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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 09/03/2025
Date Signed: 09/04/2025 03:52:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2025 and conducted by Evaluator Ellen Lindstrom
COMPLAINT CONTROL NUMBER: 27-AS-20250501155055
FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:CINDY LICHTENHANFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:114CENSUS: 83DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lacy Vincent, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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9
Staff do not ensure that residents' incontinence needs are met.
Staff speak inappropriately to residents.
Staff do not distribute resident's medication as prescribed.
Staff did not ensure resident's dietary needs were met.
Staff did not answer resident's call button in a timely manner.
INVESTIGATION FINDINGS:
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On 9/03/2025, Licensing Program Analysts (LPA) Triel Ellen Lindstrom and Arielle Pascua arrived unannounced at the facility to deliver the findings on a complaint received on 5/1/2025. The LPAs met with Administrator Lacy Vincent and explained the purpose of the visit. LPA Lindstrom had toured and made observations at the facility, reviewed records and work schedules, and interviewed residents, staff, and family members. This investigation was conducted during site visits on 5/5/25, 5/28/25, 6/9/2025 and 8/4/2025.

Allegation: Staff do not ensure that residents' incontinence needs are met
A family member (F1) of a resident (R1) was interviewed and stated that R1 had had two occurrences when incontinence care was not met. On 8/4/25, F1 discovered R1 still in bed at 8:20 AM. F1 walked into R1’s bedroom and found R1 lying in bed with soaked briefs and bed pads. In another occurrence, F1 looked throughout the unit for a caregiver to help R1 toilet and could find none. R1 subsequently got (Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 8
Control Number 27-AS-20250501155055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 09/03/2025
NARRATIVE
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feces all over themselves. A review of R1’s 602 physician’s report states that R1 needs assistance with toileting, bathing and grooming. A review of the facility’s August work schedule shows that only two caregivers were working in the memory care unit with 28 residents on the AM shift on 8/4/25.
S1 stated that they often find all residents’ briefs soaked at the beginning of an AM shift in the Memory Care unit. S2 stated that a couple of times they had discovered residents with dried feces on their buttocks at the beginning of the AM shift, which S2 said was a sign that caregivers had not changed their briefs in a while. S5 stated that sometimes when the facility was not sufficiently staffed and staff could not respond to call buttons within 10 minutes in Assisted Living, residents had accidents that resulted in soaking through their briefs and bedding.

The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of staff do not ensure that residents' incontinence needs are met is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87625(b)(3) Managed Incontinences being cited on the attached LIC 9099D.

Allegation: Staff speak inappropriately to residents
On 5/29/2025 and 6/09/2025, LPA Lindstrom conducted interviews with two staff members, S10 and S12 respectively. Both staff members stated that S9 was very verbally abusive to residents, used bad words, and was aggressive. S10 stated that S9 told resident R2 to go in their f’ing room when R2 would come out at the beginning of S9’s shift. S12 stated that S9 is rude to everyone and calls people retards. On 8/4/25, LPA Lindstrom interviewed F1, who stated that she heard S9 cuss, be vulgar, and tease residents, including saying, “What the f’ are you doing?” to a resident. A review of S9’s file shows that S9 had a history of speaking inappropriately and loudly to residents and to other staff in the presence of residents and their family. Disciplinary records show that management had been meeting with and writing up S9 for at least 8 months.

The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of staff speak inappropriately to residents is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468(a)(1) Personal Rights is being cited on the attached LIC 9099D.
(Continued on 9099-C)
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20250501155055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 09/03/2025
NARRATIVE
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Allegation: Staff do not distribute resident's medication as prescribed
On 8/4/25, a Medication Administration Report (MAR) for R1 shows that R1 was taking 10 daily medications. The MAR for July shows that medications were not documented as being given on 7/10, 7/11,7/25, and 7/26. R1 is unable to neither confirm nor deny if he received their medications on these days. S4 stated that they had observed empty medicine bottles in the medicine cart that had not been refilled.

The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of Staff do not distribute resident's medication as prescribed, therefore the allegation is SUBSTANTIATED.California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(a)(4) Incidental Medical and Dental Care is being cited on the attached LIC 9099D.

Staff did not ensure resident's dietary needs were met
LPA Lindstrom toured the facility on 5/5/25, 5/28/25, 6/9/25 and 8/4/25 and interviewed a total of fifteen staff, ten residents, and four family members. S5 stated that when the facility is not sufficiently staffed, new staff forget to order residents’ meals. F1 stated that R1 was getting their food pureed when first admitted and that R1 started to lose weight after admission. R1’s 602 states that R1 only needs their food to be easy to chew. S1 stated that staff did not meet the dietary needs of R2, who is bedridden. There have been times when R1 was hallucinating due to a side effect of medication and could not eat when his room tray was delivered. Staff put his meal in the microwave and forgot it there.

