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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603509
Report Date: 09/16/2026
Date Signed: 09/16/2026 04:27:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/14/2024 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20241114091207
FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:ZEPEDA, JESSICAFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:105CENSUS: 92DATE:
09/16/2026
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Executive Director, Jessica ZepedaTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Facility does not have adequate staffing to meet resident's needs.
Staff does not ensure resident is turned resulting in resident sustaining pressure injuries.
Staff does not ensure resident's hygiene needs are being met.
INVESTIGATION FINDINGS:
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On September 16, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings regarding the above-referenced complaint. LPA met with Executive Director Jessica Zepeda, and the investigative findings were discussed.

The Department's investigation consisted of interviews with facility staff, direct-care staff, responsible parties for other Memory Care residents, and outside sources, as well as a review of resident and facility records, including Physician's Reports, Service Care Plans, Outside Medical Provider/Agency (OMP) records maintained at the facility, wound-care documentation, progress notes, medication-related documentation, skin assessments, personal-care and incontinence-care documentation, Memory Care census information, employee schedules, and employee time-entry records.

An LIC 811 identifying R1 was provided to facility management.
Page 1 of 6 (Continue at LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 08-AS-20241114091207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 09/16/2026
NARRATIVE
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(Continue from LIC9099)

During R1's residency, R1 experienced progressive cognitive, functional, and medical decline and began receiving additional medically related services from an OMP. OMP services supplemented facility services and did not remove the licensee's responsibility to coordinate care and ensure R1's assessed needs were met.

Records established that R1 was admitted in May 2022 and was ambulatory and capable of independently transferring at admission. R1's condition later declined substantially. A June 2024 Physician's Report documented Alzheimer's disease/dementia-related impairment, bowel and bladder incontinence, poor physical health, a history of skin breakdown, nonambulatory status, and inability to independently transfer. R1 was not designated bedridden.

Service Care Plans reflected that R1 eventually required Level 7, the facility's highest assessed Memory Care service level. R1 required full or maximum assistance with bathing, dressing, grooming, oral hygiene, toileting and incontinence care, mobility and transfers, eating, medication management, skin protection, monitoring, and other activities of daily living.

Allegation: Facility does not have adequate staffing to meet resident's needs.
The complaint alleged that Memory Care was chronically understaffed and that staffing was insufficient to timely meet R1's Level 7 needs and the needs of other Memory Care residents.

LPA reviewed the November 2024 Memory Care census, which reflected approximately 29 residents, including R1. LPA also reviewed planned Caregiver and Medication Technician schedules and actual employee time-entry records covering the period surrounding the complaint. As a representative comparison, the planned November 14, 2024, schedule reflected three caregivers and one Medication Technician on the AM shift, three caregivers and two Medication Technicians on the PM shift, and two caregivers on the NOC shift. This schedule was consistent for the period relevant to this investigation. The

Department did not determine staffing adequacy by numerical ratio alone and compared the staffing records with resident acuity and actual care demands. Page 2 of 6 (Continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 08-AS-20241114091207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 09/16/2026
NARRATIVE
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(continue from LIC9099C)

The staffing records initially raised concern but did not, by themselves, establish that resident needs went unmet. Direct-care interviews provided corroborating evidence regarding the effect of staffing levels on resident care.

During interviews, direct-care staff members described ongoing staffing shortages, approximately four caregivers for 28 to 30 Memory Care residents, and occasions with fewer available caregivers. The staff interviewed reported repeated delays in toileting and incontinence care, double shifts when call-outs could not be covered, and difficulty obtaining replacement coverage. The interviews were considered primarily as evidence of the unit-wide staffing condition because some of the staff members interviewed did not identify a specific R1 incident.

Two additional direct-care staff independently described Memory Care as severely understaffed during the relevant period. The interviews described occasions with only two or three caregivers for approximately 30 residents, Medication Technicians routinely providing direct resident care, extended or double shifts, and required rounds, repositioning, and incontinence care not always completed timely because insufficient staff were available.

