Inspection Reports for Belmare Senior Living
1450 W F St, Oakdale, CA 95361, United States, CA, 95361
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to staffing shortages, medication management errors, and lapses in resident care and supervision, including delayed responses to call buttons and failure to prevent resident elopements. Several complaint investigations were substantiated, particularly for medication administration without proper orders, insufficient supervision leading to falls, and failure to report incidents timely. The facility also faced issues with improper use of restraints and cleanliness concerns, though many complaints about infection control and staff behavior were unsubstantiated. The most recent report from October 29, 2025, was clean with no deficiencies noted, indicating some improvement since earlier findings. While serious enforcement actions like fines or license suspensions were not listed in the available reports, ongoing staffing and care concerns have been a recurring theme over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
195% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
68% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 77
Capacity: 114
Deficiencies: 0
Date: Oct 29, 2025
Visit Reason
The visit was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements at Belmare Senior Living Facility.
Findings
The inspection found the facility to be generally clean, sanitary, and in compliance with regulations. The physical plant, kitchen, resident living quarters, and common areas were well maintained, with proper food storage and safety measures in place. No deficiencies or violations were explicitly stated in the report.
Report Facts
Licensed capacity: 114
Current census: 77
Memory Care residents: 24
Assisted Living residents: 53
Hot water temperature: 108
Thermostat setting: 76
Elevator last inspection date: Mar 6, 2025
Fire suppression system last serviced: Jul 28, 2025
Fire extinguishers last serviced: Jul 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kurtis Woody | Health & Wellness Director / Acting Administrator | Met with Licensing Program Analyst during inspection and accompanied on facility tour |
| Ellen Lindstrom | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 114
Deficiencies: 1
Date: Oct 1, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations that staff dispensed medication to a resident that was not prescribed and that staff did not seek timely medical attention for a resident.
Complaint Details
The complaint was substantiated regarding staff dispensing medication without a prescription order. The allegation that staff did not seek timely medical attention was unsubstantiated.
Findings
The investigation substantiated that staff administered a narcotic medication to a resident without a valid prescription order between 9/6/2025 and 9/17/2025, posing an immediate health and safety risk. However, the allegation that staff did not seek timely medical attention for the resident was found to be unsubstantiated based on interviews and record review.
Deficiencies (1)
Failure to follow facility's Plan of Operation regarding medication handling, including lack of physician order on file and improper medication storage and administration.
Report Facts
Capacity: 114
Census: 83
Medication tablets administered without order: 14
Plan of Correction Due Date: Oct 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Lindstrom | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Emily Parker | Memory Care Director | Met with during investigation and exit interview |
| Lacy Vincent | Administrator | Administrator of the facility, submitted incident report |
Inspection Report
Census: 83
Capacity: 114
Deficiencies: 0
Date: Oct 1, 2025
Visit Reason
The visit was an unannounced case management inspection related to recent elopements at the facility that were self-reported to the Department on two separate Unusual Incident/Injury Reports.
Findings
Since the elopement incidents, management replaced the door on the back fence of the Memory Care Unit's garden with a new door that has an egress lock that stays locked when pushed and sounds an alarm. An exit interview was held with the Memory Care Director and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Parker | Memory Care Director | Met with during the inspection and involved in the exit interview. |
| Triel Ellen Lindstrom | Licensing Program Analyst | Conducted the case management visit. |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 114
Deficiencies: 5
Date: Sep 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-05-01 regarding multiple allegations of inadequate care and staff misconduct at Belmare Senior Living Facility.
Complaint Details
The complaint investigation was substantiated for allegations of unmet incontinence needs, inappropriate staff speech, medication distribution failures, dietary neglect, and delayed call button response. The allegation of failure to assist with obtaining medical care was unsubstantiated.
Findings
The investigation substantiated multiple allegations including failure to meet residents' incontinence needs, inappropriate staff communication, failure to distribute medications as prescribed, failure to meet dietary needs, and untimely response to call buttons. One allegation regarding failure to assist with obtaining medical care was unsubstantiated.
Deficiencies (5)
Staff did not ensure residents' incontinence needs were met, evidenced by residents found with soaked briefs and bed pads.
Staff spoke inappropriately to residents, including use of vulgar language and verbal abuse.
Staff did not distribute resident's medication as prescribed, with missed documentation of medication administration.
Staff did not ensure resident's dietary needs were met, including missed meals and improper food preparation.
Staff did not answer resident's call button in a timely manner, with 29% of calls answered after more than 10 minutes.
