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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604079
Report Date: 01/22/2026
Date Signed: 01/22/2026 04:30:22 PM

Unsubstantiated


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
07/15/2021 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20210715123940
FACILITY NAME:WESTMONT OF LA MESAFACILITY NUMBER:
374604079
ADMINISTRATOR:ARMOUR, DAVIDFACILITY TYPE:
740
ADDRESS:9000 MURRAY DRTELEPHONE:
(619) 369-9700
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:164CENSUS: 118DATE:
01/22/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Wes HebnerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Lack of supervision resulting in resident sustaining severe bruising
Staff did not notify responsible party of change in resident's condition
Staff did not observe resident following change in condition
Staff did not meet resident's needs
Licensee did not provide resident a safe environment
Licensee did not provide required resident activities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rodgers conducted an unannounced complaint visit and met with the Executive Director Wes Hebner.

On July 20, 2021, Community Care Licensing Division (CCLD) received a complaint alleging lack of supervision resulting in a resident sustaining severe bruising, staff did not notify the responsible party of a change in the resident’s condition, staff did not observe the resident following a change in condition, staff did not meet the resident’s needs (ADLs, grooming, diet), licensee did not provide the resident a safe environment, and licensee did not provide required resident activities. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. (continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
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 6
Control Number 08-AS-20210715123940
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: 01/22/2026
NARRATIVE
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(Continued from LIC 9099) page 2 of 3

The Department interviews revealed multiple caregivers, LVNs, Med-Techs, and the Resident Services Director described monitoring practices, ADL assistance, and activity offerings for Resident #1 (R1) Executive Director David Armour explained caregivers do not chart each ADL task; refusals are documented by exception in digitized Progress Notes provided to the Department. The Department records review revealed service plans included ADL assistance, safety supervision, and activity programming; care notes documented monitoring and diet changes after physician orders; the posted monthly activity calendar was observed by LPA on multiple dates. The Department observations revealed R1 was groomed, room was clean, window intact, and activities were occurring per schedule during visits on 07/21/2021 and 10/27/2021.

Regarding the allegation, lack of supervision resulting in resident sustaining severe bruising. The Department interviews and records review revealed staff followed the facility’s fall response procedures when a large bruise was discovered on 07/06/2021: notifying clinical staff (Med-Tech/Resident Services Director), flagging the chart for increased monitoring, and conducting assessments. R1 denied an unwitnessed fall and exhibited full range of motion with no head trauma signs at the time of assessment. Staff increased observation after discovery. Based on evidence, staff acted according to policy.

Regarding the allegation, staff did not notify responsible party of change in condition. The Department records review revealed the responsible party became aware of the bruise during their 07/10/2021 visit and was informed in person at the facility. Pursuant to Title 22, Section 87211(a)(1)(B), a written report to the licensing agency and the responsible person is required within seven (7) days for serious injuries as determined by the attending physician. The bruise did not meet the definition of “serious bodily injury” under Title 22, and there is no regulatory requirement for immediate notification in this case.

(Continued on LIC9099-C)
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20210715123940
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: 01/22/2026
NARRATIVE
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(Continued from LIC9099-C) pages 3 of 3

Regarding the allegation, staff did not meet resident’s needs. The Department interviews revealed staff provided ADL assistance, with occasional refusals due to dementia-related behaviors (e.g., layering clothing, shaving refusals). ED reported the electric razor charger was replaced and shaving resumed consistently after care conferences. The Department records review revealed diet changes were implemented following physician orders post-hospitalization for Bell’s Palsy; Progress Notes reflected monitoring and adjustments. The Department observations on 10/27/2021 documented R1 cleanly shaven, well dressed, and room/restroom in good order.

Regarding the allegation, licensee did not provide resident a safe environment. The Department interviews and records review acknowledged historic concerns (e.g., cracked window and a picture frame with broken glass) that were reported and corrected. The Department observations on 07/21/2021 and 10/27/2021 revealed windows intact, no broken glass, clean non-sticky floors, and no observed hazards. Facility maintenance records and staff interviews confirmed responsive repairs.\

Regarding the allegation, licensee did not provide required resident activities. The Department interviews revealed scheduled activities in Compass Rose (memory care) including group walks, music, tactile stimulation (“busy boards”), games (e.g., dice activity), and pet therapy. The Department observations confirmed activities occurring per the posted calendar and availability of supplies (bingo, coloring, puzzles). While resident preference (walking) and engagement varied, evidence supports ongoing activity provision.

Based on interviews, observations, and records review, a preponderance of evidence does not exist to prove any of the six alleged violations occurred. Therefore, these allegations are UNSUBSTANTIATED.

An exit Interview was conducted with Executive Director Wes Hebner. 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: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
07/15/2021 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20210715123940

FACILITY NAME:WESTMONT OF LA MESAFACILITY NUMBER:
374604079
ADMINISTRATOR:ARMOUR, DAVIDFACILITY TYPE:
740
ADDRESS:9000 MURRAY DRTELEPHONE:
(619) 369-9700
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:164CENSUS: 118DATE:
01/22/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Wes HebnerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not seek medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rodgers conducted an unannounced complaint visit and met with the Executive Director Wes Hebner.

On July 20, 2021, Community Care Licensing Division (CCLD) received a complaint alleging staff did not seek medical care for a resident in a timely manner. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
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 6
Control Number 08-AS-20210715123940
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: 01/22/2026
NARRATIVE
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The Department interviews revealed that on 07/06/2021, staff observed a large bruise on Resident #1(R1) involving the right thigh, lower leg, buttock, and hip area. Staff assessments documented full range of motion and no head trauma signs; however, staff did not notify the physician upon discovery and did not send the resident for evaluation. Staff #1 stated she was aware of the bruise but “got busy and forgot.” Staff #2 confirmed she did not notify the physician or family. The Department records review revealed the facility incident report was completed on 07/13/2021, seven days after the bruise was first observed.The responsible party transported R1 to a hospital on 07/10/2021 due to concern about possible fracture. Hospital documentation revealed diagnostic testing included an X-ray of the right hip and pelvis, which showed no acute fracture or dislocation, and a CT scan of the head, which showed no acute traumatic brain injury or subdural hematoma. Hospital staff noted the bruise appeared two to three days old and expressed concern that the facility had not notified family or reported any incident.

Based on interviews, records review, and hospital documentation, the preponderance of evidence supports that staff failed to seek timely medical care for R1 after a significant change in condition was observed. Therefore, this allegation is SUBSTANTIATED.

Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with ED Hebner, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20210715123940
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: 01/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2026
Section Cited
CCR
87465(a)
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87465(a) – Incidental Medical and Dental Care(a) The licensee shall ensure that residents receive assistance in meeting their medical and dental needs… promptly notifying the physician of any significant change in a resident’s condition.
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The licensee is conduct in-service training to care staff to ensure prompt physician notification and assistance seeking medical care after significant change in condition is observed. LIcensee staff will submit proof of training by POC
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Based on interviews and record review, the licensee did not seek timely medical care for a resident after staff observed a significant change in condition, which poses a potential health 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: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6