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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 9/03/2025, Licensing Program Analysts (LPA) Triel Ellen Lindstrom and Arielle Pascua arrived unannounced at the facility to deliver a case management deficiency. The LPAs met with Administrator Lacy Vincent (S1) and explained the purpose of the visit. The department has recently conducted five visits to the facility on 5/5/25, 5/28/25, 6/9/25, 8/4/25 and 8/7/25. LPA’s Pascua and Lindstrom conducted interviews with fifteen staff, ten residents, and four family members. LPA Lindstrom interviewed S1 on 8/04/2025. During that interview, S1 stated that stafffing levels at the facility are based on the needs of the resident. S1 stated that the staffing ratio in Memory Care is one staff for every seven residents. F1 stated that on 8/4/25, there was only one caregiver working in memory care with 28 residents and R1 was soaking wet in the bed. S2 and S5 state that when they are not sufficiently staffed, they are unable to give residents showers. R6 states that when the facility is not sufficiently staffed, it can take an hour for someone to respond to her when screaming and unable to reach her call button. R7 states that the facility is often not sufficiently staffed and that staff have to work overtime. R7 states that on 6/9/25, a resident had to go to the hospital and there was a delayed response to call pendants. R7 also stated that due to insufficient staffing, the staff don’t “spot” her when walking. On 5/29/25, S10 stated she was the only one working in memory care. The facility’s August work schedule shows that only 2 caregivers were working memory care in the AM shift on August 4 th ,28 th and 31 st and that there was only one caregiver in the AM shift on August 7 th , 13 th , 14 th , 19 th , 20 th , 25 th , and 26 th . Text messages from S7 stated that hiring more staff doesn’t happen overnight and that no one should tell Licensing that they are short staffed. The following Type A deficiency is cited per California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87411(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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary……for cooking, house cleaning, laundering…. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. An 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 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.