Belmont Village Cardiff

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Amy Rodgers 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 concierge Louise Tedesco. Executive Director Wes Lavender joint the visit shortly after. The facility's license shows a maximum capacity of 175 elderly residents, age 60 and above, 30 of whom may be bedridden on the first floor only. Hospice care waiver is approved for thirty (30) residents. Facility is equipped with delayed egress and secured perimeter in the dementia unit. LPA accompanied by Executive Director Lavender toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident 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 residents. Medications were labeled, as required, and stored in locked areas. The pool located on the premises was fenced and locked. 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 was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. 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 Lavender to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 22, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Wesley Lavender, Executive Director. Today's visit was in response to Licensee’s self-reported incident report, received at the CCLD San Diego Regional Office on 06/24/2026. [See LIC 811 Confidential Names List for a description of Resident 1(R1)]. During today’s visit, LPA briefly toured the facility, collected and reviewed care records on R1, and interviewed staff. LPA performed a cursory welfare check on the remaining residents in care, finding no immediate safety concerns. Interviews of staff showed: R1 lived at the facility since 05/31/2023. R1 also has a private caregiver since they returned from the hospital in January 2026. R1 sustained a fall with a hip fracture in November 2025 and was out of the facility until January and the family had a private duty with R1 since. This incident occurred on 06/12/2026, R1 had a witnessed, assisted fall while going to the bathroom, meaning the private caregiver assisted the resident down to the floor. It was noted that R1 did not have any pain or injury on that day. Interviews revealed that the resident's POA on file was notified. Interviews revealed the private caregiver advised staff of the fall on that day immediately after it happened. On 06/15/2026 R1 reported having lower back pain and resident was transported to ER by non-emergency transport and was evaluated by the hospital team and admitted for observation and treatment of a compression fracture of lumbar vertebrae. Interviews revealed resident stayed at the hospital for 3 days. R1 returned on 06/18/2026. No surgery was completed at this time with new orders of narcotic medication for pain. During a review of records, LPA observed and Executive Director interview confirmed: R1 has been here over 3 years. The completed LIC 602 Physician’s Report on R1,was completed as was required on 01/05/2026. The report stated that R1 requires assistance with repositioning and transferring. No deficiencies observed or cited during todays visit. An exit interview was conducted with Wesley Lavender, Executive Director, to whom a copy of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 25, 2026

Allegation investigated: Lack of supervision resulted in sexual abuse.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit for 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 Director of Resident Care Services Catherine Dorrian. Executive Director Wes Lavender arrived later during the visit. On 04/22/2024, the Department received a complaint where it was alleged that a resident (identified as R1) had been sexually assaulted by another resident (identified as R2) at the facility about four to five years ago. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099-C] Unsubstantiated [Continued from LIC 9099] R1 and R2 were residents at the facility, both with a diagnosis of Dementia. R1 moved into the facility in January 2024 and R2 had moved in to the facility in January 2023. Per administrative staff member interview, both had resided at home or with family prior to moving to the community and neither had lived at another residential facility for the elderly before coming here. R1 had initially shared the allegation to another resident who then reported it to staff. Details were that R2 had assaulted R1 at another facility they lived at together four to six years ago. Interviews with R1 (by the Community Care Licensing Department and by the Sheriff's Department) revealed inconsistent statements, timelines, and details about the incident. File review of the initial crime/incident report and subsequent follow up report by the San Diego County Sheriff's Department's reveal that their investigation was closed due to inconsistencies of details and timelines provided by R1. Interviews with staff and R1's responsible party reveal that the allegation is likely false and is a symptom of R1's Dementia. Based on interviews and records review, while the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred – therefore the allegation has been determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Lavender 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, Mar 4, 2026 · control 08-AS-20240422135104

Allegation investigated: Staff did not contact police in a timely manner Staff are not assessing residents for change in level of care Staff are not meeting residents needs Staff left resident in wheel chair for extended period of time Facility is charging residents for services not used Staff are not meeting residents showering needs

