Westmont of Carmel Valley

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to the facility. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Amy Banaga and Regional Director of Residential Services Stefanie Ancheta. While conducting file review of staff records, LPA noted that a staff member (identified as S1) was not associated to the facility. Per additional LPA interview and file review, it was revealed that S1 was working temporarily at this location and associated to a sister facility nearby. Per review of the Guardian system, S1 did have an eligible background clearance, just that their clearance was not transferred over to this facility. S1 was able to be associated to this facility during the visit. One type A Deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached LIC 809-D for S1 working without having their clearance associated to the facility. A Civil Penalty is being assessed and details are noted on the attached LIC 421BG form. As a citation for the same regulation violation was assessed on 3/4/26, within a twelve (12) month period, a repeat violation Civil Penalty is being assessed and details are noted on the attached LIC 421IM. The combined amount of the Civil Penalties assessed today is $4,000.00 One Deficiency was cited during the visit. An exit interview was conducted with Executive Director Banaga to whom a copy of this report, the LIC 421BG, LIC 421IM, 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 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Apr 14, 2026

87355(e): "All individuals subject to a criminal record review [...] shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)" This requirment is not met as evidenced by: Based on LPA file review and interview, the licensee did not comply with the section cited above in ensuring that a staff member had their clearance transfered prior to working at the facility, which poses an immediate health, safety, and personal rights risk to 131 out of 131 persons in care.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: Licensee was able to associate the staff member during the visit. Licensee will review the facility association roster to ensure it is up-to-date. Additionally, Licensee will conduct review of regulation 87355 and submit proof 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 the facility. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Amy Banaga, Residential Services Director Le Sutton, and Business Office Director Erica Saade. While conducting file review of staff records, LPA noted that five (5) staff members were not included on the facility's association roster. Further review revealed that the three (3) of those staff members were minors who worked part time as kitchen/serving staff, hence no background clearances. The other two (2) staff members (identified as S1 and S2) had eligible background clearances with previously conducted background checks, however their clearances were not transferred over to this facility. Per staff interviews, S1 had been working at the facility for a few months and S2 for a period of a few weeks. S1 and S2 were able to be associated to the facility during the visit. One type A Deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached LIC 809-D for the two (2) staff working without having their clearances associated to the facility. In addition, Civil Penalties are being assessed for the total amount of $1,000.00. Details are noted on the attached LIC 421BG form. One Deficiency was cited during the visit. An exit interview was conducted with Executive Director Banaga to whom a copy of this report, the LIC 421BG, 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

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Mar 11, 2026

87355(e)(2) "All individuals subject to a criminal record review [...] shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)" This requirment is not met as evidenced by: Based on LPA file review and interview, the licensee did not comply with the section cited above in ensuring that 2 staff members had their clearances transfered prior to working at the facility, which poses an immediate health, safety, and personal rights risk to 134 out of 134 persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: Licensee was able to associate the two (2) staff members during the visit, eliminating immediate risk. Licensee will review the facility association roster to ensure it is up-to-date. Additionally, Licensee will conduct review of regulation 87355 and submit proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramin Hashemi 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 Le Sutton, Resident Services Director (RSD). The facility's license shows a maximum capacity of one hundred and thirty-eight (138) non-ambulatory residents, ages 60 and over. The facility has an approved hospice waiver for twenty (20). During today’s inspection there were 132 residents in care. LPA and Le Sutton, RSD toured the interior and exterior of the facility and inspected resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and 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 clients. Medications were labeled, as required, and stored in locked areas. Per Le Sutton, RSD, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Le Sutton, RSD to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Case Management - Incident

[Report Amendment: Correct Census is 133 for the RCFE-licensed portion, excluding the "Casitas" on the campus which are not licensed by CCLD.] Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Amy Banaga and Resident Services Director Le Sutton, 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 07/16/2025. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. Per the written report, R1 passed away at the facility on 07/16/2025. During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no immediate safety concerns. LPA also collected copies of and reviewed pertinent records, and interviewed relevant staff. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Executive Director Amy Banaga, to whom a copy of this report, 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, Jul 21, 2025

Allegation investigated: Staff did not ensure quantity of food was sufficient to meet resident's needs.