Report Facts
Census: 83
Total Capacity: 114
Medication missed days: 4
Staffing: 2
Call button response delay: 29
Call button wait times: 21
Call button wait times: 5
Call button wait times: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S9 | Named in findings for verbally abusing residents and using inappropriate language | |
| Lacy Vincent | Administrator | Met with Licensing Program Analysts during investigation |
| Ellen Lindstrom | Licensing Program Analyst | Investigator conducting complaint investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Capacity: 114
Deficiencies: 0
Date: Sep 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-05-21 regarding staff not answering pendant calls in a timely manner.
Complaint Details
The complaint alleged that facility staff does not answer pendant calls in a timely manner. The allegation was substantiated based on evidence including resident interviews and pendant call log analysis showing delayed response times.
Findings
The investigation found that staff did not answer residents' call buttons in a timely manner, with response times sometimes taking up to an hour. The allegation was substantiated based on interviews, pendant log analysis, and observations, but no deficiencies were cited as the issue is cited under a separate complaint control number.
Report Facts
Capacity: 114
Response time percentages: 21
Response time percentages: 5
Response time percentages: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Lindstrom | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Lacy Vincent | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 114
Deficiencies: 1
Date: Sep 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-05-01 regarding lack of supervision resulting in residents sustaining multiple falls, inadequate clothing for residents, and improper pest control.
Complaint Details
The complaint investigation was substantiated for lack of supervision resulting in multiple resident falls, including 12 unwitnessed falls with four serious injuries. The allegations of inadequate clothing and pest control were unsubstantiated.
Findings
The investigation substantiated the allegation that lack of supervision resulted in multiple unwitnessed falls with serious injuries among residents, citing insufficient staffing and supervision. The allegations regarding inadequate clothing and pest control were unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
Failure to provide care, supervision, and services that meet individual resident needs due to insufficient staff numbers, resulting in multiple unwitnessed falls and serious injuries.
Report Facts
Capacity: 114
Census: 114
Incident reports: 12
Residents in memory care: 28
Plan of Correction Due Date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Lindstrom | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Rios | Licensing Program Manager | Oversaw the complaint investigation |
| Cindy Lichtenhan | Administrator | Facility administrator during the investigation |
| Lacy Vincent | Administrator | Met with Licensing Program Analysts during the investigation |
| Stephenie Doub | Licensing Program Manager | Named in relation to plan of correction and appeal rights |
Inspection Report
Census: 83
Capacity: 114
Deficiencies: 1
Date: Sep 3, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to observations made during a subsequent complaint and case management visit on the same date.
Findings
A deficiency was cited for the use of a full-length bed rail on a resident without a physician's order or hospice care plan, which poses an immediate health, safety, and personal rights risk to persons in care.
Deficiencies (1)
Use of a full-length bed rail on a resident without a physician's order or hospice care plan, restricting the resident's ability to move freely off the bed.
Report Facts
Residents in Assisted Living: 57
Residents in Memory Care: 26
Residents out of Memory Care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacy Vincent | Facility Designated Administrator | Met with Licensing Program Analysts during the visit |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection and authored the report |
| Triel Ellen Lindstrom | Licensing Program Analyst | Conducted the inspection |
| Lisa Rios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 114
Deficiencies: 1
Date: Sep 3, 2025
Visit Reason
The visit was an unannounced case management inspection to deliver a case management deficiency related to staffing levels at the facility.
Findings
The facility was found to have insufficient staffing in the Memory Care unit, with fewer caregivers than the required 1:7 ratio, posing an immediate risk to residents. Multiple staff and residents reported delays in care and inadequate supervision due to staffing shortages.
Deficiencies (1)
Facility personnel were not sufficient in numbers to meet resident needs, specifically in Memory Care where staffing was below the 1:7 ratio required.
Report Facts
Facility capacity: 114
Visits conducted: 5
Staff to resident ratio: 1
Residents in memory care with one caregiver: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacy Vincent | Administrator | Met with Licensing Program Analysts during inspection and provided statements about staffing |
| Ellen Lindstrom | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
| Stephenie Doub | Licensing Program Manager | Named in deficiency section as Licensing Program Manager |
Inspection Report
Census: 79
Capacity: 114
Deficiencies: 12
Date: Aug 19, 2025
Visit Reason
The visit was a Case Management - Legal/Non-compliance Noncompliance Conference (NCC) held to discuss complaints since licensure and address ongoing non-compliance issues.
Complaint Details
The NCC was held due to non-compliance with 13 complaints since licensure, including 10 Type A citations and 9 Type B citations. The conference discussed facility staffing, care and supervision, reporting requirements, seeking timely medical attention, and care plans including fall prevention. The facility committed to increasing staffing, hiring a Memory Care Director by 09/30/2025, providing staff training, and submitting compliance plans by 08/29/2025.
