Inspection Reports for
Belmont Village Senior Living Cardiff by the Sea
3535 Manchester Ave, Cardiff, CA 92007, United States, CA, 92007
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% better than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
91% occupied
Based on a February 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 160
Capacity: 175
Deficiencies: 6
Date: Feb 22, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received regarding resident care and facility practices at Belmont Village Cardiff.
Complaint Details
The complaint investigation was triggered by multiple allegations including failure to timely contact police, inadequate resident assessments, unmet resident needs, extended periods in wheelchairs, improper billing for unused services, and unmet showering needs. The allegation of sexual abuse was unsubstantiated due to lack of evidence. The investigation found several allegations substantiated based on interviews, record reviews, and observations.
Findings
The investigation substantiated several allegations including failure to timely notify police of abuse, inadequate assessment of residents for changes in level of care, failure to meet residents' basic needs including showering and mobility assistance, leaving residents in wheelchairs for extended periods, and charging residents for services not provided. Other allegations such as sexual abuse and verbal or rough handling by staff were found unsubstantiated due to lack of evidence.
Deficiencies (6)
Failure to immediately notify law enforcement of suspected physical or sexual abuse as required by Title 22 CCR §87211.
Failure to conduct reappraisals when significant changes occur in residents' conditions, resulting in inappropriate placement and care.
Insufficient staffing to meet residents' care and supervision needs.
Residents left seated in wheelchairs for prolonged periods without appropriate repositioning or assistance.
Charging residents for services not provided, violating admission agreements.
Failure to provide personal care assistance including bathing and hygiene as needed.
Report Facts
Capacity: 175
Census: 160
Deficiency count: 6
Plan of Correction Due Dates: Mar 8, 2026
Plan of Correction Due Date: Mar 9, 2026
Plan of Correction Due Date: Feb 23, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Wes Lavendar | Executive Director | Facility representative met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 175
Deficiencies: 5
Date: Feb 22, 2026
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2021-07-15 regarding allegations of failure to provide necessary services, arrange medical care, provide adequate lighting, and follow reporting requirements at Belmont Village Cardiff facility.
Complaint Details
The complaint investigation was substantiated. The resident fell during a facility-wide power outage and was left on the floor overnight without staff assistance. Medical care was not promptly arranged, and the facility failed to provide adequate lighting and timely reporting to the licensing agency.
Findings
The investigation substantiated all allegations: a resident fell during a power outage and was left on the floor overnight without staff assistance, timely medical care was not arranged, the facility lacked adequate emergency lighting, and the facility failed to report the incident and blackout to the licensing agency promptly.
Deficiencies (5)
Personnel requirements not met; insufficient competent staff to meet resident needs, resulting in failure to provide welfare checks and timely assistance during a power outage.
Failure to arrange timely medical evaluation and care following a resident fall resulting in serious injury.
Lack of emergency adequate lighting in resident's room during blackout, contributing to fall and injury.
Failure to have a written and readily available emergency disaster plan.
Failure to timely report resident fall, extended time on floor, and hospitalization to licensing agency.
Report Facts
Capacity: 175
Census: 160
Deficiencies cited: 5
Plan of Correction Due Dates: Feb 23, 2026
Plan of Correction Due Dates: Mar 8, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Wes Lavendar | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 175
Deficiencies: 0
Date: Sep 26, 2025
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including neglect causing an unstageable wound, failure to ensure medical care, retaining a resident requiring higher level of care, and medication administration errors.
Complaint Details
The complaint investigation was unsubstantiated for all allegations: neglect causing unstageable wound, failure to ensure medical care, retaining resident requiring higher level care, and medication administration errors.
Findings
All allegations were found to be unsubstantiated based on review of medical records and documentation. The wound was attributed to a medical condition treated by outside providers, medical care was ensured by facility staff following instructions, the resident was appropriate for the facility level of care, and no medication errors were documented.
Report Facts
Capacity: 175
Census: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Wesley Lavender | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Annual Inspection
Census: 129
Capacity: 175
Deficiencies: 0
Date: Jun 18, 2024
Visit Reason
Licensing Program Analysts conducted an unannounced visit to continue a Required Annual Inspection of the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited during the annual inspection. All safety equipment and environmental conditions were compliant.
Report Facts
Resident census: 129
Total capacity: 175
Hot water temperature: 117.8
Hot water temperature: 117.1
Hot water temperature: 111.8
Hot water temperature: 112.5
Hot water temperature: 116.1
Walk-In Refrigerator temperature: 40
Walk-In Freezer temperature: 0
Facility ambient temperature: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wes Lavender | Executive Director | Met with Licensing Program Analyst during inspection and exit interview |
| Mario Castaneda | Building Engineer | Accompanied Licensing Program Analyst during facility tour |
| Liliana Silveira | Licensing Program Analyst | Conducted the inspection visit |
| Jennifer Lott | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 129
Capacity: 175
Deficiencies: 0
Date: Jun 17, 2024
Visit Reason
An unannounced required annual inspection was conducted to review the facility's compliance with licensing regulations.
