Belmont Village La Jolla

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA)Janet Ngallo conducted an unannounced case management visit. LPA identified herself and met with Catherine Tomboc Director of Resident Care, to discuss the purpose of the visit. Today's visit was in response to the self-reported incident reports. The incident reports dated 08/01/2026 and 08/19/2026, both involved medication errors. The incident reports received by the Department indicated that in both events, the residents involved were given medications intended and prescribed for other residents due to staff error. Per staff interview and the incident reports, no adverse reactions were observed or reported in any of the residents involved. One(1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 809-D page). Since the deficiency is a repeat violation within the last twelve (12) months, a Repeat Violation Civil Penalty of $250 was also assessed/charged to Licensee (refer to the LIC421-FC page). A plan of correction was jointly formed with the licensee. An exit interview was conducted with Executive Director James Arp, to whom a copy of this report, the LIC 9099-D page, LIC 421-FC page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 20, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80075(b)(5)(B) · Plan of correction due date: Sep 4, 2026

(B)Medications shall be given according to physician's direction. This requirement has not been met as evidenced by: Based on records review and interviews, the Licensee did not ensure proper medication administration procedures, resulting in a medication error, posing a potential health and safety risk to 2 out of 195 residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2026

Plan of correction: Licensee will submit proof of outside vendor medication training for all medication technician staff and submit proof to LPA via email with sign in sheet and training topic clearly noted by POC due date.

Allegation investigated: Staff neglect resulting in resident developing pressure injury in care. Staff are not assisting resident with obtaining medical care.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to deliver findings regarding the above mentioned allegations. LPA identified themselves and met with Executive Director James Arp to discuss the purpose of the visit and elements of the complaint. On 06/04/2026, it was alleged that staff neglect resulted in resident(R1) developing pressure injury in care, and that staff are not assisting resident with obtaining medical care. The department's investigation consisted of interviews, LPA observations, and records review. [Cont. on LIC 9099-C] Unsubstantiated [Cont. from LIC 9099] Regarding both allegations, interviews revealed that R1 is receiving hospice services through a hospice agency, which provides routine wound care, nursing visits, and supplies. Interviews confirmed that the facility coordinates with hospice regularly, notifies hospice when skin changes are observed, and follows hospice care instructions. Staff stated that R1 receives frequent monitoring, assistance with ADLs, and repositioning. Interviews stated that the wound observed on R1 was identified by the hospice agency as a Kennedy ulcer, which develops rapidly during end-of-life decline. Caregiver staff who had worked with R1 regularly, reported that earlier minor skin issues resolved with cream treatments, but then they observed a wound with odor that quickly became larger despite the frequent repositioning. Staff stated that the observation was reported, and that hospice assessed the wound, identified and referred to it as a Kennedy ulcer, and provided regular dressing changes and wound management more than three times a week during the past two months. Staff reported that R1 required two-person assistance for repositioning, was kept clean, and that staff notified management staff if there were any changes. Interviews with the hospice agency that provided care for R1 reported observing the wound during routine visits and confirmed the hospice team was actively treating it. The outside source(OS1) stated the wound continued to enlarge despite treatment due to R1’s overall decline. A welfare check conducted by outside authorities prior to the initial investigation resulted in no concerns regarding R1’s condition or care. LPA Persaud observed R1 during an initial visit. R1 was in bed, and staff assisted with gentle repositioning and removed R1's wound dressing for LPA observation. The sacral wound appeared smaller and appropriately managed compared to the photo submitted with the complaint. No indicators of untreated infection or distress from R1 were observed. Records review of R1's reassessment dated 05/10/2026 documented earlier redness to R1's buttock and that hospice was notified immediately on 05/06/2026 when an open sacral area was noted. Hospice orders included foam dressing, metronidazole application, frequent repositioning, and skin protection. Hospice progress notes consistently documented wound care for a Kennedy ulcer, ongoing monitoring, dressing changes, and progressive decline appropriate to hospice status. Hospice visit logs throughout May 2026 repeatedly identified the wound as a Kennedy ulcer with no infection present. R1’s medical assessment (LIC 602) indicated wound/skin management needs, non-ambulatory status, and hospice enrollment. [Cont. on LIC 9099-C pg.1] [Cont. from LIC 9099-C] Based on interviews, observations, and records review, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. An exit interview was conducted with Executive Director James Arp and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Jul 1, 2026 · control 08-AS-20260604144634

