maintained, with proper food storage, working safety equipment, and secure medication storage. One violation was cited: the facility was using delayed-exit doors in its memory care area without written approval from the local fire authority as required. The facility developed a plan to correct this issue.
“This requirement was not met, as evidenced by: Based on observation and record review, in an area of the facility where 1 of 71 residents (R1 through R24) resided, licensee utilized delayed egress devices on exterior doors but did not ensure that its fire clearance included approval of delayed egress devices. This posed a potential safety risk to persons in care. POC Due Date: 02/18/2024 Plan of Correction 1 2 3 4 By the POC due date, Licensee will E-mail to the CCLD San Diego Regional Office (RO) documents (i.e., Cover Letter, LIC200 Application, and LIC9054 Local Fire Inspection Authority Information), to begin the process for requesting another fire inspection, with the intent of securing approval for delayed-egress doors.”
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Licensing Program Analysts (LPAs) Liliana Silveira and Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 01/16/2024. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Michael Sokolowski. According to the facility’s license, the facility has a maximum capacity of 105 residents, all which will be non-ambulatory and seven may be bedridden (and the bedridden residents may only reside on the ground floor). During today’s inspection, according to records, there were a total of 71 residents in care, of which 43 were non-ambulatory and none were bedridden. During today’s visit, LPAs, accompanied by licensee’s staff, toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. LPAs privately interviewed multiple staff and residents. LPAs also reviewed multiple staff and resident records/files. The files which were reviewed contained the required documents. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained required furniture. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Confidential records and centrally stored medications were kept in locked areas. The facility had at least two days of perishable food and seven days of non-perishable food present. The facility had cooking and dining utensils to facilitate resident meal service. The Walk-In Refrigerator’s temperature was compliant at 40 F, and the Walk-In Freezer’s temperature was complaint at 0 F. The facility’s ambient internal temperature was compliant at 74 F. [CONTINUED ON LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 [CONTINUED FROM LIC 809] Where tested, hot water temperature at taps (which were used by residents for personal care) were compliant: Bedroom #107 sink was 116.1 F, Bedroom #131 sink was 115.5 F, Bedroom #214 sink was 109.7 F, Bedroom #229 sink was 114.5 F, Bedroom #246 sink was 112.4 F. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents diagnosed with Dementia. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke and fire alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. A complete first aid kit was present and readily accessible. Licensee's staff also presented proof of current/active business liability insurance. Required licensing postings were observed in visible areas of the facility. Based on LPAs’ observation and confirmed by manager interviews: The facility presently uses delayed-egress doors in its secured memory care area. However, Licensee did not ensure that the facility’s local fire authority granted approval in writing for use of delayed-egress doors, as was required before their use. Per the facility license which CCLD issued to Licensee, approval for use of delayed-egress doors was also not expressly approved. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with Licensee. LPAs also issued Technical Assistance (TA) regarding Infection Control (see the LIC 9172-TA). An exit interview was conducted with Sokolowski, to whom a copy of this report, the LIC 809-D, the LIC9172-TA, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
2024-01-16Other VisitNo findings
Plain-language summary
This was an unannounced required annual inspection of the facility. No violations were found during the visit, though the inspection was not fully completed due to time constraints and will continue on another day. Staff and residents were interviewed, records were reviewed, and facility leadership was informed of the findings.
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Licensing Program Analysts (LPAs) Dang Nguyen and Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and identified themselves to Executive Director Michael Sokolowski. LPA discussed the purpose of the visit with Executive Director Michael Sokolowski and Resident Services Director Eva Amorim. During today’s visit, LPAs briefly toured the facility, reviewed staff and resident records, and interviewed staff and residents. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with Michael Sokolowski, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
2023-12-05Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that residents were not getting timely responses when using call buttons. The investigation reviewed call button records from August and September 2023 and found five instances where buttons went unanswered for over 30 minutes, but when inspectors checked incident reports, they found no evidence that delayed responses caused injuries—residents who fell were attended to and taken to the hospital for evaluation as needed.