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with facility Executive Wes Lavendar, and explained the purpose of today’s visit. Regarding the allegation Staff did not contact police in a timely manner. The allegation was disclosed to family on 03/09/2022. Law enforcement was not contacted until 03/10/2022. Mandated reporting law requires immediate notification. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Substantiated Regarding the allegation Staff are handling residents in a rough manner. One resident reported being handled roughly and experiencing back pain. Another reported staff refused assistance and told her to “be quiet.” No corroborating evidence or documentation was provided. 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 allegation is unsubstantiated. Regarding the allegation: Staff are verbally abusive towards residents. Reports indicate a staff member told a resident to “shut up.” No corroborating evidence or documentation was found. 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 allegation is unsubstantiated. Exit interview conducted with facility Executive Director, Wes Lavender, and appeal rights provided. Regarding the allegation staff are not assessing residents for change in level of care. Collateral notes reflect multiple residents with dementia or wandering behaviors were moved from memory care into assisted living, while continuing to be billed for memory care or for “Circle of Friends” services they did not attend. Residents with ongoing needs had access to unsecured patios and were redirected after wandering off facility grounds. Based on interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding the allegation: Staff are not meeting residents’ needs. Residents reported being left in wheelchairs all day, refusing showers for extended periods, and not receiving appropriate dementia care. Documentation indicates these concerns were known but not consistently addressed. Based on information reviewed, staff did not consistently meet residents’ basic care needs. Based on interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding the allegation: Staff left resident in wheelchair for extended period of time. Resident reports indicate a lack of transfer to recliner and being left in a wheelchair throughout the day. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding the allegation: Facility is charging residents for services not used. Residents were billed for memory care or for “Circle of Friends” programming despite not receiving or attending these services. The documentation reviewed identifies several residents impacted. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding the allegation Staff are not meeting residents’ showering needs. Records indicate a facility resident had not been showered in one month. This is consistent with concerns of resident care needs not being met. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited Per Ttile 22 Regulations. Exit Interview conducted with Executive Director Wes Lavender, and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 22, 2026 · control 08-AS-20220317121016

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 23, 2026

87211(a)(1)(D) Reporting Requirements – “The licensee shall report by telephone to the licensing agency, local law enforcement, and the responsible person any suspected physical abuse … immediately, or within 24 hours.” The following requirement has not been met as evidenced by: Based on record review, the facility failed to immediately notify law enforcement when Resident #1 disclosed possible sexual abuse on 03/09/22. Law enforcement was not contacted until 03/10/22. This posed an immediate health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: The licensee shall ensure that all suspected physical or sexual abuse is reported immediately, or within 24 hours, to the licensing agency, local law enforcement, and the resident’s responsible party, as required by Title 22 CCR §87211. The licensee shall review and revise its abuse reporting procedures to ensure immediate notification occurs. All staff shall receive training on mandated reporting requirements and timelines. Documentation of reports shall be maintained in resident files and submitted to LPA by POC date of 02/23/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Mar 8, 2026

87463 Reappraisals – “The licensee shall arrange a meeting with the resident and/or representative when a significant change occurs in the resident’s condition to determine if the facility can continue to meet the resident’s needs.” The following requirement has not been met as evidenced by: Based on file review, residents with dementia and wandering behavior were moved from memory care into assisted living without evidence of reappraisal, while continuing to require memory care services. This resulted in residents not being placed at the appropriate level of care, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: The licensee shall ensure a reappraisal is conducted whenever a significant change occurs in a resident’s physical, mental, or functional condition. The licensee shall review procedures to ensure residents and/or their responsible representatives are included in the reappraisal process. Staff responsible for assessments shall be trained on identifying significant changes in condition and completing timely reappraisals. The licensee shall implement ongoing monitoring to ensure residents are placed and maintained at the appropriate level of care based on current reappraisals and send proof to LPA by POC date of 03/08/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 8, 2026

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The following requirement has not been met as evidenced by: Based on record review, residents reported not receiving assistance consistent with their care needs. This poses a potential, health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: The licensee shall ensure sufficient staff are scheduled at all times to meet residents’ care and supervision needs. The licensee shall review staffing patterns in relation to resident acuity and adjust staffing as necessary. Staff shall be trained to provide care consistent with residents’ assessed needs. The licensee shall implement ongoing oversight to ensure residents receive timely assistance and send proof to LPA by POC date of 03/08/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 8, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The following requirement has not been met as evidenced by: Based on record review, residents reported being left in wheelchairs all day. This poses a potential, health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: The licensee shall ensure residents are treated with dignity and are not left seated for prolonged periods without appropriate repositioning, assistance, or activity consistent with their assessed needs. Staff shall be trained on residents’ personal rights and mobility assistance requirements. The licensee shall review resident care plans to ensure mobility and repositioning needs are clearly identified and implemented, and send proof to LPA by POC date of 03/08/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507 · Plan of correction due date: Mar 8, 2026