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janet Ngallo 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 Executive Director (ED) James Arp. The facility's license shows a maximum capacity of 220 non-ambulatory residents, of which 100 may be bedridden. All rooms are approved for bedridden and the facility is approved for delayed egress on floors 2, 3, 4, and 5. Additionally the facility has an approved hospice waiver for 20. During today’s inspection there were 194 residents in care. LPA, accompanied by ED James Arp and Building Manager John Miller, toured the interior and exterior of the facility and inspected common areas as well as a sample of resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms inspected contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to residents were all compliant. 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. Kitchen staff demonstrated precautions taken for dietary restrictions. Cooking, dining equipment, and utensils were present. Knives were stored in areas inaccessible to residents. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to residents. Laundry areas were noted to be locked. Medications were labeled, as required, and stored in locked areas. Med room staff explained to LPA medication administration procedures. A pool exists on the premises. LPA observed the pool to have a surrounding gate per regulation and gates noted to be secured. Per interview with ED James Arp, only staff have keys to the gates and residents who check out keys are monitored by staff while in the pool area. Per ED James Arp, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, fire sprinkler system, emergency lighting, and facility telephones were all in working order. Fire extinguishers were serviced within the last 12 months. Per Building Manager John Miller, emergency drills are conducted monthly. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA observed residents engaged in multiple facility led activities. Various calendars and postings throughout common areas of the facility noted various scheduled activities and events. LPA interviewed staff and residents, 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 James Arp 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, Jul 1, 2026

Allegation investigated: Staff did not assist resident with transfer, resulting in resident experiencing unwitnessed fall.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegation. LPA identified themselves and met with Executive Director James Arp to discuss the purpose of the visit and elements of the complaint. On 06/01/2026, it was alleged that staff did not assist a resident(R1) with transfer, resulting in R1 experiencing an unwitnessed fall. The department's investigation consisted of interviews and records review. [Cont. on LIC 9099-C] Unsubstantiated [Cont. from LIC 9099] Regarding the allegation, interviews consistently reported that R1 requires assistance with most activities of daily living, including assistance with transfers, and that staff regularly prompt R1 to use their call light pendant for help before getting out of bed. Interviews consistently stated that R1 sometimes attempts to transfer independently despite frequent reminders to wait for assistance, and will be successful with ambulating and transferring independently most times. Staff reported that on the night of the fall, R1 did not activate her pendant and yelled for assistance where staff was on the floor and able to hear and assist R1 promptly. Interviews also reported that staff conduct routine wellness checks on R1 every fifteen(15) to thirty(30) minutes. Records review of R1’s assessment and service plan dated 03/27/2026 revealed that R1 requires staff assistance with ADLs, assistance to the bathroom, frequent room checks, fall prevention measures, and encouragement to use the pendant for assistance. Records also documented recent confusion, hallucinations, and mobility decline associated with medical conditions. The incident report submitted to the Department reported that R1 had an unwitnessed fall in their bedroom and stated they tripped and lost balance. EMS transport was initiated per protocol, and R1 was admitted to the hospital with altered mental status. Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. An exit interview was conducted with Executive Director James Arp and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 08-AS-20260601111215

Allegation investigated: Staff neglected resident care resulting in rash.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above-mentioned allegation. LPA identified themselves and met with Executive Director James Arp, to discuss the purpose of the visit and elements of the complaint. On 04/28/2026, it was alleged that staff neglected a resident care resulting in a rash. The department's investigation consisted of LPA observations, interviews, and records review. Regarding the allegation, interviews reported that the resident(R1) experienced a period of gastrointestinal symptoms that required frequent care and increased hygiene assistance. Staff reported that they were checking on R1 often, changing R1's continence products frequently, notified nursing staff when skin irritation was first observed, and treatment began promptly after. Staff also reported that R1 had a history of skin sensitivity. (Cont. on LIC 9099-C) Unsubstantiated (Cont. from LIC 9099) Records review of R1's physician's report revealed diagnoses of irritable bowel syndrome, and care plan revealed that R1 required assistance with changing continence products and personal hygiene. Communication logs from 04/10/2026–04/29/2026 showed frequent toileting checks, regular assistance with continence changes, and ongoing wellness checks. Review of R1's care plan notes indicated that staff reported the irritation, a follow-up medical appointment occurred, and treatment instructions were implemented. A physician’s order dated 04/27/2026 attributed the skin irritation to the resident’s gastrointestinal episode and directed increased care for R1. LPA observed R1 clean and well-groomed. LPA attempted to interview R1, however due to cognition, R1 did not qualify for further interview. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate the allegation and therefore deemed unsubstantiated. An exit interview was conducted with Executive Director James Arp. 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, Apr 30, 2026 · control 08-AS-20260428103752