Findings
No deficiencies were cited during the visit. Due to time constraints, a return visit is needed to complete the annual inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wes Lavender | Executive Director | Met with Licensing Program Analyst during inspection and exit interview. |
| Mario Castaneda | Building Engineer | Accompanied Licensing Program Analyst during facility tour. |
| Liliana Silveira | Licensing Program Analyst | Conducted the unannounced required annual inspection. |
Inspection Report
Capacity: 175
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
An unannounced Case Management Visit was conducted to correct/amend a prior facility evaluation report.
Findings
No deficiencies were observed or cited during the visit. The prior report was formally amended and discussed with the Licensee.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management Visit and amended the prior report. |
| Wesley Lavender | Executive Director | Met with Licensing Program Analyst during the visit and discussed the amended report. |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 175
Deficiencies: 1
Date: Feb 6, 2024
Visit Reason
The visit was an unannounced Case Management – Incident inspection conducted in response to two self-submitted LIC624 Incident Reports regarding medication errors involving two residents.
Complaint Details
The visit was triggered by two medication error incidents reported by the licensee involving Resident #1 receiving an overdose of a blood thinner and Resident #2 receiving medication prescribed for another resident. Both incidents were investigated, and no adverse health consequences were found. The complaint was substantiated by evidence of process errors by staff.
Findings
The inspection found that staff errors led to two residents receiving incorrect medication doses, but no adverse health consequences occurred. One deficiency was cited for failure to assist residents with self-administered medications as prescribed, and a technical violation was issued regarding reporting requirements.
Deficiencies (1)
Failure to assist 2 of 140 residents (R1 & R2) with self-administered medications as needed/prescribed, posing a potential health risk.
Report Facts
Residents involved in medication errors: 2
Deficiencies cited: 1
Technical Violations issued: 1
Plan of Correction due date: Mar 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Executive Director | Met during visit and involved in exit interview |
| Wesley Lavender | Executive Director | Met during visit and involved in exit interview |
| Elizabeth Smith | Director of Resident Care Services | Met during visit and involved in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lizzette Tellez | Licensing Program Manager | Supervised the inspection |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 175
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
An unannounced complaint investigation was conducted based on allegations that the licensee did not follow infection control protocol for a scabies outbreak and did not treat for pests.
Complaint Details
The complaint alleged failure to follow infection control protocol for scabies and failure to treat for pests. The allegations were unsubstantiated based on interviews, observations, and record reviews.
Findings
The investigation found no evidence to substantiate the allegations. Records and interviews confirmed that the facility treated residents for scabies in January 2023 and followed public health guidance. No active bed bugs or pest issues were observed during the inspection.
Report Facts
Capacity: 175
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Smith | Director of Resident Care Services | Met with during investigation and exit interview |
| Iby Strong | Licensing Program Analyst | Conducted the complaint investigation |
| Simon Jacob | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 175
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not meeting residents' hygiene needs and were not responding to residents' call buttons in a timely manner.
Complaint Details
The complaint was unsubstantiated based on interviews and record reviews. Allegations included staff not meeting residents' hygiene needs and not responding timely to call buttons. Interviews revealed staff were meeting needs and responding to call buttons despite occasional delays. No witness statements confirmed the allegations.
Findings
The investigation found that staff were meeting residents' hygiene needs according to individual care plans and were responding to call buttons, although sometimes with delays due to staff calling out. No witness statements confirmed the allegations, and the complaint was unsubstantiated.
Report Facts
Capacity: 175
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Denise Powell | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 175
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
An unannounced complaint investigation was conducted due to allegations of neglect and lack of supervision resulting in a resident sustaining injuries.
Complaint Details
The complaint alleged neglect and lack of supervision resulting in a resident sustaining injuries, including multiple falls and a forehead laceration. The investigation concluded the allegation was unsubstantiated.
Findings
The investigation found that although the resident had multiple falls, there was no preponderance of evidence to prove neglect or lack of supervision. The resident often did not use the call pendant to request assistance, and staff regularly checked in with the resident. The allegation was unsubstantiated.
Report Facts
Resident falls: 19
Resident falls: 5
Census: 137
Total capacity: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Elizabeth Smith | Director of Resident Care Services | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 175
Deficiencies: 0
Date: Apr 21, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff restrained a resident in a wheelchair.
Complaint Details
The complaint was investigated and determined to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis. The allegations were not pertinent to the licensed facility.
