Lantern Crest

Allegation investigated: Facility staff did not follow the terms and conditions of the admission agreement. Resident did not receive medication as prescribed. Facility did not meet residents needs. Resident's room was not cleaned.

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegations. LPA identified herself, explained the purpose of the visit and nature of the complaint to Executive Director Liz Najera. On July 22, 2022 the Department received this complaint which alleged facility staff did not follow the terms and conditions of the admission agreement for Resident #1 (R1), R1 did not receive medication as prescribed, facility did not meet R1’s needs, and R1’s room was not cleaned. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] There are limited records on file from when this investigation was initially opened and the facility is only required to maintain resident records for three years following the termination of services to the resident. The Department is therefore unable to collect further records. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Regarding the allegation that facility staff did not follow the terms and conditions of the admission agreement, the Reporting Party specifically alleges that R1 did not receive bathing services regularly. While the Department does have a record of R1’s admission agreement, no other records were collected that could have supported if terms and conditions were or were not being met at the time of the allegation. Per the admission agreement, R1 was being billed the agreed upon amount signed by R1’s responsible party and there were no additional records collected to indicate differently. Regarding the allegation that R1 did not receive medication as prescribed, records collected revealed all medications as administered per the Medication Administration Record (MAR) for R1. Regarding the allegation that facility did not meet R1’s needs, there were no records collected to indicate R1’s needs were being neglected by the facility. Regarding the allegation that R1’s room was not cleaned, observation notes from the LPA who initially opened this complaint observed the facility to be in a clean condition. Upon this date of delivering investigative findings, LPA observed resident bedrooms to be clean and in good repair. The Department concluded based on available records initially collected, there was no corroborating evidence to support the above mentioned allegations. LPA reviewed facility records of annual inspections and other complaint investigations and did not find any relevant information to support or corroborate these allegations, therefore it is determined that the preponderance of evidence was not met and these allegations are unsubstantiated. An exit interview was conducted with Executive Director Liz Najera, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 08-AS-20220722111442

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angelica Boyles 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 with Executive Director Liz Najera. The facility is Licensed to serve 180 residents ages 60 and above; 90 of whom may be non-ambulatory, approved for 20 bedridden residents; delayed egress approved for the first two floors. The facility also has a Hospice waiver for 20 residents. LPA accompanied by the Executive Director toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms visited contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. LPA toured the kitchens and respective dining areas. 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. (Continued on LIC 809-C) (Continued from LIC 809) No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. Per Executive Director, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. 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 Liz Najera, 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, Apr 13, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Irma Sterling, Resident Services Director and Liz Najera, Executive Director. Today's visit was in response to an Unusual Incident/Injury Report (LIC624), which licensee self submitted to the CCLD San Diego Regional Office on 2/23/26. According to the report, on 2/19/26, Staff #1 (S1) incorrectly placed a medication in the wrong destruction box, and the following day the medication was no longer present and there was no record of it being properly discarded. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour, reviewed relevant records and interviewed staff. LPA observed the room where medications are kept which is locked and inaccessible to residents. Per staff interviews, S1 did discard of the medication in the appropriate place after the mistake, but did not log the proper discarding of the medication. 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. An exit interview was conducted with Irma Sterling and Liz Najera to whom a copy of this report, the LIC 809-D, 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 24, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i)(4) · Plan of correction due date: Mar 17, 2026

Incidental Medical and Dental Care (i)Prescription medications which...are otherwise to be disposed of shall be destroyed...a record [is] to be retained...which lists the following: (4)The date of destruction. This requirement was not met as evidenced by: Based on records reviewed and staff interviews, the medication destruction record was not complete.This posed a potential health and safty risk to residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2026

Plan of correction: Administrator reported that staff will be retrained on medication destruction and will submit proof of training to LPA by POC due date.

Allegation investigated: Facility staff did not ensure that residents had access to telephone service while in care .