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Staff interviews said that there are times when the residents accidentally take their devices with them out into the community which staff are unable to answer. A review of the facility’s activity records for the months of August 2023 and September 2023, there were five residents whose call button were over the time frame of 30 minutes. Submission of incident reports (IR) were reviewed for the months of August 2023 and September 2023. Upon review of the IR’s, there was only one incident report on file submitted to the San Diego Regional Office that reported resident sustaining an injury due to a fall, but according to the Device Activity Report, there was no call to the room. According to that IR the staff responded accordingly by contacting emergency response. In review of additional submitted reports, residents who sustained falls were taken to the hospital for further evaluation and treatment. None of the IR’s displayed major injuries due to staff untimely response of call devices. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents.
2023-09-22Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint was investigated about residents' bed rails being used as restraints. Inspectors found that all 17 residents had physician orders for bed rails, which residents used to help themselves move in bed and get up safely—not as restraints—and no residents or staff had concerns about how the rails were being used. The complaint was not substantiated.
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Many of the residents said they used their bed rail as an assistive support mechanism to reposition themselves or to raise themselves from their bed. No resident or outside sources had concerns with the staff “restraining” residents with their bed rails. Review of records revealed that all 17 residents had approved orders by their physician or hospice agency for half-bed rails, as required by regulations. On September 18, 2023, LPA initiated the complaint investigation and observed that residents had half-bed rails secured to their beds as instructed by a physician. No residents’ bed rails were used as a restrictive device or restraint. LPA observed that residents used the bed rails to reposition themselves or to get out of bed. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during resident and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents.
2023-09-18Other VisitNo findings
Plain-language summary
A licensing analyst investigated a report that a resident lost approximately $100-$200 in cash that had been kept in their room, which the facility's internal investigation could not resolve. The facility reimbursed the resident for the lost money, and the analyst found no violations during the visit.
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Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a complaint investigation and conjointly conducted a case management visit. LPA Lopez identified herself and was granted entry by Amanda DeLeon, concierge . LPA Lopez stated the purpose of the visit and reviewed the basic elements of the case management visit with Executive Director Sokoloski. Today's visit was in response to an Incident Report (LIC624), which was self submitted to the Community Care Licensing Division (CCLD) San Diego Regional Office, received on 09/15/2023. According to the LIC624, on 09/11/23, a Resident #1 (R1) reported that they were unable to find the monies they kept in their personal property. R1 stated they had a total of $100 bills in $20 dollar bills and $10 dollar bills in their belongings on 08/31/23. Facility staff confirmed the monies with R1's responsible party. During the visit, LPA Lopez toured the facility, spoke with staff and residents, and requested and obtained relevant documents. According to staff interviewed, the R1 had spoken to the Resident Service Director (RSD) to report the missing money. RSD contacted the residents RP who confirmed that resident did have the money within her belongings. RSD and staff did look for the missing money in the resident’s room to no avail. According to the RSD, they attempted to report the missing money to the police, but since it was less than $10,000, they would not come out to take the report. RSD also attempted to make the report online but was unable as the online prompt did not let RSD surpass a section that the resident needed to fill out. According to the RSD, the resident did not want to pursue the incident further. According to Staff #2 (S2), residents are not allowed to have money on them if they are in the assisted living. The residents’ representative’s usually take care of the resident’s cash resources. If a resident has a large amount of money they place it in their inventory sheet, but that was something unusual that a resident would have. According to S2, staff was unaware that R1 had their money on them but it was confirmed with their RP. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Per the Executive Director (ED), the facility conducted an internal investigation. Their investigation was inconclusive as the money was not found. Per the ED, the resident was reimbursed the monies that was lost/stolen. The facility is currently licensed to serve a total of 105 residents, all of whom may be non-ambulatory and 12 of whom may be bedridden on the ground floor only; and hospice is approved for 12. Per R1’s latest LIC602 Physician’s Report (dated 05/10/2023), R1 is considered to be non-ambulatory. R1’s is able to follow instructions and is able to communicate their needs and manage their own cash resources. During the records review, LPA observed that the facility had a Certificate of Liability Insurance with an expiration date of 09/2024. The facility did reimburse R1 the amount that was stolen/lost. There were no deficiencies issued during this visit. An exit interview was conducted, with Executive Director Michael Sokolowski. A copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the documents were received.