Findings
Since licensure on 11/04/2022, the facility had 13 complaints, 10 Type A citations, and 9 Type B citations. Deficiencies noted included issues with incidental and medical care, reporting requirements, managed incontinence, basic services, personal rights, personnel, resident records, infection control, dementia care, buildings and grounds, care and supervision, and food service. No deficiencies were cited during this visit, but the facility was advised that future non-compliance could result in citations, civil penalties, and administrative action.
Deficiencies (12)
Incidental and Medical
Reporting Requirements
Managed Incontinence
Basic Services Requirements
Personal Rights
Personnel Requirements
Resident Records
Infection Control
Care of Persons with Dementia
Buildings and Grounds
Care and Supervision
Food Service
Report Facts
Complaints since licensure: 13
Type A citations: 10
Type B citations: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacy Vincent | Facility Designated Administrator | Met with during the inspection and named in the non-compliance conference |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
| Arielle Pascua | Licensing Program Analyst | Named as Licensing Program Analyst involved in the inspection |
| Stephenie Doub | Regional Manager | Present at the Noncompliance Conference |
| Dan Williams | Chief Executive Officer | Present from One Life Senior Living Management Company at the Noncompliance Conference |
| Laurie McConnell | Senior Vice President of Operations | Present from One Life Senior Living Management Company at the Noncompliance Conference |
| Cyndie Bryant | Senior Vice President of Health and Wellness | Present from One Life Senior Living Management Company at the Noncompliance Conference |
| Laura Schutt | Regional Director of Operations | Present from One Life Senior Living Management Company at the Noncompliance Conference |
| Kurtis Woody | Health and Wellness Director | Present from the facility at the Noncompliance Conference |
| Patrick Corrigan | Licensee | Present from the facility at the Noncompliance Conference |
| Austin Corrigan | Licensee | Present from the facility at the Noncompliance Conference |
Inspection Report
Plan of Correction
Census: 79
Capacity: 114
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
The visit was an unannounced Plan of Correction (POC) case management site visit to discuss the Plan of Correction developed by the Administrator and the Department during a 12/26/2024 complaint site visit.
Findings
No deficiencies were noted or cited during the site visit. The Department will follow-up at a later date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Triel Ellen Lindstrom | Licensing Program Analyst | Conducted the Plan of Correction case management site visit. |
| Lacy Vincent | Administrator | Met with Licensing Program Analyst to discuss the Plan of Correction. |
Inspection Report
Census: 95
Capacity: 114
Deficiencies: 0
Date: Jun 9, 2025
Visit Reason
The visit was a case management visit to tour the Memory Care unit and review the facility's request to increase capacity for bedridden residents from five to fourteen.
Findings
The Memory Care unit was toured and found clean with required furnishings, and residents were observed engaged in activities. The Department approved six new bedridden rooms, increasing capacity, with no deficiencies observed or cited during the visit.
Report Facts
Current census: 95
Total licensed capacity: 114
Memory Care unit capacity: 22
Approved capacity of Memory Care unit: 42
Revised maximum occupancy of Memory Care unit: 36
Increase in bedridden resident capacity: 9
Number of new bedridden rooms approved: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacy Vincent | Designated Facility Administrator | Gave tour of Memory Care unit and provided information about bedridden rooms and evacuation plans |
| Cindy Lichtenhan | Administrator/Director | Named as facility administrator/director |
| Ellen Lindstrom | Licensing Program Analyst | Conducted the case management visit |
| Arielle Pascua | Licensing Program Analyst | Conducted the case management visit |
Inspection Report
Capacity: 72
Deficiencies: 0
Date: Jan 22, 2025
Visit Reason
A virtual informal conference was held via Microsoft Teams to discuss compliance issues presented throughout the last 12 months, including waivers and exceptions, hospice, and staffing.
Findings
No deficiencies were cited during this evaluation. The facility will continue to provide care within hospice waiver allowances and follow up on capacity changes and fire clearance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Rios | Licensing Program Manager | Present at the informal conference and named in the report. |
| Arielle Pascua | Licensing Program Analyst | Present at the informal conference and named in the report. |
| Lacy Vincent | Facility Designated Administrator | Met with during the inspection and present at the informal conference. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 72
Deficiencies: 2
Date: Dec 30, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to deliver findings related to allegations that staff did not seek medical attention for a resident in a timely manner and did not notify the Community Care Licensing (CCL) of incidents.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not seek timely medical attention for a resident and did not notify CCL of incidents. The allegation that a resident developed a UTI while in care was unsubstantiated.
Findings
The investigation substantiated that staff failed to seek timely medical attention for a resident (R1) after a fall and did not notify CCL of incidents related to R1's falls on 06/18/2024 and 07/26/2024. Another allegation that a resident developed a UTI while in care was unsubstantiated due to lack of evidence.
Deficiencies (2)
Licensee did not ensure timely medical attention for R1 after a fall, posing an immediate health and safety risk.