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA)Janet Ngallo conducted an unannounced case management visit. LPA identified herself and met with Catherine Tomboc Director of Resident Care, to discuss the purpose of the visit. Today's visit was in response to the self-reported incident reports. The incident reports dated 12/20/2025, 01/17/2026, and 03/09/2026, all involved medication errors. The incident reports received by the Department indicated that, in each of the three events, the residents involved were administered a second dose of the same prescribed medication within the same day. Per the reports, the initial medication administrations were not documented in the facility’s medication administration record (MAR). Per staff interviews, no adverse reactions were observed or reported in any of the residents involved. One(1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 809-D page). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Catherine Tomboc, Director of Resident Care, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 18, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80075(b)(5)(B) · Plan of correction due date: Mar 31, 2026

(B)Medications shall be given according to physician's direction. This requirement has not been met as evidenced by: Based on records review and interviews, the Licensee did not ensure proper medication administration procedures, resulting in a medication error, posing a potential health and safety risk to 2 out of 195 residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Licensee will submit proof of outside vendor medication training for all medication technician staff and submit proof to LPA via email with sign in sheet and training topic clearly noted by POC due date.

Allegation investigated: Neglect resulted in a resident sustaining unexplained injuries. Staff overdosed a resident.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to deliver findings regarding the above mentioned allegations. LPA identified themselves and met with Executive Director James Arp to discuss the purpose of the visit and elements of the complaint. On 04/04/2024, it was alleged that neglect resulted in a resident(R1) sustaining unexplained injuries, and that staff overdosed a resident. The department's investigation consisted of interviews and records review. (Cont. on LIC 9099-C) Unsubstantiated (Cont. from LIC 9099) Regarding the allegation that neglect resulted in a resident sustaining unexplained injuries, interviews did not corroborate the allegations. Interviews with facility staff and outside sources consistently described R1 as having fragile skin, a history of frequent falls, and episodes of combative and resistive behavior. Interviews stated that R1 was often combative during care, exhibited paranoia upon admission, and would swing their arms into objects, causing skin tears and often reopened previously dressed wounds. Staff reported that R1's hospice provider visited twice weekly to provide wound care, and both hospice and facility staff provided ongoing dressing changes throughout R1's time at the facility. Outside source interviews stated that R1 experienced multiple falls, and had skin tears that were not related to abuse or neglect but instead were consistent with R1’s condition and behaviors. Records review of R1's physician's report revealed that R1 had advanced dementia with recent significant progression and had a high fall risk. The report documented episodes of refusal of care, verbal aggression, and the need for fall-prevention measures. Records review of Hospice visit notes documented almost daily falls due to R1's difficulty rising from seated positions. Visit notes also documented ongoing paranoia and aggression, including an incident in which R1 struck a caregiver. No evidence supports that R1's injuries resulted from neglect. Injuries were consistent with the resident’s diagnosis, behaviors, fall history, and skin condition. Regarding the allegation that staff overdosed R1, interviews and records review did not support that staff over-medicated R1. Interviews reported that R1 exhibited significant anxiety, agitation, and aggressive behaviors, and that all medications were administered under hospice orders. Hospice ordered the facility to adjust dosages of R1's medication based on R1's response and any side effects. Interviews stated that R1 was prescribed Lorazepam for anxiety and shortness of breath, and that sedation and reduced activity were known side effects. (Cont. on LIC 9099-C pg. 1) (Cont. from LIC 9099-C) Records review of the Medication Administration Record showed that R1 received lorazepam on an as-needed basis, with no more than one administration per day, and often administered non-consecutively. The prescribed order instructed staff to administer one tablet every four hours as needed. Records review of R1's hospice visit notes revealed that hospice initiated trials of certain medications to address the resident’s significant agitation and anxiety, and dosages were adjusted accordingly when sedation or other side effects were observed. R1's responsible party requested that one trial medication be discontinued, and hospice discontinued the medication accordingly. No evidence corroborates concerns that staff administered medication inappropriately or beyond what was ordered. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director James Arp, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 08-AS-20240404162417

