Inspection Reports for Belmare Senior Living

The visit was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements at Belmare Senior Living Facility.

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.

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.

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.

The complaint was substantiated regarding staff dispensing medication without a prescription order. The allegation that staff did not seek timely medical attention was unsubstantiated.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced case management inspection to deliver a case management deficiency related to staffing levels at the facility.

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.

The visit was a Case Management - Legal/Non-compliance Noncompliance Conference (NCC) held to discuss complaints since licensure and address ongoing non-compliance issues.

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.

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.

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.

No deficiencies were noted or cited during the site visit. The Department will follow-up at a later date.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Licensing Program Analyst Maja Jensen arrived unannounced to complete a complaint investigation regarding the facility's administration.

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.

The visit was complaint-related, focusing on the change in facility administration and compliance with reporting requirements.

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.

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.

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.

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.

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.

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.

An unannounced case management visit was conducted by Licensing Program Analyst Jason Lund to evaluate the facility's compliance and resident care status.

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.

An unannounced complaint investigation was conducted due to allegations that staff do not meet residents' needs at Belmare Senior Living Facility.

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.

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.

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.

No deficiencies were cited during this visit. Technical assistance was provided regarding restricted health conditions, prohibited health conditions, and indwelling urinary catheters.

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.

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.

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.

The visit was an unannounced continuation of a required one-year annual inspection to evaluate compliance with regulatory standards at Belmare Senior Living Facility.

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.

The inspection was an unannounced required 1 year annual visit conducted by Licensing Program Analysts to evaluate the facility's compliance with regulations.

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.

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.

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.

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.

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.

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.

The complaint alleged that staff was unable to provide proper supervision to a resident. The investigation concluded the allegation was unsubstantiated.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced case management inspection regarding a resident-on-resident altercation involving three individuals that occurred on 08/20/2023.

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.

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.

An unannounced case management – continued annual inspection was conducted to evaluate compliance with regulations and facility operations.

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.

An unannounced annual inspection was conducted at Belmare Senior Living Facility to evaluate compliance with licensing requirements and facility conditions.

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.

An unannounced case management visit was conducted to discuss and clarify incident reports, hospice, and the overall care of residents at the facility.

No deficiencies were observed or cited during the case management visit.

Unannounced post-licensing visit conducted to evaluate compliance with licensing requirements and facility operations.

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.

The visit was a pre-licensing inspection conducted to evaluate the facility prior to licensing and ensure compliance with health and safety regulations.

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.