87507 Admission Agreement – “All basic and optional services, rates, and charges shall be specified in the admission agreement. The licensee shall not charge for services that are not provided.” The following requirement has not been met as evidenced by: Based on documentation, residents were charged for memory care services and the “Circle of Friends” program despite not receiving or attending such services. This violates the admission agreement and created a financial burden on residents, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: The licensee shall ensure residents are charged only for services that are specified in the admission agreement and actually provided. The licensee shall review all current admission agreements and billing records to verify accuracy. Any billing discrepancies shall be corrected. Administrative staff responsible for billing shall be trained on admission agreement requirements and appropriate billing practices. The licensee shall implement ongoing monitoring of billing records to ensure continued compliance and submit proof to LPA by POC date of 03/08/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(a)(2) · Plan of correction due date: Mar 9, 2026

87464(a)(2) Basic Services – Personal Care and Supervision – “Basic services shall at a minimum include: (2) Personal assistance and care as needed by the resident … including assistance with bathing, grooming, dressing, mobility, and other personal needs.” The following requirement has not been met as evidenced by: Based on record review, residents reported not being assisted with showers. This poses a potential, health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: The licensee shall ensure residents receive personal care assistance, including assistance with bathing and hygiene, as needed. Staff shall be re-trained on providing and documenting personal care services in accordance with residents’ assessed needs. The licensee shall review resident care plans to ensure required personal care services are identified and implemented. Ongoing supervision and periodic audits shall be conducted to ensure residents’ personal care needs are consistently met. and proof submitted to LPA by POC date of 03/09/2026.

Allegation investigated: Licensee did not provide the services necessary to meet resident needs which resulted in serious injury Licensee did not arrange or assist medical care for resident Facility did not provide adequate lighting Licensee did not follow reporting requirements

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with facility Executive Director, Wes Lavendar, and explained the purpose of today’s visit. Regarding the allegation Licensee did not provide the services necessary to meet resident needs which resulted in serious injury. On 06/18/2021 at approximately 10:00 p.m., Resident 1 (R1) fell in their apartment during a facility-wide power outage. R1 reported being on the floor all night without staff assistance until discovered at approximately 7:00 a.m. the following morning. R1 was later admitted to the hospital and diagnosed with a spinal cord injury. Interviews with staff confirmed that R1 was not checked on throughout the night despite emergency procedures requiring staff to check resident welfare during power outages. Supervisory staff were not notified until contacted by the responsible party the next day. Based on documentation reviewed, interviews conducted, and hospital records, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Substantiated Regarding the allegation Licensee did not arrange or assist medical care for resident. On 06/19/2021 at 7:30 a.m., staff contacted R1’s responsible party and informed them that R1 had fallen, but did not disclose that R1 had been on the floor all night or that pendant response was delayed. Facility staff did not arrange immediate medical evaluation following the fall. Instead, the responsible party transported R1 to the hospital several hours later, where R1 was admitted with a spinal cord injury. Based on interviews conducted and hospital admission records, the facility did not ensure timely medical care was arranged for R1 after a known fall incident. The preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Regarding the allegation Facility did not provide adequate lighting. During the 06/18/2021 blackout, R1’s apartment did not have access to backup lighting. The only available fluorescent light in the bathroom did not illuminate the remainder of the unit. R1 attempted to locate their walker and pendant in complete darkness, resulting in a fall. Staff and supervisory personnel confirmed the facility did not have a generator or battery-operated lighting accessible to residents during the blackout. Facility policy requires ensuring resident safety during emergencies; however, residents were not provided adequate lighting. The preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Regarding the allegation Licensee did not follow reporting requirements. Records review and interviews confirmed that the facility did not notify the licensing agency of R1’s fall, extended time on the floor, or hospitalization. Supervisory staff were also not immediately informed of the blackout and fall until contacted by the responsible party. Based on interviews and documentation reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted with facility Executive Director, Wes Lavander, and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 22, 2026 · control 08-AS-20210715114337

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 23, 2026

87411 — Personnel Requirements (sufficient, competent staff to meet resident needs at all times) The following requirement has not been met as evidenced by: On 06/18/2021 during a facility-wide power outage, R1 fell in their apartment and remained on the floor overnight without staff assistance until ~0715 on 06/19/2021. Required welfare checks and timely assistance were not provided, resulting in unmet care needs and contributing to a serious injury later diagnosed at the hospital. which poses an immediate, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: All direct care staff will receive training on required welfare checks, emergency response procedures, and timely assistance to residents following an incident. Documentation of training will be maintained in personnel files and submit proof to LPA by POC date of 02/23/2026. The Administrator will implement a monitoring system to document completion of welfare checks each shift. The Administrator or designee will conduct weekly audits for 30 days to ensure compliance and ongoing monitoring thereafter.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(a)(1) · Plan of correction due date: Feb 23, 2026

