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Inspection visit

Follow-up on corrections

BELMARE SENIOR LIVINGLicense 5027012071 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

On 09/03/2025, Licensing Program Analysts (LPAs) Arielle Pascua and Triel Ellen Lindstrom arrived unannounced to this facility to conduct a case management visit. LPAs met with Facility Designated Administrator (FDA), Lacy Vincent and explained the purpose of the visit. The purpose of this visit was in response to LPA observations made during a subsequent complaint and case management visit dated September 3, 2025. Current census was 83. During the course of this visit, LPA toured the Memory Care building and the Assisted Living building. LPA confirmed with facility staff and a resident roster that there are currently 57 residents in Assisted Living and 26 in Memory Care. There are current 2 residents from Memory Care out of the facility at this time. During the visit, LPA observed one caregiver and one medication technician on duty, with one caregiver on a lunch break. Four residents were observed in the dining area, and five were in the living area watching TV. All other residents were in their respective bedrooms. During a walk-through of the Memory Care unit, LPA observed one resident (R1) in a bedroom with a mesh bed rail with the words "HOMEAL" installed along the full length of the bed. A review of R1’s facility records revealed no physician’s order for the use of a full bed rail, nor is R1 currently on hospice. Staff interviews indicated that the bed rail was installed at the request of a family member concerned about potential falls. LPA Pascua informed staff that a physician's order is required for the use of a bed rail that reaches the full length of the bed. LPA also toured the Assisted Living section, including two resident floors. During this tour, LPA observed three caregivers and one medication technician providing care and supervision to residents. As a result, the following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was attempted with FDA Vincent and a copy of this report was provided to the facility. A copy of this report will be sent to the Licensee and facility email addresses confirming delivery and read receipt.

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 other 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 other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

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.