LPA also obtained independent information from a responsible party for another Memory Care resident admitted shortly after the complaint date. The responsible party reported delayed responses to resident-assistance requests, including waits of approximately 20 to 30 minutes for incontinence care, and reported that caregivers stated other residents were being assisted. This resident was admitted two days after the complaint date, and this information was used only as corroboration of continuing conditions shortly after the complaint period.

The Department finds that the resident census and staffing records are corroborated by multiple direct-care staff who independently described the same persistent staffing problem and identified specific care affected by insufficient staffing, including rounds, repositioning, toileting/incontinence care, and response to resident needs. Page 3 of 6 (continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 08-AS-20241114091207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 09/16/2026
NARRATIVE
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(continue from LIC9099C)

When the resident census, staffing records, R1's Level 7 needs, direct-care interviews, independent responsible-party information, and contrary evidence are considered together, the evidence establishes that available staffing was not consistently sufficient in number to timely provide the services necessary to meet resident needs.

The preponderance-of-evidence standard was met. Therefore, the allegation is SUBSTANTIATED.

Allegation: Staff does not ensure resident is turned resulting in resident sustaining pressure injuries.
The complaint alleged that R1 developed pressure injuries because facility staff did not consistently turn and reposition R1.

The investigation established that R1 was nonambulatory, unable to independently transfer, incontinent, in poor overall physical health, and had a history of skin breakdown. R1 required extensive assistance with mobility, transfers, skin protection, and personal care. OMP records documented buttock/coccyx-area skin breakdown and repeated skilled wound treatment beginning in November 2024.

Two direct-care Medication Technicians independently provided substantially similar firsthand observations regarding R1. Staff recalled administering afternoon medications and later returning during the evening medication pass to find R1 in the same position. Staff described occasions in which R1 remained in the same position for several hours and stated that required repositioning and rounds were not consistently completed because sufficient caregiver coverage was not available.

Direct-care staff also reported that R1 could not independently use the resident-assistance call system and depended on routine staff monitoring to identify repositioning, incontinence, and other care needs.
The Department considered facility and OMP records documenting wound treatment, skin monitoring, barrier cream, wedges or other pressure-relief measures, and later occasions when staff completed turning and repositioning. These records establish that repositioning and skin care were provided on some occasions and were considered as contrary and mitigating evidence.

Page 4 of 6 (continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 08-AS-20241114091207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 09/16/2026
NARRATIVE
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(continue from LIC9099C)

Those episodic records do not establish that required repositioning occurred consistently between documented care events. The two independent Medication Technician interviews described the same pattern of finding R1 in the same position between afternoon and evening medication passes and are consistent with the staffing evidence showing that required rounds were not always completed timely.
Considering R1's inability to independently reposition, documented skin-breakdown risk, actual pressure-related wounds, mutually corroborating firsthand observations of prolonged periods without repositioning, and staffing-related inability to complete required rounds, the evidence more likely than not establishes that R1's repositioning needs were not consistently met and that prolonged pressure contributed to the development or persistence of R1's pressure-related skin breakdown. The preponderance-of-evidence standard was met. Therefore, the allegation is SUBSTANTIATED.

Allegation: Staff does not ensure resident's hygiene needs are being met.
The complaint alleged that R1's hygiene needs, including toileting/incontinence care and oral hygiene, were not consistently met.

R1's Service Care Plans documented bowel and bladder incontinence and required full or maximum assistance with toileting/incontinence, bathing, grooming, and oral hygiene. R1 depended on routine staff monitoring for these needs.

Direct-care staff identified toileting and incontinence care as a recurring area affected by staffing shortages throughout Memory Care. Staff interviews described a unit-wide pattern of delayed incontinence care. Two other direct-care staff provided R1-specific firsthand evidence that incontinence care was not always completed timely and that R1 at times remained wet or soiled for extended periods.

