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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604722
Report Date: 10/22/2025
Date Signed: 10/22/2025 05:10:40 PM

Document Has Been Signed on 10/22/2025 05:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:NOVELLUS CLAIREMONT LLCFACILITY NUMBER:
374604722
ADMINISTRATOR/
DIRECTOR:		LEWIS, ERNESTFACILITY TYPE:
740
ADDRESS:5219 CLAIREMONT MESA BLVD.TELEPHONE:
(858) 292-8044
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 214CENSUS: 89DATE:
10/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Executive Director Ernest "EJ" Lewis and Maintenance Director Perry GarrettTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Ernest "EJ" Lewis and Maintenance Director Perry Garrett. The facility's license shows a maximum capacity of two-hundred-and-fourteen non-ambulatory residents, eight (8) of which may be bedridden. Bedridden residents may only reside in bedrooms 124-137. Additionally, the facility is approved for fifteen (15) hospice residents and does not accept Dementia residents. During today’s inspection there were eighty-nine (89) residents in care. Note, LPA did step out for lunch from 12-1pm.
 
LPA and ED Lewis toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: bathroom sink in an unoccupied unit was 105.6F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were inaccessible to residents in care.

[Continued on LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: NOVELLUS CLAIREMONT LLC
FACILITY NUMBER: 374604722
VISIT DATE: 10/22/2025
NARRATIVE
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[Continued from LIC 809]

No toxic chemicals or poisons were accessible to clients.  Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per ED Lewis, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months, dated for service in September 2025. Last emergency drill conducted was on 10/3/25 for the topic of fire. The facility maintained excellent record keeping for maintenance and fire safety items. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed one (1) staff and one (1) client, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents, however LPA noted that staff training in the sampled records did not cover all required topics and a Type B citation was issued. Confidential records were stored in locked areas. During file review, LPA did also note that a bedridden resident (R1) was residing in a non-bedridden approved unit and had a Dementia diagnosis, which the facility's license does not approve. Two (2) additional type B citations were issued for the fire clearance violation and for operating beyond the conditions of their license.

Three (3) deficiencies total were cited during the inspection. An exit interview was conducted with ED Lewis to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/22/2025 05:10 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 10/22/2025 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: NOVELLUS CLAIREMONT LLC
FACILITY NUMBER: 374604722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in ensuring care staff members S1 and S2 completed training on required topics, which poses a potential health, safety and personal rights risk to 89 out of 89 persons in care.
POC Due Date: 11/19/2025
Plan of Correction
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Licensee will review staff training requirements and ensure S1, S2, and other applicable staff complete required training topics. Licensee will submit proof of training completion to LPA by POC due date.
Type B
Section Cited
CCR
87202(a)(2)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and file review, the licensee did not comply with the section cited above in ensuring a bedridden resident (R1) resided in a bedridden approved room, which posed a potential health and safety risk to 1 out of 89 persons in care.
POC Due Date: 11/19/2025
Plan of Correction
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Licensee will obtain an updated physician's report for R1 and share to LPA by POC due date. If R1 is still deemed as bedridden, facility will provide LPA with a decision to either move R1 to a bedridden approved room or submit an excpetion request to retain R1 in their current room. Note, an updated fire clearance inspection will be necessary should the facility choose to request the exception.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/22/2025 05:10 PM - It Cannot Be Edited


Created By: Arian Golbakhsh On 10/22/2025 at 04:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: NOVELLUS CLAIREMONT LLC
FACILITY NUMBER: 374604722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(a)
87204(a): A licensee shall not operate a facility beyond the conditions and limitations specified on the license [...]

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above by retaining a resident (identified as R1) with a Dementia diagnosis, which poses a potential health, safety and personal rights risk to 1 out of 89 persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Licensee will provide LPA with a decision to provide 30-day notice to R1 or request an exception to retain R1.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
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