Licensee failed to submit required written reports to the licensing agency regarding incidents involving R1's falls on 06/18/2024 and 07/26/2024.
Report Facts
Capacity: 72
Census: 87
Deficiencies cited: 2
Plan of Correction Due Date: Dec 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Arielle Pascua | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Rios | Licensing Program Manager | Oversaw the complaint investigation |
| Lacy Vincent | Facility Designated Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 1
Date: Dec 26, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2024-10-23 regarding staff not keeping the facility free from scabies, staff behavior posing a risk to residents, and improper reporting of incidents involving residents.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Maja Jensen. Allegations included failure to keep the facility free from scabies, staff behavior posing risk, and improper incident reporting. The scabies outbreak was handled appropriately and staff behavior allegations were unsubstantiated. The improper reporting allegation was substantiated due to failure to notify responsible parties timely.
Findings
The investigation found the allegations related to scabies outbreak and staff behavior posing risk to residents unsubstantiated due to insufficient evidence. However, the allegation that staff were not properly reporting incidents involving residents was substantiated, citing failure to notify responsible parties within 24 hours, posing a potential risk to residents.
Deficiencies (1)
Failure to report occurrences which threaten the welfare, safety or health of residents, personnel or visitors within 24 hours as required by CCR 87211(a)(2).
Report Facts
Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and verified deficiencies |
| Lisa Rios | Licensing Program Manager | Oversaw the complaint investigation |
| Lacey Vincent | Executive Director | Met with Licensing Program Analyst during investigation |
| Cindy Lichtenhan | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 72
Deficiencies: 1
Date: Dec 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations including staff not preventing a resident from dragging another resident and staff being unable to meet the needs of residents while in care.
Complaint Details
The complaint investigation was triggered by allegations received on 11/08/2024. One allegation regarding staff not preventing a resident from dragging another resident was unsubstantiated. Another allegation that staff were unable to meet residents' needs was substantiated based on interviews and record reviews indicating understaffing and resulting resident care issues.
Findings
The allegation that staff did not prevent a resident from dragging another resident was unsubstantiated due to appropriate staffing and unpredictable resident behaviors. However, the allegation that staff were unable to meet residents' needs was substantiated, with evidence showing understaffing particularly in memory care, resulting in missed showers, falls, and inadequate supervision.
Deficiencies (1)
Personnel Requirements - General: Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs.
Report Facts
Capacity: 72
Census: 67
Deficiency count: 1
Plan of Correction Due Date: Dec 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Rios | Licensing Program Manager | Oversaw the complaint investigation |
| Lacey Vincent | Executive Director | Facility representative met during the investigation |
| Cindy Lichtenhan | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 72
Capacity: 72
Deficiencies: 2
Date: Sep 30, 2024
Visit Reason
The inspection was an unannounced required 1-year annual inspection conducted by Licensing Program Analyst Maja Jensen to evaluate compliance with regulatory requirements at Belmare Senior Living Facility.
Findings
The inspection found deficiencies including outdated physician reports in 2 of 5 resident files, inaccurate needs and service plans for 2 residents, and lack of fall mitigation plans despite documented falls. A resident with diabetes lacked proper documentation reflecting their condition. Technical assistance was provided and plans of correction were requested.
Deficiencies (2)
A resident with diabetes did not have the required documentation to reflect this condition, posing a potential health, safety, or personal rights risk.
Two of five residents did not have a current physician's report, posing a potential health, safety, or personal rights risk.
Report Facts
Residents on hospice: 8
Resident files reviewed: 5
Staff files reviewed: 4
Residents with insulin dependent diabetes: 2
Capacity: 72
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Lisa Rios | Licensing Program Manager | Supervisor overseeing the inspection. |
| Cindy Lichtenhan | Administrator | Facility administrator mentioned in the report. |
| Teri Ford | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 1
Date: Sep 24, 2024
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff did not order a resident's medication refills in a timely manner.
Complaint Details
The complaint was substantiated based on interviews with two staff members and review of records showing delayed medication refills for a resident in or around July 2024.
Findings
The investigation substantiated the allegation that facility staff did not order medication refills for a resident in a timely manner around July 2024, based on interviews with staff and review of medication records.
Deficiencies (1)
Facility staff did not order refills of a resident's medication in a timely manner.
Report Facts
Facility capacity: 72
Number of medications on hold: 5
Plan of Correction due date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Desiree Soria | Business Office Manager | Met with the investigator during the visit |
| Cindy Lichtenhan | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 72
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
Licensing Program Analyst Maja Jensen arrived unannounced to complete a complaint investigation regarding the facility's administration.
Complaint Details
The visit was complaint-related, focusing on the change in facility administration and compliance with reporting requirements.
