Westmont At San Miguel Ranch

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

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

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

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

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

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

Allegation investigated: Questionable death

On 11/10/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Business Office Director Ellen Arguello and explained the purpose of the call. Regarding the allegation of questionable death, reporting party (RP) stated that aspiration occurred due to routine medications being given to the resident by facility staff (not hospice) which led to aspiration pneumonia and the death of the resident. R1 was under hospice care. Facility staff were following doctors’ orders in administering medication. On 2/16/2025, around 12:41pm, facility received fax from doctor to discontinue medication. On the evening of same date, other medications were administered. R1 was routinely checked until passing on 2/17/2025. Death certificate did not indicate that R1 passed due to aspiration pneumonia. Based on records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence tothe state’s words, verbatim · CDSS document, Nov 10, 2025 · control 08-AS-20250318135957

Allegation investigated: Resident charged for services not rendered

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Business Office Director, Ellen Arguello. The Department investigated the above-listed complaint allegation. The investigation consisted of a tour of the facility, multiple interviews with staff and residents, and a detailed records review, including medical records, health and service evaluation/assessment reports, service care plans, invoice billing statements and other relevant evidence pertinent to this investigation. On May 31, 2024, Community Care Licensing (CCL) received a complaint alleging that Resident (R1) was charged for services not rendered. [an LIC 811 Confidential Names List was provided to staff to identify the Resident]. (Continue at LIC9099) Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 10, 2025 · control 08-AS-20240531124436

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

Allegation investigated: Staff is intoxicated of alcohol while caring and supervising residents in care.

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Administrator Jessica Zepeda and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that facility staff (S1) was intoxicated while caring for and supervising residents in care. [Continued on LIC 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 17, 2024 · control 08-AS-20240515104136

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

Allegation investigated: Neglect/ Lack of supervision resulted in resident sustaining injuries

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced visit to deliver complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Jessica Zepeda. Throughout the investigation the Department requested records, and conducted interviews with external and internal sources, including staff and residents. It was alleged staff neglect resulted in a resident sustaining injury while in care. A source alleged Resident # 1 (R1) suffered multiple falls, including one on June 4th, 2018, and a second fall on January 31st, 2019, that resulted in hospitalization, and lacerations requiring stitches. R1, a Seventy-Nine (79) year old memory care resident, was diagnosed with Dementia and assessed as a high fall risk during admission to the facility. A medical assessment revealed R1 could be confused and agitated at times. A service plan dated February 19th, 2019, revealed the facility assisted the resident with incontinence care, escortingthe state’s words, verbatim · CDSS document, Sep 30, 2024 · control 08-AS-20200625151823

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

Allegation investigated: Resident's care plan does not accurately represent the care provided

Licensing Program Analyst Becky Kennedy concluded the investigation which began on 3/18/21. LPA Kennedy made an unannounced visit to the above facility today and met with Ellen Argullo, Business Office Manager. LPA advised them of the reason for today's visit and delivered the investigation findings on the above allegation. It was alleged that Resident 1’s (R1) care plan does not accurately represent the care provided. The investigation included interviews with internal and external sources, review of records, and a virtual tour of the facility. Interviews revealed that R1 had an insurance Policy that would reimburse R1 for some services. R1 had multiple conversations with facility administration to modify the care plan so that R1 could access insurance reimbursements. It was further revealed that R1 would periodically refuse services that were on the care plan and request services that were not on the care plan. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 22, 2024 · control 08-AS-20210212154050

Allegation investigated: Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Jessica Zepedaand discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that facility staff mismanaged resident’s medication. [Continued on LIC9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, May 21, 2024 · control 08-AS-20240122152834

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

Allegation investigated: Staff did not meet resident's incontinence care needs.

Licensing Program Analyst Becky Kennedy concluded the investigation which began on 7/29/21. LPA Kennedy made an unannounced visit to the above facility today and met with Jessica Zepeda, Executive Director. LPA advised Ms.Zepeda that the reason for today's visit is to deliver the investigation findings on the above allegation. The investigation consisted of interviews with internal sources, a review of reports and records, and a tour of the facility. It was alleged that Resident 1 (R1) (see LIC 811 for confidential names) requested incontinence care from facility staff and the care was not provided for approximately six hours when R1 called again to request care. Substantiatedthe state’s words, verbatim · CDSS document, Apr 26, 2024 · control 08-AS-20210726092242

Allegation investigated: Staff did not communicate with responsible party of fee increases for resident's care plan.