Findings
The investigation found the complaint to be unfounded as the restraint was performed by a private caregiver hired by the resident's family, not by facility staff. The facility notified all appropriate agencies as required.
Report Facts
Capacity: 175
Census: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Executive Director | Met with during investigation and discussed findings |
| Liliana Silveira | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Census: 150
Capacity: 175
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
Licensing Program Analyst Natasha Persaud conducted an unannounced collateral visit to interview a resident and briefly tour the facility.
Findings
No deficiencies were observed during the visit. An exit interview was conducted and Licensee Rights were provided to the Executive Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Executive Director | Met with Licensing Program Analyst during the visit and received Licensee Rights. |
| Natasha Persaud | Licensing Program Analyst | Conducted the unannounced collateral visit and interview. |
| Lizzette Tellez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 150
Capacity: 175
Deficiencies: 0
Date: Aug 12, 2022
Visit Reason
An unannounced annual required licensing inspection was conducted to verify compliance with statutes, regulations, and other requirements relevant to protecting the health of residents and staff, including infection control practices.
Findings
The facility was found to be in compliance with infection control practices, including COVID-19 mitigation measures, and no deficiencies were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Executive Director | Met with during inspection and involved in infection control plan review |
| Elizabeth Smith | Director of Resident Care Services | Met with during inspection and involved in infection control plan review |
| Liliana Silveira | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 175
Deficiencies: 1
Date: Jan 13, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including mishandling of a resident's personal belongings, a resident sustaining a pressure injury, and financial abuse of a resident while in care.
Complaint Details
The complaint investigation was substantiated regarding mishandling of resident's personal belongings. The allegations that the resident sustained a pressure injury and was financially abused were unsubstantiated.
Findings
The investigation substantiated the allegation that a resident's furniture was discarded without permission, posing a personal rights risk. The allegations of a resident sustaining a pressure injury and financial abuse were found to be unsubstantiated based on evidence and interviews.
Deficiencies (1)
Facility discarded 1 out of 139 residents' furniture without permission from the resident or responsible party in April 2020, violating personal rights.
Report Facts
Residents affected: 1
Total residents: 139
Facility capacity: 175
Census: 145
Pressure injury size: 2
Wound care visits frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Administrator | Met with during investigation and exit interview |
| Tiffany Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 143
Capacity: 175
Deficiencies: 0
Date: Dec 17, 2021
Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan including disinfection, testing, vaccination, screening protocols, and use of personal protective equipment (PPE).
Findings
No deficiencies were cited during the visit. A walk-through was conducted and a debriefing was held with facility leadership.
Report Facts
Capacity: 175
Census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Executive Director | Met with during the visit and involved in debriefing |
| Deeanna Lyons | Director of Resident Care Services | Involved in debriefing at conclusion of visit |
| Ramon Serrano | Licensing Program Analyst | Conducted the on-site HAI assessment visit |
| Jennifer West | Public Health Nurse | Conducted the on-site HAI assessment visit |
| Elizar Perez | Public Health Nurse | Conducted the on-site HAI assessment visit |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 175
Deficiencies: 0
Date: Aug 19, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 12/11/2019 regarding the facility's failure to meet residents' needs, maintain resident rooms in a sanitary condition, and assist with incontinence care.
Complaint Details
The complaint investigation was unsubstantiated based on evidence including interviews and records reviewed. Allegations included failure to meet residents' needs, unsanitary resident rooms, and inadequate incontinence care, all of which were not supported by the investigation findings.
Findings
The investigation included records review and interviews with staff, residents, and outside sources. The allegations were found to be unsubstantiated as evidence showed residents had call systems, rooms were clean and sanitary, and incontinence care needs were met with regular checks and assistance available.
Report Facts
Capacity: 175
Census: 139
Average response time: 9.2
Longest response time: 15
Incontinence care check interval: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hamilton | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ashely Marcellus | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Deenna Lyons | Director of Resident Care Services | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 175
Deficiencies: 1
Date: Aug 13, 2021
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not administer residents' medication as prescribed.
Complaint Details
The complaint was substantiated based on evidence that staff failed to administer PRN medication to Resident #1 during an episode of agitation and aggressive behavior on January 29, 2020. The investigation included interviews, records review, and confirmed the allegation.
Findings
The investigation found that Resident #1 was not offered PRN medication during an episode of agitation and aggressive behavior on January 29, 2020, despite staff knowledge of the behavior. This failure posed a potential health risk and the allegation was substantiated.
Deficiencies (1)
Staff did not assist Resident #1 with self-administration of PRN medication as prescribed, violating CCR 87465(d).