Findings
It was found that the Administrator Cindy Lichtenhan is no longer in the position as of 09/13/2024, and the facility is actively recruiting for a new Administrator. Technical assistance was provided regarding reporting requirements and documentation needed for the change in Administrator.
Report Facts
Days to appoint new Administrator: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Lichtenhan | Administrator | Named as former Administrator who left position on 09/13/2024 |
| Desiree Soria | Business Office Manager | Met with Licensing Program Analyst during visit |
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Jul 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-04-08 regarding staff not seeking timely medical attention for residents and a resident wandering away due to lack of care.
Complaint Details
The complaint involved two allegations: 1) Staff did not seek medical attention for residents in a timely manner, and 2) A resident wandered away from the facility due to lack of care from staff. Both allegations were investigated and found unsubstantiated.
Findings
Both allegations were found to be unsubstantiated after interviews with staff and residents, review of records, and consultation with law enforcement. There was no evidence that medical attention was delayed or that a resident wandered off without staff knowledge.
Report Facts
Capacity: 72
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Rios | Licensing Program Manager | Named in report as Licensing Program Manager |
| Teri Ford | Health and Wellness Director | Met with during the investigation |
| Cindy Lichtenhan | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Jul 5, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted by Licensing Program Analyst Maja Jensen to review concerns related to a resident's health condition and documentation.
Complaint Details
The complaint investigation focused on resident 1's health condition and documentation. It was substantiated that the resident has a recurring skin condition not reflected in prior physician reports.
Findings
The investigation found that resident 1 has a systemic health condition causing a recurring skin condition, despite previous reports indicating no history of skin conditions. Technical assistance was provided to ensure updated physician reports are obtained at least every 12 months or when conditions change.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and reviewed resident files. |
| Teri Ford | Health and Wellness Director | Interviewed during the investigation regarding resident 1's health condition. |
Inspection Report
Census: 68
Capacity: 72
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
An unannounced case management visit was conducted by Licensing Program Analyst Jason Lund to evaluate the facility's compliance and resident care status.
Findings
No deficiencies were observed during the visit. Seven residents were on hospice care, none were bedridden, and the facility has clearance for five bedridden residents but currently has none.
Report Facts
Residents on hospice: 7
Bedridden residents clearance: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the case management visit and observed facility conditions |
| Cindy Lichtenhan | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 1
Date: Apr 12, 2024
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff do not meet residents' needs at Belmare Senior Living Facility.
Complaint Details
The complaint alleging that staff do not meet residents' needs was substantiated based on observations of soiled undergarments, delayed call signal responses, a resident with wounds and pain without proper medication follow-up, and unsanitary conditions.
Findings
The investigation found substantiated evidence of unmet resident needs including soiled undergarments left in resident rooms, delayed response to call signals (20 minutes or more on 60 occasions), a resident with unstageable wounds in pain without adequate follow-up on pain medication, and unsanitary conditions posing immediate risk to residents' health and safety.
Deficiencies (1)
Basic services requirement not met including care and supervision as defined in CCR 87564(f)(1).
Report Facts
Call signal delayed responses: 60
Total licensed capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and documented findings |
| Cindy Lichtenhan | Executive Director | Facility administrator who met with the investigator and agreed to seek higher level of care for resident with wounds |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 65
Capacity: 72
Deficiencies: 0
Date: Jan 25, 2024
Visit Reason
The visit was an unannounced case management conducted by Licensing Program Analyst Maja Jensen to address an inquiry regarding acceptance of a resident with a potentially restricted/prohibited condition returning from a skilled nursing facility with a higher level of care needed.
Findings
No deficiencies were cited during this visit. Technical assistance was provided regarding restricted health conditions, prohibited health conditions, and indwelling urinary catheters.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the case management visit and provided technical assistance. |
| Teri Ford | Executive Wellness Director | Met with Licensing Program Analyst during the visit and initiated inquiry regarding resident acceptance. |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff were not addressing a scabies outbreak at the facility.
Complaint Details
The complaint alleged that staff were not addressing a scabies outbreak. The investigation found this allegation to be unsubstantiated based on interviews and record reviews.
Findings
The investigation included interviews with staff and review of medical and training records. It was found that residents were being treated for potential scabies exposure and management had conducted training on scabies prevention. The allegation was determined to be unsubstantiated as the evidence did not prove the claim.
Report Facts
Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation |
| Cindy Lichtenhan | Executive Director | Met with Licensing Program Analyst during investigation |
| Teri Ford | Nursing Director | Met with Licensing Program Analyst and reviewed medical records |
| Lisa Rios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 59
Capacity: 72
Deficiencies: 5
Date: Nov 30, 2023
Visit Reason
The visit was an unannounced continuation of a required one-year annual inspection to evaluate compliance with regulatory standards at Belmare Senior Living Facility.
