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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603509
Report Date: 02/12/2026
Date Signed: 02/12/2026 10:10:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2024 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20241017162021
FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:ZEPEDA, JESSICAFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:105CENSUS: 89DATE:
02/12/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Business Office Director, Ellen ArguelloTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not provide adequate supervision of resident resulting in AWOL and serious bodily injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Business Office Director, Ellen Arguello. LPA identified herself and explained the purpose of the visit.

Regarding the allegation of Staff did not provide adequate supervision of resident resulting in AWOL and serious bodily injury, Reporting Party (RP) stated that R1 wears a security bracelet due to R1 having wandering tendencies, RP states on 09/14/2024, staff allowed R1 to sit outside in the front area of the facility, and they turned off the alarm for R1s bracelet so that it would not continue to go off. RP states R1 was able to walk away and made it approximately 1000 yards down the street, slipped and fell, injuring R1s right knee.

During the investigation, staff members were interviewed, and records were reviewed. (continue at LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 08-AS-20241017162021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 02/12/2026
NARRATIVE
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(Continue from LIC9099)

According to R1s records, facility staff will support the resident with orientation, redirection, and wayfinding. It is also noted R1 cannot leave the facility unassisted. The facility utilizes a system that activates alarmed doors when the sensor the resident is wearing is in close proximity to exiting the area. S1 stated R1 had this sensor and staff would watch R1 sit outside the front of the facility.

S2 stated he/she saw R1 walk outside through the computer screen and called for staff assistance. From S2s vantage point behind the concierge’s desk, there is no line of sight to the bench in front of the facility. S3 responded to S2s call for assistance. While outside of the facility, S2 and S3 called out for R1. S3 stated, “We found R1 by the bus stop on the public street corner.” S2 and S3 did not see R1, nor did R1 say he/she fell or was injured. However, on initial assessment, S2 stated that S2 saw a wound on R1s right knee.

R1 was able to elope from the facility on 09/14/2024. No supervision was being provided to R1 which allowed R1 to make his/her way to the bus stop and sustain an unwitnessed fall that resulted in serious injury.

Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Business Office Director, Ellen Arguello. An immediate civil penalty of $500 was assessed today. In accordance with Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Community Care Licensing Division.

An exit interview was conducted with Business Office Director, Ellen Arguello, who was provided with a copy of this report, the LIC 9099-D Deficiency Report, the LIC 811 Confidential Names List, and the LIC 9058 Licensee Appeal Rights.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20241017162021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2026
Section Cited
CCR
87464(f)(1)
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87464 (f)(1)Basic Services
Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This was not met as evidenced by:
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The licensee agreed to conduct staff training on regulations regarding providing care and supervision to meet residents' needs by an independent contractor. Documentation of the training will be submitted to CCL by the POC due date.
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Based on interviews and records review, R1 was able to elope from the facility on 09/14/2024 due to lack of care and supervision which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2024 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20241017162021

FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:ZEPEDA, JESSICAFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:105CENSUS: 89DATE:
02/12/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Business Office Director, Ellen ArguelloTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not arrange medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Business Office Director, Ellen Arguello. LPA identified herself and explained the purpose of the visit.

During the investigation, staff members were interviewed, and records were reviewed.

Regarding the allegation of Staff did not arrange medical care for resident, RP stated that facility staff did not seek any medical attention when R1 slipped and fell, injuring R1s right knee during the elopement.
On 09/14/2024, R1 sustained an unwitnessed fall during an elopement. Upon assessment, S2 observed a wound to the R1s right knee. Records were reviewed and a communication dated 09/14/2024 was sent to R1s primary care physician.
(Continue at LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20241017162021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 02/12/2026
NARRATIVE
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(Continue from LIC9099A)

The facility staff denied R1 exhibited signs and symptoms of serious injury upon return to the facility, and the days following the unwitnessed fall. The facility staff also denied R1 requested for emergency medical services as well.

R1 received day care center services offsite. On 09/16/2024, a Licensed Vocational Nurse (LVN) assessed R1 right knee as it was scraped and swollen. A Registered Nurse (RN) documented the R1s fall at the facility on 09/14/2024. Basic wound care was provided for knee abrasion and complaints of right knee pain. During the interview with health care provider, Director of Quality and Compliance (DQC), stated R1 was seen each day at the clinic from 09/16/2024 to 09/19/2024, and the scrapes to the knee were cleansed.

Documentation shows facility staff provided first aid to R1s knee on 09/14/2024, and the resident was also assessed by licensed medical professionals on 09/16/2024.

Based on interviews and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Business Office Director, Ellen Arguello, who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2024 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20241017162021

FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:ZEPEDA, JESSICAFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:105CENSUS: 89DATE:
02/12/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Business Office Director, Ellen ArguelloTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not keep resident free from mental abuse
Staff did not follow reporting requirements
Unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Business Office Director, Ellen Arguello. LPA identified herself and explained the purpose of the visit.

During the investigation, staff members were interviewed, and records were reviewed.

Regarding the allegation of Staff did not keep resident free from mental abuse, RP stated that due to R1s injury and being moved around to different facilities, R1 experienced frustration and trauma.

While reviewing the documents, R1 was sent to the hospital to have the injury assessed and it was advised for R1 to go to a skilled nursing facility. On 9/23/24, R1 was developing hospital acquired delirium.

(Continue at LIC9099C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20241017162021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 02/12/2026
NARRATIVE
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(continue from LIC9099A)

Also on the records, it was noted that an RN from the hospital reviewed the care plan for R1 with the facility resident services director (RSD) and reported the services delivered are consistent with the care plan.

For the allegation of Staff did not follow reporting requirements, the facility submitted an incident report to Licensing and also to R1s doctor. Responsible parties were also contacted.

Regarding the allegation of Unlawful eviction, records show that upon discharge to the hospital, R1 hasn’t come back to the facility. Transition of care (TOC) team met with RSD on 9/25/24 and noted that RSD understands R1 needs to be discharged from skilled nursing facility and they are willing to accept R1 back temporarily while a new facility is found for her, due to R1 having a higher level of care needed. Per facility, R1, will have to move from the assisted living side and go to memory care side. On the same day, RSD noted that a call from a family member regarding expediting R1s discharge from skilled nursing, RSD educated family member regarding discharge process and resident's care. On 9/26/24, an inter disciplinary team (IDT) contacted responsible party to discuss the recommendation of memory care placement. Responsible party agreed with the plan to move R1.

Based on records review, the department has determined that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

An exit interview was conducted with Business Office Director, Ellen Arguello , who was provided with a copy of this report, and the LIC 9058 Licensee Appeal Rights.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7