Report Facts
Census: 139
Total Capacity: 175
Deficiency Type Count: 1
Plan of Correction Due Date: Sep 10, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Executive Director | Met with during investigation and exit interview |
| Deeanna Lyons | Director of Resident Care Services | Met with during investigation and exit interview |
| Carmen Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Denise Powell | Licensing Program Manager | Conducted the complaint investigation |
| Rebecca Hedgecock | Licensing Program Manager | Named in deficiency and plan of correction section |
Inspection Report
Census: 139
Capacity: 175
Deficiencies: 0
Date: Aug 13, 2021
Visit Reason
The visit was a Case Management follow-up on a related concern observed during a complaint investigation regarding medication administration.
Findings
A Technical Assistance Advisory was provided to the facility regarding administration of medications after review of staff interviews and multiple resident records related to the concern.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Executive Director | Met with during the visit and involved in exit interview. |
| Carmen Lopez | Licensing Program Analyst | Conducted the Case Management visit. |
| Denise Powell | Licensing Program Manager | Conducted the Case Management visit. |
| Rebecca Hedgecock | Licensing Program Manager | Named in report header as Licensing Program Manager. |
Inspection Report
Annual Inspection
Census: 139
Capacity: 175
Deficiencies: 0
Date: Aug 12, 2021
Visit Reason
An unannounced required 1-year visit was conducted to evaluate the facility's compliance with licensing requirements and infection control protocols.
Findings
No deficiencies were cited or observed during the inspection. The facility was found to be in compliance with infection control measures including disinfection, testing surveillance, screening protocols, and use of personal protective equipment.
Report Facts
Capacity: 175
Census: 139
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Administrator | Met with Licensing Program Analyst during inspection |
| Tiffany Holmes | Licensing Program Analyst | Conducted the unannounced required 1-year visit |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 140
Capacity: 175
Deficiencies: 0
Date: Jul 6, 2021
Visit Reason
The visit was an unannounced case management visit to deliver an amended report from a previous complaint visit dated December 20, 2019.
Findings
The Licensing Program Analyst and Licensing Program Manager conducted the visit, identified themselves to the Resident Services Director, and provided a copy of the amended report along with Licensee/Appeal Rights. An exit interview was conducted and confirmation of receipt was requested.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deanna Lyons | Resident Services Director | Met during the visit and exit interview. |
| Elizabeth Hamilton | Licensing Program Analyst | Conducted the unannounced visit. |
| Denise Powell | Licensing Program Manager | Conducted the unannounced visit. |
Inspection Report
Census: 134
Capacity: 175
Deficiencies: 0
Date: Apr 21, 2021
Visit Reason
An unannounced case management virtual visit was conducted due to the COVID-19 pandemic following a self-reported incident regarding a resident injury.
Findings
The Licensing Program Analyst toured the facility, reviewed records, and interviewed staff. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Ryan | Licensing Program Analyst | Conducted the unannounced case management virtual visit. |
| Mary Jane Rodriguez | Operations Specialist | Met with during the visit and participated in the exit interview. |
| Deeanna Lyons | Director of Residential Care | Participated in the visit and exit interview. |
| Ashley Marcellus | Administrator | Facility administrator named in the report header. |
Inspection Report
Census: 134
Capacity: 175
Deficiencies: 0
Date: Dec 30, 2020
Visit Reason
The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan including disinfection, testing surveillance, screening protocols, and use of personal protective equipment (PPE).
Findings
During the visit, no deficiencies were issued. The team interviewed the Administrator and staff, conducted a walk-through including Memory Care areas, and provided a debriefing at the conclusion of the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Marcellus | Administrator | Participated in discussions via telephone during the visit. |
| Mary Jane Rodriguez | Interim Executive Director | Met with the Licensing Program Manager and team during the visit. |
| Denise Powell | Licensing Program Manager | Led the on-site visit and discussions. |
| Michelle House | Health Facility Evaluator Nurse | Participated in the on-site visit with the HAI Program. |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 175
Deficiencies: 1
Date: Dec 20, 2019
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2019-12-11 regarding the licensee not storing cleaning products inaccessible to residents.
Complaint Details
The complaint was substantiated based on observations during the unannounced visit. The allegation that cleaning products were not stored inaccessible to residents was found valid.
Findings
The Licensing Program Analyst observed unlocked supply storage with cleaning supplies accessible to dementia residents, substantiating the complaint. This posed an immediate safety risk to 23 residents in care.
Deficiencies (1)
Care of Persons with Dementia - unsecured cleaning supplies in Memory Care area inside an unlocked cabinet accessible to residents.
Report Facts
Residents at immediate safety risk: 23
Deficiency count: 1
Capacity: 175
Census: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Powell | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Sheryl Johnston | Administrator | Met with Licensing Program Analyst during inspection and received report |
| Rebecca Hedgecock | Licensing Program Manager | Named in report as Licensing Program Manager |
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