Findings
The facility was generally maintained with compliant grounds, physical plant, and safety equipment. However, deficiencies were noted including unsecured medications and toxins in a resident's room, medication count discrepancies, and incomplete or missing staff and resident records. Technical assistance was provided throughout the inspection.
Deficiencies (5)
Open top waste disposal cans observed in common area bathrooms.
Numerous bottles of prescription medications, PRN medications, and cleaning chemicals stored with food in resident 2's living area without precautions to secure them from other residents.
Medication count discrepancies for residents 3 and 4 with unexplained differences between medication on hand and Medication Administration Record.
7 of 7 staff files missing first aid certifications or had expired certifications.
11 of 12 resident files had service need assessments missing or incomplete due to missing signatures; 2 resident files lacked current Physician Reports; 4 of 11 files lacked completed property inventory lists.
Report Facts
Staff files reviewed: 7
Resident files reviewed: 12
Residents with incomplete service need assessments: 11
Residents without current Physician Reports: 2
Resident files missing property inventory lists: 4
Facility capacity: 72
Facility census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Teri Ford | Health and Wellness Director | Met with Licensing Program Analyst during inspection and was notified of medication discrepancies |
| Lisa Rios | Licensing Program Manager | Supervisor and manager overseeing the inspection process |
Inspection Report
Annual Inspection
Census: 58
Capacity: 72
Deficiencies: 0
Date: Nov 21, 2023
Visit Reason
The inspection was an unannounced required 1 year annual visit conducted by Licensing Program Analysts to evaluate the facility's compliance with regulations.
Findings
During the visit, the analysts toured the facility, reviewed resident and staff files, interviewed staff and residents, and conducted a medication room audit. The inspection was not completed due to time constraints and will be continued at a later date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Lichtenhan | Executive Director | Met with Licensing Program Analysts during the inspection visit. |
| Maja Jensen | Licensing Program Analyst | Conducted the inspection visit. |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection visit. |
| Lisa Rios | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 72
Deficiencies: 1
Date: Oct 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff do not properly respond to the call button system for residents and that the call signal system is not in good working order.
Complaint Details
The complaint investigation was substantiated for the allegation that staff do not properly respond to the call button system, with a preponderance of evidence meeting the standard. The allegation that the call signal system was not in good working order was unsubstantiated.
Findings
The allegation that staff do not properly respond to the call button system was substantiated based on resident interviews and a signal system response time report showing staff took longer than 10 minutes to respond 44% of the time. The allegation that the call signal system is not in good working order was unsubstantiated based on resident and director interviews and review of the signal system report.
Deficiencies (1)
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 staff taking more than ten minutes to respond to the signal system 44% of the time during a randomly selected 10 day period, posing a potential risk to residents.
Report Facts
Signal system activations: 797
Response time 0-10 minutes: 449
Response time 11-29 minutes: 262
Response time 30-56 minutes: 86
Deficiency plan of correction due date: Nov 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Teri Ford | Health and Wellness Director | Met with Licensing Program Analyst during investigation and agreed to conduct in-service training and audits |
| Cindy Lichtenhan | Administrator / Executive Director | Facility administrator who denied issues with the signal system during investigation |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff was unable to provide proper supervision to a resident in care.
Complaint Details
The complaint alleged that staff was unable to provide proper supervision to a resident. The investigation concluded the allegation was unsubstantiated.
Findings
The investigation found that a resident in Memory Care became aggressive and assaulted another resident and a staff member, resulting in police and hospital involvement. The resident was temporarily assigned to an empty room with 1-1 supervision upon return. Based on records, observations, and interviews, the allegation of inadequate supervision was unsubstantiated.
Report Facts
Capacity: 72
Census: 57
Estimated Days of Completion: 0
Complaint Control Number: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cindy Lichtenhan | Executive Director | Met with Licensing Program Analyst during investigation |
| Teri Ford | Director of Health and Wellness | Met with Licensing Program Analyst during investigation |
| Liza King | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
The visit was conducted as a case management investigation in relation to an incident report received on 2023-09-17 regarding a resident who left the facility unassisted and without staff knowledge.
Complaint Details
The visit was complaint-related due to an incident report of a resident elopement. The resident was found to have left unassisted, and citations were issued pursuant to California Code of Regulations Title 22, Division 6.
Findings
The investigation found that Resident 1 left the facility unassisted on 2023-09-16, posing an immediate risk to resident safety. The resident was located and returned by a family member, and had a prior elopement incident two months earlier. The resident was subsequently moved to the memory care unit.
Deficiencies (1)
Basic services including care and supervision were not met as Resident 1 left the facility without staff knowledge, posing an immediate risk to health, safety, and personal rights of residents.