Type of visit: Case Management - Incident

Purpose of Visit: Incident Follow-Up – Death of Resident Licensing Program Analyst (LPA) Renita Hall conducted an unannounced case management visit to follow up on an incident reported to Community Care Licensing. LPA met with the Executive Director and the Director of Resident Care and discussed the purpose of the visit. This report documents the follow-up related to the death of Resident 1 (R1). A review of records indicates that R1 was assessed on 03/26/2025 and determined to be independent and not requiring assistance. A Physician’s Report dated 04/25/2025 documented that R1 was 89 years old with a diagnosis of Atrial Fibrillation (A-Fib). The report noted no physical or mental health limitations, no diagnosis of dementia, and that R1 was able to communicate needs, follow instructions, self-administer medications, ambulate independently, and transfer independently. R1 was able to leave the community unassisted and was in good physical health. Continued on 809C Facility notes dated 12/11/2025 reflect that R1 remained independent with ambulation, was physically in good condition, worked with a personal trainer once per week, required no redirection, and was actively engaged in community social activities. On 12/26/2025, records indicate that R1 experienced a fall in their apartment and struck the back of their head. No bleeding was noted. R1 was taking Xarelto, a blood thinner. Emergency services were contacted, and R1 was transported to the hospital via 911 for further evaluation. R1 was evaluated and returned to the facility the same day. Staff conducted rounds to make sure R1 was doing well. On 12/30/2025, R1 was found unresponsive in bed by their partner, who contacted the front desk. The nurse on duty assessed R1 and noted no pulse, no heart sounds, and no respirations. R1 was designated as Full Code, and CPR was initiated but was unsuccessful. Emergency Medical Services responded and pronounced R1 deceased on 12/30/2025 at 7:42 a.m. No additional information was obtained during this follow-up. Based on the information gathered, the facility appears to have acted appropriately and in compliance with applicable regulations regarding this incident. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to the Director of Resident Care along with appeal rights (LIC9058 03/22) and an LIC 811.the state’s words, verbatim · CDSS document, Jan 6, 2026

Allegation investigated: Lack of supervision resulting in resident elopement.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to conduct 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 James Arp. Note, LPA did step out for lunch from 12 to 1pm. On 12/15/2025, the Department received a complaint where it was alleged that a resident, identified as R1, had eloped from the facility due to lack of required supervision. The complaint alleges that R1 was supposed to have 1:1 supervision and did not at time of elopement. The Department’s investigation consisted of an unannounced facility visit, records review, and interviews with residents, staff, and outside sources. [Continued on LIC 9099-C] Substantiated [Continued from LIC 9099] On 12/17/25, the Department received an incident report from the facility regarding the elopement of R1. Per the report, the facility had received a phone call from the fire department that the resident was at their fire station. The fire department transported R1 to the hospital for evaluation and was discharged back to the facility same day with no noted injuries. Per interview with administrative staff, after review of facility camera footage, it was determined that R1 had wandered alone from their unit to the ground floor common area and eloped through a side door by the cafe into the fenced in patio area outside. R1 then exited through the gate leading from the patio to the front entrance and street where staff did not notice R1 wander away. Per administrative staff interview, the external doors and gate were not alarmed during the day. Per review of R1's records, R1 is diagnosed with Dementia and is unable to leave the facility unassisted. Per R1's assessment and service plan dated November 2025, R1 required escorts while going to meals and activities due to confusion. Additionally, the service plan stated that R1 required redirection and guidance, which is noted to be done through the use of frequent "eyes-on" checks. R1 is also noted to have a score of two (2) on their wander risk, and a comment that R1 "likes to walk outside in the neighborhood at home." Interview with R1's spouse revealed that R1 had attempted to wander off the facility once before but that staff immediately saw and redirected them back into the property. 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 is found to be SUBSTANTIATED. A deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D. As this is a violation pertaining to absence of supervision, a Zero Tolerance Violation (ZTV) Civil Penalty is being assessed. The Civil Penalty is being assessed in the total amount of $500.00 and details are noted on the attached LIC 421IM. An exit interview was conducted with Executive Director Arp 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, Dec 18, 2025 · control 08-AS-20251215101832