87465(a)(1) — Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The following requirement has not been met as evidenced by: Following the known fall on the morning of 06/19/2021, facility staff did not arrange timely medical evaluation for R1. The responsible party transported R1 to the hospital several hours later, where a spinal cord injury was diagnosed. Facility did not ensure prompt medical care was obtained. which poses an immediate, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: All direct care staff will be retrained on fall protocols, including immediate assessment, documentation, and timely arrangement of medical services when indicated. Training will include when to contact emergency services versus responsible parties.. Documentation of training and monitoring will be maintained at the facility, and submit poof to LPA by POC date of 02/23/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(d) · Plan of correction due date: Feb 23, 2026

87212 Emergency Disaster Plan (a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. The following requirement has not been met as evidenced by: The facility did not have emergency adequate lighting in resident 1's room possibly contributing to a fall sustaining injuries, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: The Administrator will conduct a facility-wide inspection to ensure all emergency lighting fixtures are operational and sufficient to ensure resident safety. Any deficiencies will be corrected immediately.Staff will be instructed to promptly report non-functioning or inadequate lighting to management. The Administrator or designee will monitor emergency lighting conditions during monthly safety checks to ensure ongoing compliance, and send Emergency disaster plan to LPA by POC date of 02/23/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211 · Plan of correction due date: Mar 8, 2026

87211 — Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: The following requirement has not been met as evidenced by: The facility did not timely report R1’s fall, overnight time on the floor, or subsequent hospitalization to the licensing agency. Supervisory staff were also not promptly notified of the outage and incident until contact by the responsible party the following day, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2026

Plan of correction: All staff will receive retraining on identifying reportable incidents, required timelines, and proper notification procedures, including notifying the licensing agency, supervisory staff, and responsible parties without delay. Documentation of training will be maintained in personnel files and send proof to LPA by POC date of 03/08/2026.

Allegation investigated: Resident developed unstageable wound due to neglect Staff did not ensure medical care for resident Facility retained resident who required higher level of care Staff did not administer medications as prescribed

Licensing Program Analyst (LPA) Sarah Hurt conducted a telephone call vmeeting/ visit on 09/26/2025 to deliver Complaint findings on the allegations listed above. LPA met with facility staff Wesley Lavender and explained the purpose of the phone meeting. Regarding the allegation, Resident developed an unstageable wound due to neglect. Documents show Resident 1 developed a wound on the right forearm that progressed over time. Medical records attribute the wound to a separate diagnosed medical condition. Facility staff were not responsible for wound care; instead, AccentCare Home Health and Tri-City Medical Center provided ongoing treatment. Facility staff monitored and reported changes. Although the wound worsened, the evidence does not show that neglect by facility staff caused or contributed to the condition. Based on records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. Unsubstantiated Regarding the allegation Staff did not ensure medical care for resident. Records confirm Resident 1 was under the care of Tri-City physicians and AccentCare Home Health nurses. Facility staff followed medical instructions and family also retained private caregivers. Allegations that staff failed to ensure medical care could not be corroborated with available documentation. Based on records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. Regarding the allegation Facility retained resident who required higher level of care. Reporting party alleged Resident 1 should have been transferred to skilled nursing due to the wound. However, treating clinicians documented the wound required simple dressing changes and that Resident 1 remained ambulatory, alert, and appropriate for RCFE level of care with home health support. There is insufficient evidence to establish that the facility retained a resident beyond its licensed capacity. Based on records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. Regarding the allegation staff did not administer medications as prescribed. The complaint alleged medication errors; however, available records do not contain documentation of missed or incorrect medication administration. No corroborating evidence was provided to show Resident 1’s prescribed medications were not administered properly. Based on records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. No deficiencies cited Per title 22 regulations. An exit interview was conducted with facility Administrator Wesley Lavender. A copy of this report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 08-AS-20220404094758