Report Facts
Capacity: 72
Census: 57
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Terri Ford | Health and Wellness Director | Interviewed regarding the resident elopement incident |
| Maja Jensen | Licensing Program Analyst | Conducted the investigation and authored the report |
| Kimberly Viarella | Licensing Program Analyst | Assisted in conducting the investigation |
| Liza King | Licensing Program Manager | Supervisor and named in the report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 3
Date: Sep 21, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-08-28 regarding staff not addressing a scabies outbreak, staff restraining a resident, and staff not ensuring the facility is clean.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not address a scabies outbreak, restrained a resident improperly, and failed to ensure the facility was clean. The allegation that residents were not fed timely was unsubstantiated.
Findings
The investigation substantiated that staff failed to address a scabies outbreak properly, restrained a resident without a physician's order for postural support, and did not maintain cleanliness in resident rooms. One allegation regarding residents not being fed timely was unsubstantiated.
Deficiencies (3)
Facility was not following its own scabies policy by requiring skin scrapings despite policy stating it is not necessary.
Resident R1 was restrained with a seat belt without a physician's order indicating the need for postural support.
Facility failed to maintain cleanliness; 2 out of 3 resident beds lacked sheets or had soiled mattress protectors, and one room was malodorous.
Report Facts
Capacity: 72
Census: 57
Deficiencies cited: 3
Plan of Correction Due Date: Sep 28, 2023
Plan of Correction Due Date: Sep 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maja Jensen | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Terri Ford | Director of Health and Wellness | Facility staff member interviewed during the investigation |
| Cindy Lichtenhan | Administrator | Facility administrator named in the report |
| Liza King | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Census: 57
Capacity: 72
Deficiencies: 0
Date: Sep 11, 2023
Visit Reason
The visit was an unannounced collaborative case management visit focused on infectious disease outbreak, specifically to provide technical support regarding recent treatment of 2 residents and 2 staff for scabies.
Findings
The visit was informational and educational with no citations issued. The team provided best practice recommendations for infection control related to scabies, including separation of symptomatic and asymptomatic individuals, enhanced cleaning, PPE use, and communication strategies.
Report Facts
Residents treated for scabies: 2
Staff treated for scabies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Lichtenhan | Executive Director | Met with the inspection team and discussed infection control |
| Terri Ford | Director of Wellness | Met with the inspection team and reviewed resident files |
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection visit |
| Zaurina Jones | Public Health Nurse | Participated in the inspection visit |
| Jose Contreras | Medical Investigator | Participated in the inspection visit |
Inspection Report
Follow-Up
Census: 57
Capacity: 72
Deficiencies: 2
Date: Sep 7, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on deficiencies observed the previous day related to safety hazards in the Memory Care unit.
Findings
The Licensing Program Analyst observed a 5 inch pair of scissors in an unlocked drawer and 10 toxic hygiene items accessible in three open resident rooms, posing safety risks to residents with dementia. The facility was cited for failing to secure these items as required.
Deficiencies (2)
Observed a 5 inch pair of scissors in an unlocked drawer in a memory care resident's open room.
Observed 10 toxic hygiene items accessible among 3 open resident rooms including Pantene shampoo and conditioner, Jergens Hydrating Coconut moisturizer, Neutragena shower gel, and CalProtect ointment.
Report Facts
Toxic hygiene items observed: 10
Census: 57
Total capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and identified deficiencies |
| Cindy Lichetenhan | Executive Director | Met with Licensing Program Analyst during inspection |
| Liza King | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 1
Date: Sep 6, 2023
Visit Reason
The visit was an unannounced case management incident visit triggered by an incident report indicating that resident #1 was Absent without Leave (AWOL) on 08/27/2023.
Complaint Details
The visit was complaint-related due to an incident report of resident #1 being AWOL on 08/27/2023. The complaint was substantiated by the finding that the resident left unassisted contrary to physician orders.
Findings
The facility failed to comply with California Health and Safety Code section 1569.312(d) by not being aware of the resident's whereabouts, resulting in the resident leaving the facility unassisted despite a physician report stating the resident was not allowed to leave unassisted. This presented an immediate health and safety risk.
Deficiencies (1)
Failure to be aware of the resident's general whereabouts, allowing resident #1 to leave the facility unassisted contrary to physician orders.
Report Facts
Immediate Civil Penalty: 500
Census: 57
Total Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the unannounced case management incident visit and authored the report. |
| Cindy Lichtenhan | Administrator | Met with Licensing Program Analyst and was involved in the investigation of the resident's absence. |
| Liza King | Licensing Program Manager | Supervisor overseeing the licensing program and cited in the report. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 1
Date: Aug 23, 2023
Visit Reason
The visit was an unannounced case management inspection regarding a resident-on-resident altercation involving three individuals that occurred on 08/20/2023.
