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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604079
Report Date: 01/07/2026
Date Signed: 01/07/2026 03:19:26 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
10/27/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20251027152209
FACILITY NAME:WESTMONT OF LA MESAFACILITY NUMBER:
374604079
ADMINISTRATOR:WES HEBNERFACILITY TYPE:
740
ADDRESS:9000 MURRAY DRTELEPHONE:
(619) 369-9700
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:164CENSUS: 122DATE:
01/07/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Executive DIrector Wes HebnerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not met resident's hygiene needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Wes Hebner.

The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review.

On 10/27/2025, Community Care Licensing Division (CCLD) received a complaint alleging staff did not meet resident’s hygiene needs. More spefically, the reporting Party alleged that Resident #1 (R1) was often dirty and in clothing soiled with feces upon arrival. The department observations revealed that common areas and bathrooms were clean and sanitary; a random sample of resident rooms inspected were clean, odor-free, and stocked with hygiene supplies.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
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 5
Control Number 08-AS-20251027152209
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 OF LA MESA
FACILITY NUMBER: 374604079
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2026
Section Cited
CCR
87625(b)(2)
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Section 87625(b)(2) – Managed Incontinence…the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidenced by:
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The licensee will provide in-service training on proper incontinence care protocols and submit documentation of staff training by the POC.
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Based on records review, interviews with staff, and outside sources, the licensee did not provide incontinent care to meet R1’s needs. This posed a potential health, safety and personal risk to 1 of 122 residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/27/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20251027152209

FACILITY NAME:WESTMONT OF LA MESAFACILITY NUMBER:
374604079
ADMINISTRATOR:WES HEBNERFACILITY TYPE:
740
ADDRESS:9000 MURRAY DRTELEPHONE:
(619) 369-9700
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:164CENSUS: 122DATE:
01/07/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Executive DIrector Wes HebnerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not ensure resident received medical attention
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Wes Hebner.

The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, outside sources, and records review.

On 10/27/2025, Community Care Licensing Division (CCLD) received a complaint alleging staff did not ensure resident received medical attention following falls, More specifically: Reporting Party alleged that resident #1(R1) fell four times in eight days and that the POA(Responsible Person) refused hospital transport after these falls. (Continued on Lic9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
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 5
Control Number 08-AS-20251027152209
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 OF LA MESA
FACILITY NUMBER: 374604079
VISIT DATE: 01/07/2026
NARRATIVE
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(Continued from LIC9099)

The department interviews with staff as well as records review reveal staff reported that EMS(Emergency Medical Services) was called for serious falls, and the resident was transported to the hospital on multiple occasions between late January and mid-February 2025. Facility documentation reflects several falls during this period, with medical transports occurring for the most significant incidents. There is no documentation indicating that the staff or the POA refused medical care. The department Interviews with outside sources indicated differing perspectives: While some confirmed that facility staff responded appropriately and did not refuse medical care, others provided accounts suggesting concerns about the timeliness or adequacy of the response.


Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred; therefore, the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Wes Hebner to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 08-AS-20251027152209
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 OF LA MESA
FACILITY NUMBER: 374604079
VISIT DATE: 01/07/2026
NARRATIVE
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(Continued from lic9099)

The department staff interviews revealed that staff reported hygiene care was provided daily and that supplies were available. Department records review revealed that facility documentation, including service plans, indicated regular care for R1. However, outside source interviews (OS1 and OS2) revealed frequent observations of R1, a resident of Compass Rose, in soiled briefs, sometimes saturated through clothing, upon their arrival. They stated they assisted R1 with incontinence care and showers during their visits. One source also described an incident involving another resident who remained soiled for approximately two hours before staff responded.

Based on interviews, records review, and outside source statements, the Department determined that a preponderance of evidence exists to support that staff did not consistently meet R1’s hygiene needs as alleged. Therefore, the allegation is SUBSTANTIATED.

An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5