374603509-2-25-2026-08-AS-JROO-DWV9JU-20260811232520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603509
Report Date: 02/25/2026
Date Signed: 02/25/2026 05:39:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2024 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20240412101930

FACILITY NAME:	WESTMONT AT SAN MIGUEL RANCH		FACILITY NUMBER:	374603509
ADMINISTRATOR:	MICHAEL SOKOLOWSKI		FACILITY TYPE:	740
ADDRESS:	2325 PROCTOR VALLEY RD		TELEPHONE:	(619) 271-4385
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91914
CAPACITY:	105	CENSUS: 89	DATE:	02/25/2026
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Executive Director, Jessica Zepeda		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Resident sustained multiple unexplained injuries in care.
Resident sustained multiple falls due to lack of supervision.

AMENDED COMPLAINT INVESTIGATION REPORT DELIVERED ON 3-5-2025

INVESTIGATION FINDINGS:

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AMENDED COMPLAINT INVESTIGATION REPORT

On February 25, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to the facility to deliver amended findings regarding the above-referenced allegations. LPA met with Executive Director, Jessica Zepeda, and discussed the purpose of the visit and elements of the complaint.

This complaint investigation was previously completed on March 5, 2025. The complaint was subsequently reassigned to the undersigned LPA for further investigation.

Community Care Licensing (CCL) conducted an amended investigation consisting of an additional review of facility and medical records, as well as interviews with facility staff who were present during the timeframe of the allegations, residents’ family members, and outside sources. (Continue at LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240412101930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH	FACILITY NUMBER: 374603509
	VISIT DATE: 02/25/2026

NARRATIVE

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AMENDED REPORT DELIVERED ON 3-5-2025

It was alleged that Resident 1 (R1) sustained multiple unexplained injuries while in care and sustained multiple falls due to lack of supervision.

Regarding the allegation: Resident sustained multiple unexplained injuries while in care

It was alleged that R1 sustained a skin tear to the forearm in June 2022, a bruise to the buttocks in August 2022, and a bruise to the forearm in October 2023.

Record review revealed that during the timeframe of the alleged incidents, R1 was receiving services from an external health care provider and was bedbound. Records documented that R1 experienced intermittent skin integrity issues. Documentation indicated that each incident involving a skin issue was reported to R1’s responsible party, external health care provider, and R1’s primary care physician. Records further showed that R1’s skin conditions were monitored and treated in accordance with physician and external health care provider orders.
Additional interviews conducted with facility staff who were present during the timeframe of the alleged incidents did not disclose concerns regarding unexplained injuries or neglect in care. Interviews with outside sources, including responsible parties of residents who were in care during the same timeframe, did not reveal concerns related to repositioning practices or the level of care provided by facility staff.

Review of available medical records did not disclose any corroborating evidence indicating that the reported injuries were the result of neglect or improper care.

Regarding the allegation: Resident sustained multiple falls due to lack of supervision
It was alleged that R1 sustained multiple falls due to lack of supervision.
Record review indicated that R1 had a witnessed fall on July 19, 2023, which did not result in injury. Documentation showed that the responsible party, external health care provider, and R1’s primary care physician were notified in accordance with reporting requirements as required in Tittle 22 regulations. Records further reflected that following the incident, R1’s fall risk was reassessed and addressed through updates to the facility’s service plan. (Continue at LIC9099C)

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240412101930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH	FACILITY NUMBER: 374603509
	VISIT DATE: 02/25/2026

NARRATIVE

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AMENDED REPORT FROM 3-5-2026

(Continue from LIC9099C)

Mitigation measures were implemented in response to the reassessment, including increased supervision, assistance with activities of daily living, and staff monitoring consistent with R1’s assessed needs to reduce the risk of future falls. Ongoing reassessment of R1’s fall risk and supervision needs was documented and incorporated into care planning as appropriate.

Additional interviews conducted with staff present during the timeframe of the alleged incident did not disclose concerns regarding lack of supervision. Interviews with residents’ responsible parties and outside sources did not indicate concerns related to staffing levels, supervision, or the implementation of fall prevention measures for residents in care.

Based on observations, interviews, and record reviews conducted during the course of both the initial and amended investigations, there was insufficient evidence to support the allegations that R1 sustained unexplained injuries due to neglect or sustained multiple falls due to lack of supervision while in care. The preponderance of evidence standard was not met; therefore, the allegations are deemed Unsubstantiated.

An exit interview was conducted with Executive Director, Jessica Zepeda. A copy of this amended report, LIC811, and the Licensee Appeal Rights (LIC 9058, 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

LIC9099 (FAS) - (06/04)

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