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Resident Services Director Eva Amorim and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that staff did not communicate with responsible party of fee increases for resident’s care plan. [Continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 27, 2024 · control 08-AS-20240112134103

Allegation investigated: Staff are not providing residents with food Staff did not meet the needs of incontinent resident (s) Staff did not administer medications as prescribed Facility staff falsified a document Staff are not following residents care plan Facility did not ensure that hazardous items were inaccessible to residents Facility did not maintain comfortable temperature for residents Facility staff failed to follow reporting requirements

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Michael Sokolowski. Throughout the investigation, the Department requested pertinent records and conducted interviews with external and internal sources, including staff and residents. It was alleged staff did not provide residents food. It reported to the Department staff would not assist residents with feeding, and often food trays were witnessed to be untouched. Interviews with internal and external sources revealed the facility used food trays to deliver food to residents during the COVID-19 Pandemic. These sources did not corroborate witnessing lack of assistance with feeding, nor witnessing undelivered food trays. It was also revealed staff had provided the resident in question with different options, including cultural food choices. (See LIC 9099-C for continuthe state’s words, verbatim · CDSS document, Jan 30, 2024 · control 08-AS-20200713094709

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

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

Allegation investigated: - Insufficient staff to respond to residents' call buttons timely

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver investigative findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Alyssa Antolin, concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Michael Sokolowski. The Department’s investigation consisted of interviews with residents and staff, and records review of relevant documents pertinent to this investigation. On September 20, 2023, it was alleged that there were insufficient staff to respond to residents’ call button timely resulting in injuries. Interview with residents did not coincide. Upon interviews, most residents did say that the staff response time once their call buttons were pushed were timely. One resident reported staff responding to call buttons untimely of about 20 minutes or not at all. None of the residents reported being injured in the process of staff response to theithe state’s words, verbatim · CDSS document, Dec 5, 2023 · control 08-AS-20230920152253

Allegation investigated: - Staff did not meet training requirements

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings of a complaint investigation regarding the above-mentioned allegation. LPA identified herself and was granted entry by Alyssa Antolin, concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Michael Sokolowski. The Department’s investigation consisted of interviews with residents and staff, and records review of relevant documents pertinent to this investigation. On October 2, 2023, it was alleged that staff did not meet training requirements. It was specifically alleged that staff #1 (S1) was inappropriately trained to provide medications to residents. Interview with S1 confirmed that they assisted with passing out medications, but there was always an assigned Medication Technician (Med Tech) dispensing the medications into a cup for the residents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 5, 2023 · control 08-AS-20231002095754

Allegation investigated: - Staff are inappropriately restraining residents in care

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit and delivered investigation findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Paola Partida, concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Michael Sokolowski. The Department’s investigation consisted of interviews with residents and outside sources, records review of relevant documents pertinent to this investigation, and LPA observations of the residents’ living arrangements. On September 18, 2023, it was alleged that the staff inappropriately restrained residents in care. It was specifically alleged that there were 17 bed rails being used as a restraint. Interviews with residents and outside sources were consistent. Neither the residents nor outside sources had concerns regarding the bed rails being used as a restrictive device towards residents, to limit their movement or prevent thethe state’s words, verbatim · CDSS document, Sep 22, 2023 · control 08-AS-20230915082323

Allegation investigated: - Facility did not obtain resident’s Physician’s Report prior to admission

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility LPA investigated and delivered findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Amanda DeLeon, concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Michael Sokolowski. The Department’s investigation consisted of interviews with staff and resident, records review of relevant documents pertinent to this investigation, and LPA observations of the residents’ living arrangements. On September 14, 2023, it was alleged that the facility did not obtain resident’s Physician’s Report prior to admission. A review of records revealed that resident #1 (R1) and resident #2 (R2) were admitted to the facility on 08/10/2023, per their Admission Agreement. The Physician’s Report for R1 and R2 were dated 08/21/23, which was after their admission date. Basthe state’s words, verbatim · CDSS document, Sep 18, 2023 · control 08-AS-20230914094405

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

Allegation investigated: - Staff placed bedridden residents on second floor of facility

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Paola Partida, concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Michael Sokolowski. The Department’s investigation consisted of interviews with staff, records review of relevant documents pertinent to this investigation, and LPA observations of the residents’ living arrangements. On August 29, 2023, it was alleged that the facility placed bedridden residents on the second floor of the facility. An outside source claimed that the facility had about four residents on the second floor who were either bedridden or required more assistance with their activities of daily living. The Executive Director mentioned that there were no bedridden residents, but there were residents who did require additional assistance. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 14, 2023 · control 08-AS-20230829095420

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

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