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 19, 2025

87468.2: In addition to the rights listed in Section 87468.1 [...] 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 This requirment is not met as evidenced by: Based on file review and interviews, the Licensee did not ensure R1 was supervised as needed, resulting in elopement, posing an immediate health and safety risk to 1 out of 187 residents in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Licensee will submit a plan of operations in measures/changes made to mitigate elopement risk at the facility and review resident supervision needs. Licensee will submit this to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) James Arp. Note, LPA did step out for lunch from 12pm-1pm. Community Care Licensing received an Incident Report on 12/05/25 in which it was reported that Resident #1 (R1) had eloped from the facility during the night and had been located by police approximately a block away from the facility, and taken to the hospital. Per the report, R1 sustained a laceration to the head, which was treated at the hospital. R1's responsible party and primary care physician were notified of the incident. LPA had also received a verbal report via phone call by ED Arp same day, where additional details regarding the incident were shared. Per the verbal report, R1 had a Diagnosis of Dementia and that exterior door alarms had failed, thus not notifying staff. Additionally, per ED Arp, the security guard that was supposed to be at the front entrance where R1 passed as they left the property was not at their post, and thus did not see R1 wander away either. During today's visit, LPA conducted a health and safety visit with R1 and provided consultation with ED Arp. The facility has moved R1 to the secured Memory Care unit post hospital discharge. The facility is working on updating/repairing their exterior door alarm systems and adding additional alarms to them. Additionally, the facility has increased staff presence at the front entrance to ensure someone is present at all times. The facility plans to implement trackable devices for at-risk residents for wandering/elopement in the coming months. [Continued on LIC 809-C] [Continued from LIC 809] Per review of R1's physician's report dated from May 2023, though R1 had no noted wandering/exit seeking behaviors, they were noted to be unable to leave the facility unassisted. Per review of R1's care assessment and service plan from November 2025, R1 required escort assistance to meals and activities due to their memory, but needed no assistance with guidance and redirection. Interviews with staff and R1's responsible party corroborated that R1 did not exhibit wandering behaviors prior to this incident. Interviews also corroborated that R1 received multiple staples to treat the laceration to their head sustained during their elopement. A type A deficiency was cited per Title 22 regulations and are noted on the attached LIC 809D. The citation is issued for the facility having been unable to meet the needs of R1 to ensure they did not leave the facility unassisted. As this is a violation that resulted in an injury to an individual in care, a Zero Tolerance Violation Civil Penalty is being assessed in the total amount of $500.00 and details are noted on the attached LIC 421IM. Additional Civil Penalties are under review by the Community Care Licensing (CCL) Department and may be assessed at a later date. A Technical Violation (TV) was also issued due to an accessible body of water located in the outdoor patio area of the ground floor. LPA explained the risks of residents who require additional supervision being around such fixtures. One deficiency was cited during the visit and one TV. An exit interview was conducted with Executive Director Arp 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, Dec 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 19, 2025

87468.2: In addition to the rights listed in Section 87468.1 [...] 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 This requirment is not met as evidenced by: Based on file review and interviews, the Licensee did not ensure R1 was unable to leave the facility unassisted, resulting in elopment causing serious bodily injury to R1, posing an immediate health and safety risk to 1 out of 187 residents in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: R1 has been moved to the secured memory care unit. Licensee will submit a plan of operations in measures/changes made to mitigate elopement risk at the facility. Licensee will submit this to LPA by POC due date.

