Westmont of Encinitas

Allegation investigated: Licensee did not respond to resident grievance in a timely manner

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to open a complaint investigation and delivered findings regarding the above mentioned allegation. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Executive Director Donelle Williams. Note, LPA did step out for lunch from 12-1pm. On 08/03/2026, the Department received a complaint where it was alleged that the facility did not provide a timely response to a grievance presented to the facility. The Department’s investigation consisted of an unannounced facility visit, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099-C] Substantiated [Continued from LIC 9099] Per the complaint, a grievance was presented to the facility via email in June 2026 requesting updates to the facility's policies on video surveillance devices in resident units. Per the grievance, the current policy does not allow for residents to implement their own surveillance devices of any kind in their units, and residents would like the policy amended to allow for their own video surveillance devices, should they wish to use any. Per the complaint, as of the beginning of August 2026, an official response to the grievance had not yet been received, although the facility had been giving verbal updates in the meantime. Additionally, it was shared that the facility's corporate office had undergone a major position change, which was causing a delay in review of grievance at a corporate level. On 8/6/26, LPA received an email from the facility with a copy of the facility's written response to the grievance, in which the facility agreed to update its policies on the topic. LPA was also sent a copy of the proposed amendment to the facility's resident admissions contract to reflect the change. Per interview with the Executive Director of the facility, they had met with resident council members a few times a week to give verbal updates on the grievance proceedings, corroborating that there were major organizational changes that affected the timeliness of an official response in writing. In addition, it was shared that the proposed policy updates would affect all the company's facility locations, not just this one, hence the need for extended review. Interview with an outside source from the county Long-Term Care Ombudsmans office corroborated this information and the timeline from grievance filing to response, as well. Interviews with residents revealed that the Executive Director did give verbal updates in response to the grievance prior to the official final resolution. Resident interviews also revealed that resident concerns are generally handled promptly and communication between residents and management was great. [Continued on LIC 9099-C] [Continued from LIC 9099-C] File review of the facility's agreement contract and grievance procedures policy revealed that the facility shall respond in writing within 14 calendar days of any action or inaction taken in response to the grievances and/or recommendations submitted. Review of the facility's grievance log revealed documentation of receipt of the grievance, and documentation of verbal communication with resident council members was done same day and the grievance was elevated. Date of official written response for the grievance resolution is well over two (2) weeks (14 days) from date of the grievance having been received. Based on LPA's review of records, interviews with staff, residents, and outside sources, the preponderance of evidence standard has been met, therefore the above allegation that the facility did not respond to the grievance in a timely manner is found to be SUBSTANTIATED. A deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached LIC 9099D. An exit interview was conducted with Executive Director Williams to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 12, 2026 · control 08-AS-20260803111826

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(9) · Plan of correction due date: Aug 26, 2026

87468.2(a): "In addition to the rights listed in Section 87468.1 [...] residents [...] shall have all of the following personal rights: (9) [...] The licensee shall respond to residents’ grievances and recommendations promptly." This requirement is not met as evidenced by: Based on LPA file review and interviews, the licensee did not comply with the section cited above in ensuring resident grievances were responded to in a timely manner as outlined in the facility's operating procedures, which poses a potential personal rights risk to all persons in care.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: Licensee issued a written response to the grievance. POC was cleared during the visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Concierge Carlos Gomez and Executive Director Donelle Williams. The facility's license shows a maximum capacity of one-hundred-and-one (101) non-ambulatory residents. Additionally the facility is approved for a hospice waiver for ten (10). During today’s inspection there were ninety-six (96) residents in care, with seven (7) currently receiving hospice services. LPA and Executive Director Williams toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: One resident unit bathroom sink on the first floor was 111.9F and a bathroom sink on the second floor read at 109.6F. 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. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. [Continued on LIC 809-C] [Continued from LIC 809] While touring the kitchen area, LPA noted that the kitchen area is unlocked after hours, and thus knives in the kitchen are technically accessible to residents in care. As kitchen staff were currently present and supervising the area, no immediate danger/risk was present to any residents in care. LPA provided a Technical Violation (TV) and provided consultation on having such items locked and/or inaccessible when not in use by staff. Executive Director Williams purchased an appropriate lockable storage container for the knives during LPA's visit and showed proof of purchase/delivery estimate. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. An indoor swimming pool is present on the property and LPA noted that the access doors were kept locked. Per Executive Director Williams, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months, dated for June 2026. Last staff emergency drill was conducted on 6/17/26 for the topics of fire and bus safety. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed one (1) staff and two (2) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Williams to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jun 19, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to the facility. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Donelle Williams. The purpose of today's visit was to consult with the facility on their policies pertaining to video surveillance. Community Care Licensing (CCL) received recent inquiries on whether the facility can prohibit residents from placing video surveillance devices in their own private units, as outlined in the admissions agreement. During today's visit, LPA conducted file review of the facility's admissions agreement and consulted with Executive Director Williams. While current Title 22 regulations don't outright prohibit a facility from having such policies pertaining to the use of personal cameras by residents, resident's still have the right to do so should they wish, granted they follow general guidelines to protect privacy for all involved (including but not limited to, having a sign/notification of video recording in progress, no use of audio recording, and devices only being in/showing private resident areas). LPA provided consultation on possible updates to the facility's policies on the topic. No Deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Williams to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 21, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Resident Services Director Ma Caballero, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1), who alleged that Staff 1 (S1) grabbed their arms and took away their pendant. LPA conducted a wellness check at the facility for R1, and interviewed staff and collected facility records. The investigation revealed conflicting information regarding the incident. It was unable to be determined if S1 intentionally grabbed R1 or attempted to restrain them. Documentation revealed that R1's bruises were consistent with the positioning in their wheelchair while they sleep. This positioning was directly observed by LPA during the facility visit. Interviews and records showed that S1 admitted to removing R1's pendant from their person, which was the reason for S1's termination per facility documents. No health or safety issues were identified during the visit. A technical violation was issued to the facility for personal rights regarding S1 removing R1's pendant. An exit interview was conducted with Resident Services Director Ma Caballero, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Resident Services Director Stefanie Ancheta, to discuss the purpose of the visit. Today's visit is in response to two self reported incidents for Resident 1 and Resident 2 (See LIC811 Confidential Names List). LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Resident Services Director Stefanie Ancheta, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Resident Services Director. The facility's license shows a maximum capacity of 101 non-ambulatory residents, ages 60 and above. During today’s inspection there were 101 residents in care. Hospice waiver for 10. LPA and Resident Services Director toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, 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. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. The facility has a pool on the premises which was locked and inaccessible. Per Resident Services Director, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Resident Services Director Stefanie Ancheta to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 7, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Donelle Williams, to discuss the purpose of the visit. Today's visit is in response to the self reported incident of possible financial abuse of a resident. LPA interviewed staff and residents and collected records. A wellness check was completed; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director Donelle Williams, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Dec 3, 2024