LPA Correia conducted an unannounced visit to commence and conclude a complaint investigation. Upon arrival, LPA was greeted by the facility receptionist, Diane How, identified herself, and met with Memory Care Coordinator (MCC) Angela St. Mars and Executive Director (ED) Liz Najera. LPA explained the purpose of the visit to both individuals. The Department’s investigation included a review of facility records, a tour of residents’ rooms, and interviews conducted with staff, residents in care, and an outside source (OS1). Unfounded On January 28, 2026, the Department received a complaint alleging that the facility’s telephone service had been inoperable for approximately 2 to 3 weeks, leaving residents without a way to contact family or call 911 in case of an emergency. A facility tour revealed that the phones in residents’ rooms were in working order. An interview with Outside Source (OS1) indicated that the phone outage occurred in a building named The Ridge, identified as the Independent Living Facility (ILF), which is not state licensed but operates under the corporation’s umbrella. A review of the resident roster and facility tour confirmed that the residents affected by the phone outage reside in the ILF and are not under the jurisdiction of Community Care Licensing (CCL). Based on interviews with staff, residents, and outside sources, as well as a review of facility records and a facility tour, the above allegation was determined to be unfounded, and the complaint has been dismissed. An exit interview was conducted with ED Najera, to whom was provided a copy of the reports (LIC 9099) and Licensee Rights (LIC 9058). Signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 08-AS-20260128170818

Allegation investigated: Facility staff did not safeguard resident's belongings. Facility staff did not ensure resident received meals.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced complaint visit to investigate allegations regarding missing personal belongings and lack of meal provision for Resident 1 (R1). LPA was greeted by Concierge Diane How, identified herself, explained the purpose of the visit, and met with the Executive Director Najera and Resident Service Coordinator (RSD) Irma Sterling, and Memory Care Coordinator (MCC) St. Mars, to whom were explained the purpose of the visit. The Department’s investigation included staff and outside source interviews and a facility and resident records review. It was alleged by an outside source (OS1) that Resident 1 (R1) was missing belongings from the facility, including a phone and a remote control. OS1 also alleged facility staff did not ensure R1 received proper meals. An interview conducted with R1's Responsible Person (RP) revealed they were in consistent contact with facility staff and conducted regular visits. The RP stated R1 is well taken care of by staff, has no missing belongings, and received meals as scheduled. Unsubstantiated Interviews conducted with facility staff and records reviews corroborated the RP statements (as mentioned above). Staff interviews and documentation reviewed during the visit did not reveal any evidence to support the allegations. Based on the information obtained, the allegations are Unsubstantiated. An Unsubstantiated finding means there was not a preponderance of evidence to prove the violations occurred. An exit interview was conducted with Resident Service Coordinator (RSD) Irma Sterling. A copy of this report along with Licensee Rights (LIC 9058 01/16) will be provided to RSD Sterling. Signature on this form confirms the documents were received. LPA left for approximately 2 hours for lunch break and other CCL related tasks.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 08-AS-20250218150907

Allegation investigated: Staff mismanaging resident’s medication.

LPA conducted an unannounced follow-up visit to deliver findings on a complaint investigation. LPA was greeted by Concierge Diane How, identified herself, explained the purpose of the visit, and subsequently met with ED Nagaria, RSD Sterling, and MCC St. Mars. The Department’s investigation consisted of staff interviews, and a facility and resident records review. On February 21, 2025, the Department received a complaint that the facility was mismanaging Resident 1 (R1’s) medication. Staff interviews and a review of the hospital discharge report, dated February 15, 2025, included a discontinuation of two (2) of R1’s medications. On February 17, 2025, facility staff sent a request to R1’s Primary Care Physician (PCP) for an order to discontinue the medication per the hospital discharge report/instructions, to no avail. Interviews with facility staff revealed they are not allowed to stop, administer, or change residents’ medication without the PCP approval. Unsubstantiated Title 22, California code of regulations, 87465 (h)(2) supports the facility’s position that it cannot discontinue medications without a physician’s order, even when hospital discharge instructions indicate such changes. Based on staff interviews and a review of facility and resident records the above mentioned allegation, due to lack of corroborating evidence, the finding was established to be unsubstantiated. There is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Resident Service Coordinator (RSD) Irma Sterling. A copy of this report along with Licensee Rights (LIC 9058 01/16) will be provided to RSD Sterling. Signature on this form confirms the documents were received.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 08-AS-20250221112306