Allegation investigated: Staff do not respond to residents' calls for assistance in a timely manner. Staff do not ensure residents' incontinence needs are being met. Staff did not prevent resident from developing a pressure injury. Unlawful eviction.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced visit to conduct a complaint investigation and delivered findings regarding the above mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Executive Director James Arp. On 05/19/2025, the Department received a complaint where it was alleged that the facility was not meeting the incontinence care needs of a resident (identified as R1) resulting in the development of pressure injuries. Additionally, the complaint alleges R1's calls for assistance are not responded to by staff in a timely manner and that R1 is being unlawfully evicted from the facility. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources. R1 was a non-ambulatory resident at the facility with no diagnosis of cognitive impairment or Dementia, per their physician's report. [Continued on LIC 9099-C] Unsubstantiated [Continued from LIC 9099] On April 21st, 2025, R1 was given a 30-day notice from the facility due to failure to follow facility rules, specifically for engaging in verbal abuse against staff and other instances of disruptive behavior in common areas. Initially a cease and desist, dated March 7th, 2025 was provided to R1, however R1's behaviors continued, and the facility issued the 30-day notice. An appeal meeting with R1 was held May 27th, 2025 and on June 6th, 2025 the facility provided R1 with a notice of the denied appeal and an unlawful detainer was filed. File review of over ten (10) staff member statements throughout April and May 2025 revealed a pattern of racial and derogatory statements being made by R1 towards staff. Staff interviews corroborated abusive behavior by R1, as well as multiple outside sources interviewed. The facility followed regulations regarding eviction procedures and failure to adhere to facility policies falls under the list of valid reasons for evictions, per regulation 87224. Regarding the allegation of staff not preventing the development of R1's pressure injuries, review of R1's physician's report (dated September 2024) revealed R1 had no history of skin condition or breakdown and that R1 did not require continuous bed care. Interview with administrative staff revealed R1 had a history of pressure injuries and even had one prior to move in, which delayed R1's official move in as the facility requested the injury be treated and resolved before moving in. Review of R1's medical documents do note a history of stage 1 pressure injuries since 2020. Records reviewed revealed Home Health and Hospice treatment for R1's recurring pressure injuries from 2024-2025. Per staff interviews, though R1 was not formally bed bound (R1 is noted to be non-ambulatory on their physician's report) they spent most of their time in bed. Two (2) staff interviews corroborated that R1 had periodic sores in their genital area and facility staff would assist with applying ointments to the affected area(s) per instruction from Home Health. Home Health visit records note instructions for facility staff in care for the wounds. Interview with an outside source medical professional revealed that R1's diagnosed condition of Renal Disease contributes to the development of the pressure injuries. This interview also corroborated that facility staff assist in care for the injuries and keep the area clean. [Continued on LIC 812-C] [Continued from LIC 812-C] Regarding the allegation of staff not ensuring R1's incontinence care needs are being met, this is also entwined with the allegation of staff not answering R1's pendant calls in a timely manner. Per the complaint, R1 would regularly wait over an hour and a half for staff to respond to their pendant calls and that R1 has sat in their feces for nearly four hours before staff changed their briefs. Multiple staff and outside source interviews revealed that R1 tends to "exaggerate" their claims on how long it takes to be tended to, when in reality it's only been several minutes. Two (2) staff interviews revealed that R1 specifically calls around shift changes in order to know who is working. Per staff interviews, during shift changes there is a brief staff meeting to pass over information, which then can cause a slight delay in responding to calls during that time. Staff interviews revealed that as R1 is a two (2) person assist, it can take additional time for a secondary staff member to assist on a call if they are assisting someone else at the moment, one (1) mentioning that it on average takes up to 20 minutes to assist R1. The outside source medical professional interviewed revealed that there was no physical indication of R1 having been sitting in their stool for long periods of time as it would've been apparent on R1's pressure injuries. This interview also revealed that as R1 is fully incontinent, they cannot feel when they have had a bowel movement. Other residents interviewed revealed no concerns about the timeliness of staff responses to pendant calls or the speed of incontinence care. File review of R1's Needs & Services plan reveal that staff provide 3-4 brief checks per shift. File review of call button response logs for R1 for a span of three (3) months reveal that R1 utilized their call button on average ten (10) to fifteen (15) times a day and that the majority of calls were resolved within 25 minutes. However, on several occasions response times exceeded an hour, with two (2) being over 2 hours. Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Arp 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, Nov 21, 2025 · control 08-AS-20250519093916

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director James Arp and Assistant Executive Director Donnie Johnson. Community Care Licensing received an Incident Report on 8/6/25 in which it was reported that on 7/20/25 staff responded to a resident fall. Per the report, the resident, identified as R1, was found sitting on the floor with a laceration to the head and a bruise with swelling on the right lower extremity. Emergency services were contacted and R1 was taken to the hospital where they were treated for a C2 fracture, nose fracture, and right ankle fracture. R1's Responsible Party and Primary Care Physician (PCP) were notified. During today's visit, LPA conducted file review, interviews, and provided consultation with Executive Director Arp. A health and safety visit with R1 could not be conducted as R1 has since passed away. No Deficiencies were cited during the visit as the facility responded accordingly and appropriately. An exit interview was conducted with Executive Director Arp to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to offer an Amended Report for a complaint visit conducted on 8/8/2025. LPA met with Executive Director (ED) James Arp and Assistant Executive Director Donnie Johnson and informed them of the purpose of LPA's visit. During today's visit, LPA obtained Executive Director Arp's signature on the amended report LIC 9099 (10/8/2025). ED Arp was also provided a copy of the amended report. An exit interview was conducted with Executive Director Arp 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, Oct 8, 2025