Independent information from the responsible party for another Memory Care resident also described delayed incontinence assistance and feces odors in resident rooms during the same complaint period. In addition, this same resident sustained several unwitnessed falls in less than two months which resulted in a voluntary relocation from the facility. The responsible party stated that staff were not able to meet the resident’s supervisory needs. This information was used as corroboration of continuing conditions and not as proof of a specific R1 incident. Page 5 of 6 (continue on LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 08-AS-20241114091207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 09/16/2026
NARRATIVE
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The Department considered contrary evidence, including OMP Home Health Aide records documenting showers, bed baths, and personal-care services, as well as facility and OMP documentation of brief changes, cleansing, barrier cream, oral swabbing, and other hygiene services on multiple dates. These records establish that hygiene care was provided on many occasions. The finding is not that all hygiene care was omitted.

The direct-care evidence nevertheless establishes that required incontinence care for R1 was delayed or missed on other occasions. Multiple interviews independently described delayed incontinence care associated with staffing shortages, including R1-specific observations. The evidence therefore establishes by a preponderance that R1's toileting/incontinence hygiene needs were not consistently met timely. The investigation did not establish that every oral-hygiene task was omitted; the Substantiated finding is principally supported by untimely incontinence and toileting hygiene care.
The preponderance-of-evidence standard was met. Therefore, the allegation is SUBSTANTIATED.

Based on records reviewed, interviews conducted, and all information obtained during the investigation, all three allegations are SUBSTANTIATED.

Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and are detailed on the LIC 9099-D. Plans of Correction (POCs) were jointly developed with Executive Director Jessica Zepeda.

An exit interview was conducted with Executive Director Jessica Zepeda. A copy of this report, the LIC 9099-D, the Licensee Appeal Rights (LIC 9058), and LIC 811 were provided electronically at the conclusion of the virtual visit.

Page 6 of 6
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 08-AS-20241114091207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2026
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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ED agreed to review current hospice care plans for repositioning and pressure-relief needs, train staff responsible for implementation, and complete a 14-day supervisory audit of required repositioning. Proof of correction will be submitted to CCL by the POC deadline.
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Based on staffing records, resident census information, and interviews, the licensee did not comply with the section cited above. Multiple direct-care staff described persistent staffing shortages and delayed or incomplete rounds, repositioning, and toileting/incontinence care because sufficient staff were not available. This posed a potential health, safety, and personal-rights risk to R1 and (92) other residents in care.
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Type B
10/16/2026
Section Cited
CCR
87633(d)
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87633(d) Hospice Care for Terminally Ill Residents.The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the resident's care needs are being met at all times. This requirement was not met as evidenced by:
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ED agreed to review current hospice care plans for repositioning and pressure-relief needs, train staff responsible for implementation, and complete a 14-day supervisory audit of required repositioning. Proof of correction will be submitted to CCL by the POC deadline.
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Based on records review and interviews, the licensee did not comply with the section cited above. R1 was nonambulatory, unable to independently reposition, had pressure-related skin breakdown, and required pressure-relief care. Direct-care staff independently observed R1 remaining in the same position for several hours and reported that repositioning was not consistently completed. This posed a potential health and safety risk to R1 and (92) other residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 08-AS-20241114091207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2026
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Managed Incontinence
The licensee is responsible for ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:
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ED agreed to review current incontinence-care needs, train staff on timely incontinence care and CCR 87625(b)(3), and complete a 14-day supervisory audit to ensure residents are kept clean and dry. Proof of correction will be submitted to CCL by the POC deadline.
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Based on records review and interviews, the licensee did not comply with the section cited above. R1 required full assistance with incontinence care, and direct-care staff reported that R1 at times remained wet or soiled for extended periods. Additional interview information described delayed incontinence assistance in Memory Care. This posed a potential health, safety, and personal-rights risk to R1 and (92) other residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
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