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers 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 Executive Director Wes Lavender. The facility's license shows a maximum capacity of 175 elderly residents, age 60 and above, 30 of whom may be bedridden on the first floor only. Hospice care waiver is approved for thirty (30) residents. Facility is equipped with delayed egress and secured perimeter in the dementia unit. During today’s inspection, there were 151 residents in care. LPA accompanied by Executive Director Lavender toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident 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 residents. Medications were labeled, as required, and stored in locked areas. The pool located on the premises was fenced and locked. Per Executive Director Lavender, 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 was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC809-C] 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 Lavender to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 26, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPA) Liliana Silveira conducted an unannounced visit to continue a Required Annual Inspection, which began on 06/17/2024. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Wes Lavender. According to the facility’s license, the facility has a maximum capacity of 175, age 60 and above, 30 of whom may be bedridden on the first floor only. A hospice care waiver is approved for thirty (30) residents. The facility is equipped with delayed egress and secured perimeter in the dementia unit. During today’s inspection, according to records, there were a total of 129 residents in care. During the visits, LPA, accompanied by Building Engineer Mario Castaneda, toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. LPA privately interviewed multiple staff and residents. LPA 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 68 F. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Where tested, hot water temperature at taps (which were used by residents for personal care) were compliant: Bedroom #122 sink was 117.8 F, Bedroom #114 sink was 117.1 F, Bedroom #236 sink was 111.8 F, Bedroom #238 sink was 112.5 F, Bedroom #313 sink was 116.1 F. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents diagnosed with Dementia. A pool was present at the facility with secured entrance and a fence at least 5 feet high, which completely surrounds the pool. Per Wes Lavender, 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. Complete first aid kits were present and readily accessible. Licensee presented proof of current/active business liability insurance. Required licensing postings were observed in visible areas of the facility. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Wes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 18, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and identified themselves to Executive Director Wes Lavender. LPA discussed the purpose of the visit with Executive Director Wes Lavender. During today’s visit, LPA toured the facility with Building Engineer Mario Castaneda and reviewed staff and resident records. 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 Wes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jun 17, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to correct/amend a report. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Wesley Lavender. During today's visit, LPA formally amended a prior facility evaluation report and discussed the changes made with the Licensee. Licensee agreed to remove any copies of the prior report they have, substituting/replacing with the amended report. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Lavender, to whom a copy of the amended report, this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Apr 25, 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 outgoing Executive Director Ashley Marcellus and Director of Resident Care Services Elizabeth Smith. LPA also met with incoming Executive Director Wesley Lavender later during the visit. Today's visit was in response to two (2) LIC624 Incident Reports, which Licensee self-submitted to the CCLD San Diego Regional Office (both were received on 01/12/2024). According to the first LIC624: during the evening of 01/06/2024, an error by Staff #1 (S1) led to Resident #1 (R1) receiving an overdose of one (1) of their prescribed medications. [See LIC811 Confidential Names List for a description of select person identifiers used.] According to the second LIC624: during the evening of 01/09/2024, an error by S1 led to Resident #2 (R2) receiving medicine which was not prescribed to them [the medicine was instead prescribed to Resident #3 (R3)]. The above incidents did not result in any adverse health consequences to either R1 or R2. During today’s visit, LPA briefly toured the facility and performed a welfare check on both R1 and R2, verifying that both were safe. LPA also collected copies of and reviewed pertinent care records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 04/09/2019), R1 was diagnosed with Dementia, and their doctor determined that R1 required staff assistance with taking their prescribed medications. According to their latest LIC602 Physician’s Report (dated 01/24/2023), R2 was diagnosed with Mild Cognitive Impairment (MCI), and their doctor determined that they required staff assistance with taking their prescribed medications. Manager interview confirmed that both R1 and R2 were on paid medication assistance service with the Licensee during the above incidents. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] Staff Interviews showed: During the 01/06/2024 incident, S1 opened a pouch of medications assigned to R1 (which arrived pre-sealed from the pharmacy), then added one additional required blood thinner tablet to this pouch (as was normal process for R1), in anticipation of providing the set to R1 to ingest. However, before giving the medications to R1, S1 was called away to another task. While S1 was away, teammate Staff #2 (S2) stepped in to continue S1’s medication pass. S2 was not aware that S1 had already added one blood thinner tablet to the pouch; S2 added a second blood-thinner pill to the set, before handing all to R1 to ingest. R1 thus ingested one (1) extra dose of blood thinner medication, beyond what was prescribed to them that evening. S1 and S2 soon realized the error and notified facility management, who notified R1’s prescribing physician (PCP) and responsible person (RP) the same day. Date and time stamped progress notes, in conjunction with a review of the Medication Administrator Record (MAR) for R1, corroborated that facility withheld one of R1’s subsequent scheduled doses of the blood-thinner medication, consistent with PCP instruction. Staff continued to observe R1, who did not develop any adverse health consequence. Staff interviews showed: During the 01/09/2024 incident, S1 was preparing/readying medications for R2 and R3 at the same time, by placing medications in each resident’s respective plastic medication cup. S1 accidentally handed R3’s cup to R2. R2 then ingested one (1) medication dose which was not prescribed to them. S1 soon realized the error and notified facility management, who notified R2’s PCP and RP the same day. The PCP did not instruct any special follow up action for R2. Staff continued to observe R2, who did not develop any adverse health consequence. Date and time stamped progress notes, in conjunction with a review of the Medication Administrator Records (MAR), corroborated that R2 still received their other prescribed medications on the evening of 01/09/2024. Also, staff took additional action to ensure that the described error with R2 did not cause a medication error for R3. A preponderance of evidence exists to show that during the above respective incidents, process errors by Licensee’s staff (S1) resulted in R1 and R2 not receiving medications exactly as they were prescribed by their physicians. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] 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 also issued one Technical Violation (TV) regarding reporting requirements (see the LIC 9102-TV page). An exit interview was conducted with Lavender, Marcellus, and Smith, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, 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 6, 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, the licensee did not assist 2 of 140 residents (R1 & R2) 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: Manager interviews and training/personnel records, showed: On 01/08/2024, facility management met with both S1 and S2 to verbally debrief about the 01/06/2024 incident. On 01/11/2024, facility management met with S1 to perform formal/written corrective coaching and retraining with S1, regarding both the 01/06/2024 incident and the 01/09/2024 incident. Facility management also undertook additional training with the larger medication team on 02/05/2024 and 02/06/2024. These actions resolve the deficiency.