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 Associate Executive Director (AED) Donnie Johnson. The facility's license shows a maximum capacity of 220 non-ambulatory residents, of which 100 may be bedridden. All rooms are approved for bedridden and the facility is approved for delayed egress on floors 2, 3, 4, and 5. Additionally the facility has an approved hospice waiver for 20. During today’s inspection there were 171 residents in care. LPA, accompanied by AED Johnson and Building Manager John Miller, toured the interior and exterior of the facility and inspected common areas as well as 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 inspected 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: Bathroom sinks tested on floors 4, 5, 8, 11, 14, 15, and 16 temped at 106.6, 105.2, 105, 105, 108.6, 105.2, and 106.5F, respectively. 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. Kitchen staff demonstrated precautions taken for dietary restrictions. Cooking, dining equipment, and utensils were present. Knives were stored in areas inaccessible to residents. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Laundry areas were noted to be locked or if they were in use and doors opened, staff were present to monitor. Medications were labeled, as required, and stored in locked areas. Med room staff demonstrated to LPA medication administration procedures and LPA also observed med room staff pass medications to residents. A pool exists on the premises. LPA observed the pool to have a surrounding gate per regulation and gates noted to be secured. Per interview with AED Johnson and Building Manager Miller, only staff have keys to the gates and residents who check out keys are monitored by staff while in the pool area. Per AED Johnson, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, fire sprinkler system, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. Most recent emergency drill conducted with staff was held on 6/26/25 for the topics of earthquakes and fires. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA observed residents engaged in facility led activities, particularly in the Connections for Living and Memory Care units. Various calendars and postings throughout common areas of the facility noted various scheduled activities and events. LPA observed various staff and resident interactions throughout their visit and noted residents to be attended to quickly and treated with respect. LPA interviewed 2 staff and 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. LPA did provide a Technical Assistance for best practices on ensuring 1st Aid/CPR Certificates were current and valid. No deficiencies were cited during the inspection. An exit interview was conducted with Associate Executive Director Johnson 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, Jul 25, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) James Arp and Assistant Executive Director (AED) Donetta Johnson. Community Care Licensing received an Incident Report on 5/21/25 in which it was reported that Resident #1 (R1) had been given another resident's medications by Staff #1 (S1). Per the report, once S1 noticed the error, they reported to the nurse on duty, who performed an assessment on R1. R1 experienced a change in condition and emergency services were called. R1 was evaluated by medical personnel in the hospital and cleared to return back to the facility the same day. R1's Responsible party and Primary Care Provider (PCP) were notified of the incident. During today's visit, LPA conducted file review, a health and safety visit with R1, and provided consultation with ED Arp and AED Johnson. A Deficiency was cited during the visit. An exit interview was conducted with ED James Arp 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 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80075(b) · Plan of correction due date: May 29, 2025

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on file review and interviews, the Licensee did not ensure proper medication administration procedures, resulting in a medication error, posing a potential health and safety risk to 1 out of 166 residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: Licensee will submit proof of medication re-training with S1 and submit to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabel Martinez conducted a case management visit to obtain signatures and deliver an amended 9099D form. The LPA met with Assistant Executive Director Donnie Johnson, introduced himself and disclosed the purpose of the visit. Executive Director James Arp arrived during the visit. During the visit, the LPA secured signatures and delivered an amended 9099D form. An exit interview was conducted with Johnson and Arp, to whom a copy of the this report, and Licensee Rights (LIC 9058), were provided via email.the state’s words, verbatim · CDSS document, Mar 13, 2025

