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Inspection visit

complaint

BELMARE SENIOR LIVINGLicense 5027012071 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

sometimes it is 30 to 45 minutes. R7 stated that due to inadequate staffing, staff are unable to assist her when walking with her walker. On 7/25/25, the Department received an incident report that stated a resident’s family member found this resident bent over his wheelchair and bleeding from his knee. Camera footage showed that the resident had vomited three times and run his wheelchair into a pillar hurting his knee. No care staff were nearby to witness the incident. On 8/2/25, the Department received an incident report that the resident was found on his floor by a care staff bleeding from his elbow. The resident stated he was walking without his walker when he slipped and fell. There were no care staff nearby to witness the fall. On 8/4/25, F1 stated that there was only one person working in memory care that morning. A review of the August Caregiver Work Schedule showed only one person working in memory care on the A.M. shift on August 7th, 13th, 14th, 19th, 20th, 25th, and 26..The current census shows that there are twenty-eight residents in memory care. Between August 4th and August 22nd, 2025, the Department received twelve incident reports of unwitnessed falls. On 8/5/25, S7 stated in a text sent to staff to stop telling residents and family that the facility is short staffed. On 8/8/25, the Department received an incident report of an unwitnessed fall. R1 had been found on the floor of his room with his head in a pool of blood. On 8/8/25, F1 stated that R1 had another unwitnessed fall and was in the hospital with a brain bleed and fractured hip. On 8/15/25, the Department received an incident report of R8 found on the floor due to an unwitnessed fall. The resident was transported to hospital via EMS and returned with a splint and sling due to a fracture of her arm. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of lack of supervision resulted in residents sustaining multiple falls is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities is being cited on the attached LIC 9099D. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility. Allegation: Facility staff are not properly addressing pests in the facility 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.

Citations

8 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87468.2(a)(4)Type A

    87468.2 Additional Personal Rights of Residents...(a) Residents shall have…the...rights (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...This requirement is not met as evidenced by: Based on interview with R6 and R7, incident reports of 12 unwitnessed falls with four serious injuries, and staff schedule review, adequte care and supervision is not being met. This poses an immediate risk to residents in care.

  • 87411(a)Type A

    87411 Personnel Requirements-General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement is not met as evidenced by: Based on interviews with residents and staff, records review, and observations made, the Memory Care facility has less than the 1:7 ratio the Administrator said is needed to meet the residents' needs.This poses an immediate risk to residents in care.

  • 87608(a)(5)(B)Type A

    (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This is not met as evidenced by: Based on observation, record review, and interview, the licensee did not ensure that that resident did not have a full length bedrail with a doctors order, which prohibited the resident from movely freely off of their bed. This poses an immediate health, safety, and personal rights risks to persons in care.

  • 87464(f)(1)Type A

    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. 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.

  • 87465(a)(4)Type A

    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: Based on review of medication administration records, R1 did not receive all required daily medications, This poses an immeidate risk to residents in care.

  • 87468(a)(1)Type B

    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: 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.

  • 87555(b)(1)Type A

    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: 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.

  • 87625(b)(3)Type B

    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: 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.

FAQ · About this visit

Common questions about this visit

What happened during the September 3, 2025 inspection of BELMARE SENIOR LIVING?

This was a complaint inspection of BELMARE SENIOR LIVING on September 3, 2025. 1 citation were issued: 1 Type A (serious).

Were any citations issued to BELMARE SENIOR LIVING on September 3, 2025?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "87468.2 Additional Personal Rights of Residents...(a) Residents shall have…the...rights (4) To care, supervision, and se..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.