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia visited the facility to conduct an annual required licensing inspection. LPA Correia was greeted by Concierge Diane Hom, and subsequently met Resident Service Director (RSD) Irma Sterling, identified herself and was granted entry into the facility, and explained the purpose of the visit. The facility is Licensed to serve 180 residents ages 60 and above; 90 of whom may be non-ambulatory, approved for 20 bedridden residents; delayed egress approved for the first two floor. The facility also has a Hospice waiver for 20 residents. The facility's current census is 134, consisting of 98 residents who reside in Assisted Living and 36 residents who reside in the Memory Care facility unit. During today's visit, LPA Correia, conducted resident records reviews. review of resident records was complete and current; including the following forms Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, and Admission Agreement. LPA also conducted a review of facility personnel facility records. were reviewed for First Aid/CPR certification, Criminal Record Clearance, TB clearance, and Health Screening Report, and proof of attendance to required training. Due to time restraints, Resident Service Director Irma Sterling was notified the remainder of the annual inspection will be completed at a later date. No deficiencies were cited during today’s initial Annual Inspection. An exit interview was conducted with ED Santana and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided via email. signature below confirms receipt of the reports.the state’s words, verbatim · CDSS document, May 12, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA), Debbie Correia, made an unannounced visit to conduct the continuation of the One-year annual Inspection. LPA Correia was greeted by the facility Concierge Diane How, introduced herself, and met with Executive Director (ED) Diana Santana. LPA, accompanied by ED Santana, conducted a facility tour, and inspected resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Required postings were observed. Resident bedrooms contained the required furnishings, a private bathroom, showers were equipped with non-skid flooring and grab bars. Doors, windows and screens, toilets, and showers were in working order. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. The facility was equipped with a back-up generator, a supply of emergency food, first-aid kit, and evacu-chairs at staircases. Medications were housed in a locked med-cart with-in a locked office. Cleaning supplies and other toxins were inaccessible to residents in care. There were no bodies of water on the facility property. The facility had ample space for activities as well as a theater. Per ED Santana, there are no firearms or other weapons on the facility premises. The facility had two (2) large communal dining areas, the facility has a commercial kitchen with a 7-day supply of non-perishable and 2 days of perishable food. The temperature of the walk-in refrigerator and freezer were with-in compliance per Title 22 regulation. The facility’s ambient internal temperature was compliant, at 71 F. The facility's hot water temperature for faucets used by residents measured at 105.1 and 111.2. LPA Correia left the facility at 1:00 p.m.to take a lunch and draft this report and returned at 2:15.p.m to deliver the report and obtain signatures. Based on today’s inspection, there are no deficiencies being cited. An exit interview was conducted and a copy of this report, and Licensee Rights - LIC 9058 (rev. 01/16) were be provided to ED Santana, whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 8, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Debbie Correia, made an unannounced visit to conduct the required One-Year Inspection. LPA Correia was greeted by the front lobby concierge Diane How, introduced herself and met with Memory Care Coordinator Angela St. Mars and explained the purpose of the visit. Shortly later Executive Director (ED) Diana Santana joined the inspection. Resident Service Coordinator (RSC) Naz Balagot also joined the inspection. The facility is licensed to serve 180 residents age 60 and above, 90 of whom may be non-ambulatory, 20 bedridden, and 20 residents who may be on hospice care. Resident records were reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, and Admission Agreement, and personnel records were reviewed for First Aid/CPR certification, Criminal Record Clearance, TB clearance, and Health Screening Report, and required training. The facility carbon monoxide and smoke alarms were last inspected on January 20, 2024. The facilities liability insurance policy is current and set to renew on March 1, 2025. The facilities last disaster drill was conducted on March 22, 2024. The facility employs 3 (three) activities specialists and maintains a monthly activity calendar. The facility also employs a dietician that creates monthly menus however the residents are also provided an additional menu with an array of food to choose from if wanted. During today’s visit, LPA Correia conducted a partial interior tour of the facility, resident, staff, and facility records reviews. An overall inspection of the facility began today, however, due to time constraints LPA was unable to complete the visit and will return later time to conduct the remaining portion of this inspection. Based on today’s inspection, there are no deficiencies being cited. An exit interview was conducted and a copy of this report, and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) will be provided to RSC Balagot, whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 2, 2024

Allegation investigated: Staff do not provide adequate hygiene care to residents. Staff do not dispense medication to resident as prescribed. Staff do not adequately supervise residents, resulting in multiple unwitnessed falls.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to commence a complaint investigation. LPA was greeted by Concierge Sandy Vance, identified herself, and met with Resident Service Director (RSD) Stacey Dickman and Resident Care Coordinator (RCC) Elida (Vidal) Tapia. LPA discussed the purpose of the visit and the basic elements of the allegations mentioned above with RSD Dickman and RCC Dickman. During today's visit, a record review revealed the alleged victim resides in the Independent Living section of the facility. The San Diego Regional Office (SDRO) Community Care Licensing (CCL) Division does not have jurisdiction over Independent Living Facilities (ILF), therefore the above allegations are determined to be unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with RCC Tapia a copy of this report will be been provided for facility records. Unfoundedthe state’s words, verbatim · CDSS document, Nov 21, 2023 · control 08-AS-20231117162109

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.