Complaint Details
The visit was complaint-related due to a resident altercation incident on 08/20/2023. The complaint was substantiated by the deficiency cited for failure to report the incident timely.
Findings
The facility failed to report the incident within the required 24-hour timeframe, violating reporting requirements. A deficiency was cited for failure to submit the required LIC 624 and SOC 341 forms timely.
Deficiencies (1)
Failure to report the resident altercation within 24 hours by fax or phone call to the licensing agency and local health officer as required.
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Sep 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the unannounced visit and authored the report. |
| Liza King | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report. |
| Terri Ford | Facility staff who spoke with the Licensing Program Analyst during the visit. | |
| Cindy Lichtenhan | Administrator | Facility Administrator named in the report. |
Inspection Report
Annual Inspection
Census: 57
Capacity: 72
Deficiencies: 0
Date: Jul 26, 2023
Visit Reason
An unannounced case management – continued annual inspection was conducted to evaluate compliance with regulations and facility operations.
Findings
The inspection found the facility's exterior and common areas in good repair and accessible, with appropriate resident activities observed. Four out of five resident files reviewed lacked consent for treatment forms and inventories of personal items, but updated consent forms were provided during the inspection. No deficiencies were cited.
Report Facts
Resident files reviewed: 5
Resident files missing consent forms: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and identified herself during the visit |
| Cindy Lichtenhan | Designated Facility Administrator | Met with the Licensing Program Analyst and provided updated consent forms |
Inspection Report
Annual Inspection
Census: 57
Capacity: 72
Deficiencies: 2
Date: Jul 24, 2023
Visit Reason
An unannounced annual inspection was conducted at Belmare Senior Living Facility to evaluate compliance with licensing requirements and facility conditions.
Findings
The facility was found to have clean resident accommodations with adequate furniture and safety features. Some non-approved toxins and personal hygiene items were found and immediately removed. Food storage issues were noted with some packages not securely closed or dated, which were disposed of by staff. Smoke and carbon monoxide detectors and fire extinguishers were in place and inspected. Medication storage and administration policies were reviewed and found compliant with audits performed twice yearly.
Deficiencies (2)
Presence of toxins and personal hygiene items not approved in resident's LIC 602
Two food packages in refrigerator not securely closed and one not dated
Report Facts
Non-perishable food supply days: 7
Perishable food supply days: 2
Facility capacity: 72
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the inspection and authored the report |
| Cindy Lichtenhan | Designated Facility Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Capacity: 72
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
An unannounced case management visit was conducted to discuss and clarify incident reports, hospice, and the overall care of residents at the facility.
Findings
No deficiencies were observed or cited during the case management visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sonja Gonzalez | Administrator | Facility administrator met during the visit. |
| Kimberly Viarella | Licensing Program Analyst | Conducted the case management visit. |
| Charlie Yang | Licensing Program Analyst | Conducted the case management visit. |
| Liza King | Licensing Program Manager | Named in the exit interview. |
Inspection Report
Original Licensing
Census: 40
Capacity: 72
Deficiencies: 2
Date: Mar 8, 2023
Visit Reason
Unannounced post-licensing visit conducted to evaluate compliance with licensing requirements and facility operations.
Findings
The facility was generally clean and well-maintained with adequate resident accommodations and safety features. However, two deficiencies were cited related to water temperature exceeding the allowed maximum and cleaning solutions being accessible to residents, both posing immediate health and safety risks.
Deficiencies (2)
Water temperature measured at 125 degrees, exceeding the allowed maximum of 120 degrees Fahrenheit.
Cleaning solutions were found in areas accessible to residents, posing a safety hazard.
Report Facts
Residents on hospice: 2
Bedridden residents: 1
Residents in memory care corridor: 7
Water temperature: 125
Emergency cord response time: 340
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sonya Gonzalez | Administrator | Interviewed during inspection and demonstrated visitor check-in system |
| Kimberly Viarella | Licensing Program Analyst | Conducted inspection and authored report |
| Charlie Yang | Licensing Program Analyst | Conducted inspection |
| Liza King | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Original Licensing
Capacity: 72
Deficiencies: 0
Date: Nov 4, 2022
Visit Reason
The visit was a pre-licensing inspection conducted to evaluate the facility prior to licensing and ensure compliance with health and safety regulations.
Findings
The facility was found to be in compliance with no violations cited during the pre-licensing inspection. The physical plant, infection control measures, food supplies, medication storage, and safety equipment were all reviewed and found satisfactory.
Report Facts
Hot water temperature: 109.5
Facility temperature: 70
Capacity: 72
Census: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sonya Gonzalez | Administrator | Facility designated Administrator who assisted with the inspection and holds a current certificate |
| Tung Truong | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Czarrina A Camilon-Lee | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
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