Allegation investigated: Resident was sexually assaulted while in care.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced a follow up complaint investigation visit and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Operation Specialist Benjie Doctolero. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources, including staff and residents. It was alleged a resident was sexually assaulted while in care by Staff #1 (S1). (See 811 – Confidential Names Form). A review of R1's LIC 602 (Physician's report), and Preplacement Appraisal, collected from the facility, revealed R1 was considered ambulatory, in good health, diabetic, able to communicate, but may be confused and disoriented. (See LIC 9099C for continuation of report.) Unsubstantiated The Department interviewed facility management. According to facility management, R1 provided inconsistent statements, changing the gender of the caregiver, and inconsistencies on when the abuse took place. R1 sometimes stated it occurred during medication application, while being assisted with changing, or that it had occurred in the shower during a bath. R1 was not able to provide a specific date or time as to when the abuse occurred. The facility was only aware of the Sheriff’s investigation, as an officer came out to the facility after R1 was Hospitalized for an unrelated medical issue on 5/8/2022. Facility management was not aware of any other similar report from R1. Facility management believed R1 may have reported abuse to facilitate R1’s transfer out of the facility. An incident report obtained from the San Diego County Sheriff’s Office reported the following information. On 5/9/2022, a Sheriff’s officer interviewed R1, who reported the alleged incident had occurred approximately six months prior. R1 did not recall the exact date or time, only that the incident had occurred in the morning and that S1 had raped R1. During the interview, R1 had difficulty staying focused, would veer off topic, and would become agitated with unrelated topics. There were no witnesses, no evidence collected, and due to the time elapsed since the incident, no Sexual Assault Response Team (SART) exam was conducted. R1 also told the responding officer the incident had already been reported to the Sheriff's Department, but that officer was unable to complete the report. The responding officer’s search for the report did not produce any previous reports from R1. The officer attempted contacts with the reporting party, and with S1, but all were unsuccessful. An interview with S1, conducted by the Department, revealed S1 assisted R1 with showers, medication management, and partial toileting needs. S1 was aware R1 had made allegations of being touched inappropriately by S1, but S1 denied any sexual interaction from S1, nor from other staff at the facility. Interviews with residents, and current and former staff did not reveal any concerns regarding abuse at the facility. These sources did not witness any type of abuse at the facility. Based on the evidence obtained, there was not enough evidence to prove the alleged violation occurred, therefore, the allegation was Unsubstantiated.An exit interview was conducted with Doctolero, to whom a copy of this report, LIC 811 Confidential names list, and Licensee/Appeals Rights (LIC 9058) were provided.the state’s words, verbatim · CDSS document, May 31, 2024 · control 08-AS-20220509093246