The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that staff did not ensure resident’s dietary needs were met, therefore the allegation is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87555(b)(1) General Food Service Requirement is being cited on the attached LIC 9099D.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20250501155055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 09/03/2025
NARRATIVE
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Staff did not answer resident's call button in a timely manner
On 5/5/25, LPA Pascua interviewed S7, who stated that the expectation regarding response time to pendant calls was 10 minutes. An analysis of the pendant log for April 2025 showed that the wait 11-20 minutes 21% of the time, 21 to 30 minutes 5% of the time, and over 30 minutes 3% of the time. LPA Lindstrom interviewed a resident R6, who stated that when the facility is not sufficiently staffed, it can take staff up to an hour to respond to calls for help, often times leaving R6 screaming as they cannot reach the call button. R7 stated that staff response time to her call button is usually around 15-20 minutes, although has taken up to 30 to 45 minutes.

The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that staff did not answer resident's call button in a timely manner, therefore the allegation of is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87464(f)(1) Basic Services is being cited on the attached LIC 9099D.

An exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2025 and conducted by Evaluator Ellen Lindstrom
COMPLAINT CONTROL NUMBER: 27-AS-20250501155055

FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:CINDY LICHTENHANFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:114CENSUS: DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lacy Vincent, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist resident with obtaining medical care
INVESTIGATION FINDINGS:
1
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On 9/03/2025, Licensing Program Analysts (LPA) Triel Ellen Lindstrom and Arielle Pascua arrived unannounced at the facility to deliver the findings on a complaint received on 5/1/2025. The LPA met with Administrator Lacy Vincent and explained the purpose of the visit. LPA Lindstrom had toured and made observations at the facility, reviewed records and work schedules, and interviewed residents, staff, and family members. This investigation was conducted during site visits on 5/5/25, 5/28/25, 6/9/2025 and 8/4/2025.

Allegation: Staff did not assist resident with obtaining medical care
LPA Lindstrom toured the facility on 5/5/25, 5/28/25, 6/9/25 and 8/4/25 and interviewed a total of fifteen staff, ten residents, and four family members. 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 allegation is UNSUBSTANTIATED.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20250501155055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Administrator refused to participate in developing plan of correction.

The licensee will provide to the Department their plan to meet the regulation by the POC date
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Based on review of medication administration records, R1 did not receive all required daily medications, This poses an immeidate risk to residents in care.
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Type A
10/03/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision...
This requirement is not met as evidenced by: Based on an interview with S7, the expected staff response time to call buttons is ten minutes.
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Administrator refused to participate in developing plan of correction.

The licensee will provide to the Department their plan to meet the regulation by the POC date
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 Review of pendant logs show that 29% of call buttons are answered in more than ten minutes. This poses an immediate risk to residents in care.
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The licensee will provide to the Department their plan to meet the regulation by the POC date
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: Stephenie Doub
LICENSING EVALUATOR NAME: Lisa Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20250501155055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2025
Section Cited
CCR
87555(b)(1)
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87555 General Food Service Requirements (b)The following...shall apply: (1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day.

The requirement is not met as evidenced by:
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Administrator refused to participate in developing plan of correction.

The licensee will provide to the Department their plan to meet the regulation by the POC date.
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Based on interviews with F1 and S5 and review of R1's LIC602, modifications were made to R1’s diet that were not required by the doctor, and that when not sufficiently staffed, R2 missed his meal. This poses an immediate risk to residents in care.
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Type B
10/03/2025
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b)…the licensee shall be responsible for...(3) Ensuring that incontinent residents are kept clean and dry...
This requirement is not met as evidenced by:
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Administrator refused to participate in developing plan of correction.

The licensee will provide to the Department their plan to meet the regulation by the POC date.
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Based on interview with F1, R1 was found on 8/4/25 with soaked briefs and bedpads. According to R1's LIC 602, resident is not ambulatory and requires assistance for toileting needs.This poses a potential risk to 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: Stephenie Doub
LICENSING EVALUATOR NAME: Lisa Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20250501155055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2025
Section Cited
CCR
87468(a)(1)
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5
6
7
87468 Personal Rights (a) Residents…shall have…the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced. by:
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Administrator refused to participate in developing plan of correction.

The licensee will provide to the Department their plan to meet the regulation by the POC date
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Based on a review of S9’s disciplinary records and interviews with F1, S10, and S12, which showed that S9 did not treat residents in care with dignity by using curse words when speaking to them. This poses a potential risk to 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: Stephenie Doub
LICENSING EVALUATOR NAME: Lisa Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8