Allegation investigated: Staff do not provide 1 on 1 care for resident as agreed

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director James Arp. Throughout the investigation, the Department secured pertinent records and conducted interviews with several sources, including staff and residents. It was alleged staff did not provide one on one care for a resident as agreed. An interview with an internal source revealed the facility provided private pal (caregiver) agreements as an additional service. This service provided additional assistance with activities of daily living, wellness checks, incontinence care, escorts, housekeeping services, safety support, socialization services, and companion services. (See LIC9099C form continuation of report.) Substantiated The number of days, hours, and frequency varied and was dependent on the resident and resident’s responsible party. Most of the interviews conducted did not reveal any concerns with the agreements not being followed. One source revealed an instance when a caregiver providing one to one assistance was asked to assist other caregivers. The resident being provided one to one assistance was escorted to a common area where other residents were supervised by staff. A separate source recalled an instance where the assigned one to one caregiver was asked to assist with meal prepping. The staff agreed and the resident being provide one to one assistance remained in the common area, within eyesight of the caregiver. Although the residents remained under staff supervision, the agreement of one-to-one care was not followed. This deficiency was cited in an LIC 9099D page and a plan of correction was jointly formulated with the Executive Director James Arp. An exit interview was conducted with James Arp, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by James Arp. R1’s Physician’s Report (LIC 602) dated July 12th, 2022, revealed a primary diagnosis of Hyperlipidemia (HLD), Spinal Stenosis (cervical), and Sciatica. A secondary diagnosis of Gerd, and Neuropathy of fingers. No cognitive impairment was disclosed in this report. A records review that included the facility and nurses’ notes dated March 13th, 2023, revealed that R1 was found on the floor by staff, who summoned Emergency Medical Services (EMS). The facility and nurses notes further revealed that on March 14th, 2023, upon R1’s request, staff transported R1 to urgent care with complaint of pain. An X-ray revealed R1 had a rib fracture and medication was prescribed. R1 declined further testing and denied any head injuries had occurred. Interviews with staff confirmed that staff responded to R1’s call for help, evaluated R1 and EMS was summoned. Interviews with staff and R1’s relative confirmed R1 had a history of declining medical assistance and often declined to be transported to the hospital for further evaluation. During this incident, Staff and a relative encouraged R1 to obtain medical evaluation from emergency personnel, but R1 continued to decline further evaluation. Based on evidence obtained, staff responded quickly, evaluated R1 and summoned EMS. R1 was R1’s own responsible party and declined further medical attention, therefore, the allegation was Unsubstantiated. It was alleged neglect resulted in R1 receiving delayed medical care. During R1’s fall on March 18th, 2023, there were no visible injuries, but R1 complained of right-side pain. Staff were unable to determine if R1 struck their head during the fall. Paramedics were immediately called and assessed R1 for injuries. Paramedics advised R1 to be transported to the hospital for further evaluation, but R1 refused. R1’s relative was called while paramedics were still present and tried to convince R1 to be transported to the hospital for evaluation. R1 still refused. R1 was their own POA and in charge of their own medical care. The evidence shows that R1 was immediately provided emergency services after the fall, but R1 declined further evaluation against the paramedic’s advice. Therefore, the allegation of Neglect/Lack of Care and Supervision resulting in untimely medical care was Unsubstantiated. It was alleged staff did not meet resident's toileting needs. Interviews with several sources, including staff and residents, denied having concerns with lack of incontinence care, or with lack of assistance with toileting. Sources consistently reported staff would respond within a reasonable time to residents’ requests. The allegation was unsubstantiated based on the evidence obtained during the investigation. An exit interview was conducted Executive Director James Arp, to whom a copy of this report was provided via email. An email read receipt confirms the documents were received by Arp.the state’s words, verbatim · CDSS document, Feb 28, 2025 · control 08-AS-20230905110217

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Feb 28, 2025

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on review of documents and interviews, the Licensee did not ensure one on one care was provided to residents as agreed, which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 28, 2025

Plan of correction: Administrator agreed to modify the private pal agreement and submit a copy to the LPA by 3/28/2025.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management - Incident visit. The LPA introduced himself and discussed the purpose of the visit with Executive Director James Arp. Nursing Director Cat Tomboc and Assistant Executive Director Donnie Johnson assisted the LPA during the visit. Today's visit was in response to an LIC624A Death Report, which the licensee self submitted to the CCLD San Diego Regional Office (received on 1/28/2025). [See LIC 811 Confidential Names List for a description of Resident # 1 (R1).] During today’s visit, the LPA conducted a tour of the facility, conducted interviews, and collected pertinent records. A death certificate for R1 was also requested during the visit. No immediate health and safety concerns were observed during today's visit and no deficiencies were cited. An exit interview was conducted with Johnson, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058), were provided.the state’s words, verbatim · CDSS document, Jan 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Director of Resident Care Services, Cat Tomboc. The facility was licensed for a capacity of two hundred twenty (220) non-ambulatory residents, of which one hundred (100) may be bedridden. The facility was also approved a hospice waiver for twenty (20) residents. Floors # 2, # 3, # 4, and #5 were approved for delayed egress. A secured perimeter was also approved. The LPA, accompanied by staff, toured the interior of the facility. The facility was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards. Residents bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Pull cords were tested randomly to confirm the signal system in different floors was operational. Sufficient space was observed for resident activities, meetings, visitation, and laundry. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment, utensils, and emergency supplies were present. There were no toxic chemicals/poisons accessible to clients, and medications were labeled, and stored in a locked area. The LPA reviewed resident and staff records. Due to time constraints, a continuation visit on a subsequent day is necessary to complete the annual inspection. No deficiencies were observed, nor cited on today's date. An exit interview was conducted with Director Tomboc, to whom a copy of this report, and Licensee/Appeal Right (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Jul 31, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Resident Service Director Cat Tomboc during the visit. Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 01/31/2024 as well as self-reported incident report received at the CCLD San Diego Regional Office on 1/15/2024 and 1/31/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the self-reported death document, R1 passed away on 01/30/2024. During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no safety concerns. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff. The Death Certificate was also requested during the visit. No deficiency was cited at the time of the visit. An exit interview was conducted with Resident Service Director Cat Tomboc, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Rights (LIC 9058 01/16).the state’s words, verbatim · CDSS document, Feb 5, 2024