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to initiate and deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Resident Services Director Le Sutton. On May 5, 2025, it was alleged that staff did not ensure quantity of food was sufficient to meet resident's needs. It was alleged that the facility staff were not providing Resident #1 (R1) food. [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. (CONTINUED ON LIC9099-C) Unsubstantiated Review of R1’s medical assessment records dated March 27, 2025, revealed that R1 had a diagnosis of dementia, was confused/disorientated, exhibited sundowning behaviors, and could feed themselves but required assistance with all other activities of daily living. Review of R1’s service plan date April 1, 2025, revealed that R1 was independent with feeding but required on going care for advanced dementia that caused speech, functional, and behavioral impairments. LPA conducted a tour of the facility, during the facility’s lunch hour, to which LPA observed three different meal options being provided to the residents. LPA did not observe a lack of food for the residents. Review of the facility’s menu revealed that residents are provided three meals a day with lunch having three different entrée options and dinner consisting of four different entrée options. Interviews with staff revealed that the residents are provided a snack three times a day in addition to a snack station that residents have ongoing access to. Interviews with residents and outside sources did not reveal a concern for an insufficient amount of food to meet residents' needs. Based on interviews, direct LPA observations and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not ensure quantity of food was sufficient to meet resident's needs. Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Resident Services Director Sutton, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 13, 2025 · control 08-AS-20250505141836

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced Required 1 year Annual Visit. LPA was allowed entry by Chad Boeddeker, Executive Director. LPA identified herself and disclosed the purpose of the visit with the Executive Director and was later joined by Le Sutton, LVN. Physical Environment: The facility was found to be clean, well-maintained, and free from any safety hazards.Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were present and in good working condition. The facility's outdoor spaces were properly maintained and accessible to residents. Staffing and Training: The facility had a sufficient number of qualified staff members to meet the needs of the residents. The staff member was observed to be professional, courteous, and knowledgeable in their respective roles. All staff members had completed the required training and certifications per the licensing regulations. Continued on 809C Resident Care and Services: Residents' care plans were reviewed and found to be comprehensive and up-to-date. Medication administration was observed to be in accordance with the facility's policies and procedures. Residents' nutritional needs were met, and the meals provided were nutritious and well-balanced. Recreational activities and social engagement opportunities were available to residents regularly. Health and Safety: Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals. Infection control measures were in place and followed by staff members. The facility had established protocols for emergencies and evacuation plans were readily available. Overall, the facility was found to comply with the licensing regulations. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to Chad Boeddeker, Executive Director. His signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Nov 22, 2024

Allegation investigated: Licensee’s staff did not timely respond to resident signals/alerts.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Allen "Chad" Boeddeker. The Complainant alleged that between April 2024 and June 2024, Licensee’s staff did not timely respond to residents’ pendant device calls (which are part of the facility’s signals system) to provide them assistance. CCLD’s investigation involved an unannounced facility visit / welfare check and interviews of multiple pertinent staff. The Department also reviewed caregiver work schedules and date and time-stamped electronic data from the facility’s signals system. [CONTINUED ON LIC 9099-C] Unsubstantiated [CONTINUED FROM LIC 9099] CCLD studied the signals data for six (6), randomly selected, twenty-four-hour days, chosen from the complaint allegation period. During the surveyed days, there were a total of 227 resident pendant calls, of which 182 (or 80.2%) were answered by staff in ten (10) minutes or less, and of which 206 (86.3%) were answered by staff in fifteen (15) minutes or less. Work schedules showed that on the surveyed days, Licensee consistently utilized third-party staffing agencies, when needed, to plug/fill staffing vacancies which were not already filled internally by facility caregivers. Interviews of Medication Technicians and Caregivers showed a pattern of teamwork, communication, and clarity of expectation, as it related to responding to resident signal alerts. Staff interviews and documentation further showed that facility managers met several times per week to review and discuss signals report data, from a quality assurance standpoint. Based on the totality of records and interviews, a preponderance of evidence does not exist to show that Licensee’s staff did not timely respond to resident signals/alerts. The allegation was therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Boeddeker, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099] Interviews showed: After P1 slipped and fell in the facility’s dining room, they told staff they had pain in their hip. There was brief hesitation from facility staff about whether they could call 911 for P1. Ultimately, another visitor of the facility called 911 for P1. (Interviews showed the delay being somewhere between three and ten minutes. The delay was not consequential for P1’s subsequent treatment/recovery). Based on records and interviews, the allegation that Licensee did not arrange medical care for resident in care is Unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The Department has therefore dismissed the allegation, and no deficiency was cited for it. During today’s visit, LPA provided Technical Assistance (TA) to Licensee regarding CCR 87411 Personnel Requirements – General (refer to the LIC9102 page). An exit interview was conducted with the Boeddeker, to whom a copy of this report, the LIC9102 page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 08-AS-20240621090110

Allegation investigated: Staff did not issue medication as prescribed Staff did not maintain medication records

-Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegations. LPA met with Executive Director Chad Boeddeker and discussed the purpose of the visit. On May 16, 2024, Community Care Licensing (CCL) received a complaint staff did not issue medication as prescribed by medical professional and staff are not documenting medication issued accurately. -During investigation, LPA Strong collected pertinent facility documentation and conducted interviews. According to allegation, staff at the facility have issued incorrect dosage of medication to residents in care and some doses are missed due to lack of refills. Records collected revealed that Resident 1 (R1) was issued a larger dose than prescribed of medication 1 (M1) on March 27, 2024, and March 28, 2024. Observations of M1 corroborated that facility had incorrect dosage available to R1. Medication administration record for R1 also revealed R1 was not issued multiple other medications between March 30, 2024, and March 31, 2024 as the medication was pending delivery. Interview with another resident corroborated that some medication doses have been missed on at least one occasion. Substantiated Interview with outside source corroborated that such resident had missed a dose. It was also alleged that staff did not maintain medication administration records (MAR) accurately. Interview with staff revealed that some staff have been instructed by previous Memory Care Director to sign MAR even though medication was not issued. Records collected revealed R1’s MAR was not signed on March 29, 2024, and there was no documentation of reason medication was not issued. Interview with outside sources corroborated that MAR was not filled out accurately in March of 2024. -Based on records reviewed and interviews, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Chad Boeddeker to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, May 24, 2024 · control 08-AS-20240516135258

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jun 7, 2024

Incidental Medical and Dental Care (c)facility staff designated by the licensee shall be permitted to assist the resident with self-administration as, providing the following is met (2) Once ordered...the medication is given according to the physician's directions. This requirement was not met as evidence in; Based on records and interviews the licensee did not issue medications as prescribed in 2 of 70 persons in care [R1/R2] which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, May 24, 2024

Plan of correction: Licensee agrees to provide staff with an in-service training regarding medications.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Jun 7, 2024

Incidental Medical and Dental Care (c)facility staff designated by the licensee shall be permitted to assist the resident with self-administration as, providing the following is met (3)A record of each dose is maintained in the resident's record. This requirement was not met as evidence in; Based on records and interviews the licensee did not maintain record of medication dose in 1 of 70 residents in care [R1] which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, May 24, 2024

Plan of correction: Licensee agrees to provide staff with an in-service medication administration record.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to the applicant’s representative, Regional Vice President of Operations Maria Rossi. The facility fire clearance was granted on 10/10/2023 and reflected that the facility was approved for 138 residents in total, of which all may be non-ambulatory but none may be bedridden. The facility's fire clearance included approval for delayed-egress doors specific to the facility's memory care unit, and LPA found that such doors were compliant during today's visit. The facility's fire clearance did not include approval for secured perimeter, and that was not present during today's visit. The submitted facility sketch was consistent with the current layout of the facility. During today’s visit, LPA, accompanied by the applicant’s representative, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was compliant at 71 degrees F. Hot water temperature at taps accessible to residents were also compliant: 1st Floor Men's Public Restroom sink was 114.1 F, 1st Floor Women's Restroom sink was 115.3 F, Memory Care Public Restroom sink was 107.1 F, Courtyard Men's Restroom sink was 116.6 F, Courtyard Women's Restroom sink was 114.1 F, Bistro/Cafe sink was 117.1 F, Activity Room sink was 116.4 F, and Lounge sink was 118.4 F. Room #102 sink was 109.2 F, Room #125 sink was 110.3 F, Room #164 sink was 109.9 F, Room #184 sink was 117.5 F, Room #202 sink was 107.2 F, Room #224 sink was 111 F, Room #246 sink was 118.4 F, and Room #260 sink was 118.8 F. [CONTINUED ON LIC 808-C] [CONTINUED FROM LIC 809] The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for resident use. All kitchen appliances were in working order. Refrigerator and freezer temperatures were also compliant: In the Main Kitchen, the Walk-In Refrigerator was 40 F, the Walk-In Freezer was 0 F, and the Ice Cream Freezer was -13 F. The Bistro Freezer was 0 F. The Medication Room Refrigerators were both 39 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of sharp objects, medication, and confidential resident and staff records. The facility's swimming pool was secured behind a fence and locking gates meeting regulatory requirements. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant’s representative, no firearms or ammunition are or will be stored at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. All fire extinguishers were serviced within the last twelve months. A complete first aid kit was present. Required licensing postings were observed in visible areas of the facility. The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. Rossi was advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the applicant’s representative, 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, Nov 22, 2023