Allegation investigated: Licensee did not address resident's change in condition.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Business Office Director Angie De Asis. During the visit Senior Regional VP of Operations Steven Harms was present at the facility and met with LPA. On 2/5/24 it was alleged that the Licensee did not address a change in condition for resident 1 (R1), resulting in numerous falls. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interview revealed that upon observing the increase in weakness and falls, the Licensee updated R1's care plan to level 6 to reflect the need for stand-by assistance for all activities of daily living (ADLs). Staff interview, corroborated by facility and outside source records, revealed that staff contacted the family for each of R1's falls, communicated with the POA regarding R1's change in condition, and remained in contact with the family throughout R1 being admitted into Hospice. (Continued on LIC9099-C p.2) Unsubstantiated (Continued from LIC9099 p.1) Outside source interviews corroborated staff statements that paramedics responded to the facility numerous times due to R1's falls, and that R1 frequently refused to be transported to the hospital. Outside sources informed that R1's family and Responsible Party were notified regarding the falls, and were involved in the conversation regarding R1 needing an increased level of care. Facility and outside source records review revealed that R1 suffered multiple falls due to attempting to ambulate on their own, even after staff reminded them to use their pendant to call for help before trying to walk. Facility incident reports, email communication, and progress notes showed that the Licensee was monitoring R1's change in condition, reassessed R1, and communicated the changes to the Responsible Party. Records review further showed that R1 was placed on Hospice per the family's request, and the Licensee assisted with the transition into Hospice care. Interview with R1 was not possible, due to their passing away. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Senior Regional VP of Operations Steven Harms, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 12, 2024 · control 08-AS-20240205151341

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Senior Regional VP of Operations Steven Harms. The facility's license shows a maximum capacity of one hundred one (101) non-ambulatory residents. During today’s inspection there were 80 residents in care. LPA and Senior Regional VP of Operations Steven Harms toured the interior and exterior of the facility, and inspected resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, 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. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. The facility has an indoor pool which was locked at all entrances and inaccessible to residents. Per Senior Regional VP of Operations Steven Harms, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Senior Regional VP of Operations Steven Harms to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 12, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Randal Newton, Executive Director, to discuss the purpose of the visit. Today's visit is in response to the self reported death of Resident 1 (R1 - see LIC811 Confidential Names List). R1 passed away on 2/11/24. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Randal Newton, Executive Director, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Feb 13, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Randal Newton. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 01/17/2024. According to the LIC624: during the morning of 01/17/2024, an error by staff led to Resident #1 (R1) receiving double (i.e., twice as much) of their prescribed dose for each of eight (8) of their medications. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. The overdoses did not result in any adverse health consequence for R1. During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe and well. LPA collected copies of and reviewed pertinent care and personnel records. LPA also interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 04/05/2022), R1 was able to administer their own prescription medications. However, according to the latest Service Plan (dated 09/23/2023) which Licensee prepared on R1, they required assistance with medication management. Manager interview also confirmed that R1 now had mild memory impairment and was paying Licensee to help them take their medications during the time of the incident. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Staff interview and records showed: Around 7:30 AM on 01/17/2024, Staff #1 (S1), who was assigned to the facility’s second floor, gave one dose each of eight (8) prescribed medications to R1, but did not immediately document their administration in the facility’s electronic Medication Administration Record (MAR) software, as Licensee had trained and expected S1 to do. R1 then went to eat breakfast in the facility’s first floor dining room. Around 8:30 AM, R1 approached Staff #2 (S2), who was assigned to the facility’s first floor, to request their medications. S2, not realizing that S1 had already given R1 their morning medications, gave R2 second doses for each of the same eight (8) medications. S2 subsequently realized an error had occurred and notified a facility nurse/manager, Staff #3 (S3). S3 observed R1 and took their blood pressure and pulse vital signs, which were in normal range. S3 timely contacted R1’s prescribing physician (PCP) for guidance and timely notified R1’s responsible person (RP) of the incident. S3 personally met with S1 and S2 to discuss the incident, then suspended S1 from medication pass duties. S3 performed formal/written coaching with S1 and retrained them (to include a written test), before reinstating R1 in medication pass duties a few days later. Progress notes show facility staff continued to provide increased observation to R1 for 72 hours following the incident, during which R1 continued to be free of any adverse reaction. A preponderance of evidence exists to show that during the above incidents, a documentation process error by Licensee’s staff (S1) resulted in R1 not receiving medications exactly as they were prescribed by their physician. 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 the licensee. LPA issued one (1) Technical Violation (TV) regarding reporting requirements. LPA also provided Technical Assistance (TA) regarding medical assessments. An exit interview was conducted with Newton, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Feb 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 5, 2024

87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not assist 1 of 80 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Feb 6, 2024

Plan of correction: Staff interview and personnel records showed: Following the incident, Licensee immediately suspended S1 from medication pass duties, performed written/formal coaching with S1, and then tested S1’s knowledge of med pass procedures, before reinstating S1 back in their med pass duties. Licensee agreed to retrain its larger medication staff team on the importance of immediate recording of medications given in the electronic MAR system, and the potential consequences of not doing so timely. Licensee agreed to submit the training-sign in sheet to LPA, by the POC due date.