374604079-4-8-2026-08-AS-SJAB-DTDUD9-20260422152911

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604079
Report Date: 04/08/2026
Date Signed: 04/08/2026 04:43:08 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
01/29/2026 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20260129154601

FACILITY NAME:	WESTMONT OF LA MESA		FACILITY NUMBER:	374604079
ADMINISTRATOR:	WES HEBNER		FACILITY TYPE:	740
ADDRESS:	9000 MURRAY DR		TELEPHONE:	(619) 369-9700
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	164	CENSUS: 122	DATE:	04/08/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Executive DIrector Wes Hebner		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff are not addressing resident's fall risk
Resident sustained injuries due to staff neglect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themself 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 source, review of records, and LPA observations.

On January 29, 2026, the Community Care Licensing Division (CCLD) received a complaint alleging that staff are not addressing the resident’s fall risk, and the resident sustained injuries due to staff neglect. The Reporting Party submitted an SOC 341 stating Resident #1 (R1) experienced multiple unwitnessed falls over a period of months, resulting in injuries including a skin tear, bruising, eyebrow laceration, and pain.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20260129154601

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: 04/08/2026

NARRATIVE

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(Continued from LIC9099)
Department staff interviews revealed R1 frequently refused to sleep in the bed and instead slept in a recliner, which contributed to repeated falls or near falls. Staff stated that R1 did not consistently use ambulatory devices. Staff confirmed multiple unwitnessed falls and stated they responded promptly, contacted 911 when needed, notified the POA, and assisted R1 back to bed or chair as appropriate. Staff stated R1 was monitored with regular rounds. Department was unable to interview R1 due to discharge from the facility and subsequent placement.

Department outside source interview revealed (OS1) they observed R1 attempting to stand from the recliner in an unsafe manner. OS1 reported never witnessing a fall during visits but observed balance issues, weakness, and progressive decline. OS1 also reported that staff appeared attentive and caring and observed multiple staff on duty and throughout the building during their visits.

Department records review revealed that facility care notes documented repeated unwitnessed falls dating back to September 2025. Records repeatedly documented that R1 refused to sleep in the bed and preferred to sleep in a recliner, which may have contributed to falls when attempting to get up without lowering the footrest. Records also documented refusal or inconsistent use of the cane and shoes, intermittent confusion, and several instances of R1 sliding, kneeling, or being found on the floor.

Department observations revealed on multiple occasions over the months that staff were present and attentive. Staff demonstrated knowledge of resident care needs and fall-risk protocols.

Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

LIC9099 (FAS) - (06/04)

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