Allegation investigated: Licensee did not follow infection control protocol for scabies outbreak Licensee did not treat for pests

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate an investigation on the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Director of Resident Care Services Elizabeth Smith. On January 25, 2024, Community Care Licensing (CCL) received a complaint alleging licensee did not follow infection control protocol for scabies outbreak, and licensee did not treat for pest. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to allegation, the licensee did not follow infection control protocol resulting in multiple scabies outbreaks. According to staff interview, the facility has not had an outbreak of scabies since January of 2023. Records reviewed revealed that all residents associated to the January 2023 outbreak were treated for scabies by medical providers. Unsubstantiated Interview with staff did reveal that in January of 2024 Resident 1 (R1) was suspected of having scabies and R1 was treated preventively. Records collected confirmed that R1 was treated for symptoms related to scabies. Interviews with staff also revealed they did receive training to counter the spread of scabies. Interview with outside source confirmed that facility followed public health guidance in eradicating the outbreak. It was also alleged that licensee did not treat for bed bugs. On today’s date, LPA Strong conducted room inspections and did not observe any active bed bugs. Records collected also confirmed that facility has had pest control inspections and records confirmed there was no bed bug activity. Interview with multiple residents did not reveal any corroborating information to prove that facility has pests. Based on LPA's interviews, observations and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Director of Resident Care Services Elizabeth Smith to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 08-AS-20240125155452

Allegation investigated: Staff are not meeting residents hygiene needs Staff are not responding to residents call buttons in a timely manner

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close out the complaint investigation regarding the above-mentioned allegations. LPA identified herself and met with Ashley Marcellus Administrator, to discuss the purpose of the visit and elements of the complaint. It was alleged that staff are not meeting residents hygiene needs. The Department's investigation included interviews, and a review of pertinent records, Interviews revealed the staff are meeting the residents needs by responding to them when they need something and assisting the residents with daily needs. Interviews revealed that the staff have been busy but the work with the residents is still getting done. The interviews revealed that the level of care is based on the individual residents care plans and that is how they determine how much assistance a resident needs. There were no witness statements that confirmed staff are not meeting residents hygiene needs. Unsubstantiated It was alleged staff are not responding to residents call buttons in a timely manner. Interviews revealed the staff are responding to the call button although at times it is taking a little longer due to staff calling out. Interviews revealed that the facility is responding to the call button. Interviews with residents also revealed that some residents press the call button for things that are not very important and that does waste time for the staff to respond to a resident that may really need more assistance. There were no witness statements that confirmed staff are not responding to residents call buttons in a timely manner The complaint allegations are unsubstantiated. An exit interview was conducted with Ashley Marcellus, Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 08-AS-20210803164339