2023-09-18Complaint InvestigationMixedType B · 1 finding
Plain-language summary
This complaint investigation had mixed results: one allegation was substantiated (the facility's executive director confirmed he took a resident's belongings to a donation company when the resident was moving to a smaller room), while a separate allegation was found to be unsubstantiated with no violation identified. A plan of correction was developed for the substantiated issue.
“Based on records review, staff did not obtain residents Physician’s Report (LIC602) prior to admission. This posed a potential health risk to two of 78 [R1 & R2] residents in care.”
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Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Executive Director did confirm that they took a box to the donation company for the resident. R3 confirmed that they were moving to a smaller room and was giving personal items away and gave the Executive Director about three to four boxes to donate about three to four weeks ago. On September 18, 2023, during an interview with R3, LPA observed that the resident’s room was somewhat disheveled with belongings in boxes and items still in need to be put away. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents.
2023-09-14Other VisitNo findings
Plain-language summary
An unannounced visit was conducted to deliver findings from a previous complaint investigation and to provide case management guidance. The facility received technical assistance regarding hospice care for terminally ill residents and procedures for reassessing residents when their condition changes, and the facility confirmed it will monitor residents closely and maintain compliance with its license.
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Licensing Program Analyst (LPA), Carmen Lopez conducted an unannounced visit to deliver complaint findings and concurrently conducted a case management visit. LPA identified herself and was granted entry by concierge Paola Partida. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Michael Sokolowski. LPA provided the facility with additional guidance for hospice care for Terminally Ill Residents, and Reappraisals for residents change in condition. The facility will closely monitor residents and have a plan in place to ensure their compliance with their approved license. The facility is being issued technical assistance and can be found on the LIC 9102TA. An exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the documents were received.
2023-09-14Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint was investigated about whether residents were placed on floors that didn't match fire safety rules for their mobility level. The facility's records showed that the four residents in question were appropriately classified based on medical assessments, and the investigation found no violation of fire safety housing requirements.
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A review of records revealed that the facility had approved fire clearance to serve 105 non-ambulatory residents, of whom 12 may be bedridden, to be housed only on the ground floor. A review of resident records revealed that the ambulatory status of the four residents in question did not indicate that they were medically assessed as bedridden at the time of this investigation. Per Physician’s Reports (LIC602), three of the identified residents were currently evaluated as non-ambulatory and one resident was evaluated as ambulatory. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Executive Director Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents.
2023-09-06Other VisitNo findings
Plain-language summary
A state licensing analyst visited the facility on September 6, 2023, to investigate a complaint and review resident records. The analyst found that one resident's physician report was not kept up to date, which is a technical violation. The facility was notified of this finding at the end of the visit.
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Licensing Program Analyst (LPA), Carmen Lopez conducted an unannounced visit to open a complaint investigation and conjointly conducted a case management visit for review of resident records. LPA identified herself and was granted entry by Executive Director Michael Sokolowski. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Sokolowski. On Wednesday, September 6, 2023, LPA Lopez initiated a complaint investigation that was submitted to the Department on August 29, 2023, for investigation. During the visit, LPA reviewed residents’ documentation and observed that resident #1 (R1’s) Physician’s Report (LIC602) was outdated. Based on records reviewed and LPA’s observations, it was determined that the facility did not keep R1’s LIC602 updated. The facility is being issued technical violation and can be found on the LIC 9102TV. An exit interview was conducted with Executive Director Michael Sokolowski and Brittany Blaul, Resident Service Director . A copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the documents were received.
8 older inspections from 2022 are not shown above.
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