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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603509
Report Date: 09/16/2026
Date Signed: 09/16/2026 04:16:14 PM

Substantiated


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
02/18/2025 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20250218125138
FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:ZEPEDA, JESSICAFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:105CENSUS: 92DATE:
09/16/2026
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director, Jessica ZepedaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not provide records to a resident's authorized person
Facility illegally evicted a resident
INVESTIGATION FINDINGS:
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On September 16, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings regarding the above-referenced allegations. LPA explained the purpose of the visit, and met with Executive Director Jessica Zepeda. The investigative findings were discussed.

The Department's investigation consisted of a review of resident and facility records, Service Care Plans, Power of Attorney (POA) documentation, written and certified records requests, proof of delivery, facility and family correspondence, outside-provider and mortuary correspondence, progress notes, information received by Community Care Licensing (CCL), and interviews with facility staff and outside sources.

An LIC 811 identifying R1 was provided to facility management.
Page 1 of 5
(Continue at LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
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 9
Control Number 08-AS-20250218125138
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: 09/16/2026
NARRATIVE
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(Continue from LIC9099)

Allegation: Staff did not provide records to resident's authorized person.

The complaint alleged that facility staff failed to provide requested resident records to R1's authorized representative after repeated requests.

Early in the investigation, an outside source repeatedly requested numerous documents from the facility, including resident-file information, injury-related records, behavioral incident information, medication administration records, progress notes, Service Care Plan information, and other records. The investigation also established that the outside source was not R1's POA. This evidence was considered because the facility had a legitimate basis to verify authorization before releasing confidential resident records directly to the outside source.

LPA reviewed documentation identifying R1's spouse as R1's POA/authorized representative. A handwritten communication dated February 5, 2025 identified an outside source as the POA's advocate/spokesperson and requested that communications be directed through the outside source. The communication specifically requested R1's June 2023 Service Care Plan. A facility notation documented that the June 2023 Service Care Plan was provided, which was considered as evidence that the facility fulfilled at least one specific request.

Additional evidence obtained later in the investigation materially changed the records-access analysis. Following R1's death, the POA submitted written requests directly to the facility. A March 21, 2025 certified request was received on or about March 26, 2025. The request included a death-related document later clarified as the official death certificate. The investigation did not establish that the official death certificate was a facility-generated or facility-maintained resident record; therefore, the death certificate is not used as the basis for this finding.

LPA also reviewed the POA's May 1, 2025 written second request. The May 1 request directly sought multiple categories of facility-maintained information concerning R1, including records and reports regarding unexplained injuries, behavioral incident information, medication records, R1's Memory Care file, and records concerning assessments and appraisals. Page 2 of 5 (continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 08-AS-20250218125138
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: 09/16/2026
NARRATIVE
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(continue from LIC9099C)

The request also referenced the facility's Plan of Operation. Because some requested items were facility-wide documents rather than resident records, LPA distinguished those items from the facility-maintained resident records that form the basis of this allegation.

CCL records documented repeated follow-up in March, April, and May 2025 stating that requested resident records remained outstanding. During a subsequent interview, an outside source stated that the POA requested records in person, by email, and by certified mail and that requested facility-maintained resident records remained outstanding. The outside source also reported that facility staff stated some requested information would not be provided because management did not consider the information part of R1's resident file.

Before finalizing the finding, LPA provided facility management an additional opportunity to identify what records responsive to the written requests had been provided, the date and method of production, the recipient, and the reason any requested facility-maintained resident records were not produced. The evidence available for final review did not include documentation establishing that the facility provided the requested facility-maintained resident records, nor did it establish a timely supported response for withholding those records.

The Department considered the contrary evidence that the initial outside source was not the POA, that the June 2023 Service Care Plan was documented as provided, and that some requested documents, including the official death certificate and facility-wide Plan of Operation, were analytically distinct from facility-maintained resident records. Those facts do not overcome the later written requests made directly by the POA for facility-maintained resident records or the absence of documentation establishing that those records were provided.

Based on the direct written requests from the POA, proof that the facility received the requests, repeated follow-up that resident records remained outstanding, corroborating interview information, and the absence of documentation establishing production of the requested facility-maintained resident records, the preponderance-of-evidence standard was met. Therefore, the allegation is SUBSTANTIATED. Page 3 of 5 (continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 08-AS-20250218125138
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: 09/16/2026
NARRATIVE
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(continue from LIC9099C)

Allegation: Facility illegally evicted a resident.
The complaint alleged that facility management illegally evicted, or attempted to compel the involuntary transfer of, R1 during R1's decline and end-of-life period.

LPA reviewed records and correspondence concerning R1's changing needs and the facility's proposal that R1 transition to a higher level of care. Facility management stated that updated care information and involvement of an Outside Medical Provider/Agency supported consideration of a higher level of care, including possible skilled-nursing placement. Facility management later maintained that R1 was not evicted and that a higher level of care was recommended because R1's needs had increased.

The Department considered this explanation. However, a February 14, 2025 email chain contained material evidence showing that facility management described R1's move to a higher level of care as necessary, referenced a possible placement, stated that legal counsel had been consulted, and communicated that eviction proceedings would be pursued if the family did not provide communication or cooperation with the proposed transfer.

Outside sources objected to the proposed relocation while R1 was experiencing substantial decline and receiving end-of-life services. The communication therefore went beyond a general recommendation to explore another placement. Facility management expressly tied cooperation with the proposed transfer to the initiation of eviction proceedings.

Records established that no completed physical eviction occurred before R1's death. LPA did not identify a final written eviction notice, effective move-out date, or completed involuntary discharge. R1 remained at the facility and continued receiving facility and outside-provider services until February 17, 2025, when R1 died at the facility. This evidence was considered as contrary evidence.

The absence of a completed physical removal does not negate the facility's written communication that eviction proceedings would be initiated if cooperation with the proposed transfer was not received. The communication used the threatened initiation of eviction proceedings to obtain cooperation with a licensee-initiated transfer. Page 4 of 5 (continue on LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 9 of 9
Control Number 08-AS-20250218125138
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: 09/16/2026
NARRATIVE
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(continue from LIC9099C)


After review of the written management communication, outside-source responses, higher-level-of-care records, facility management's contrary statement that no completed eviction occurred, and the fact that R1 died before a formal process was completed, the Department determined that the evidence more likely than not established an improper involuntary-transfer/eviction action as alleged. The preponderance-of-evidence standard was met. Therefore, the allegation is SUBSTANTIATED.

Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and are detailed on the LIC 9099-D. Plans of Correction (POCs) were jointly developed with Executive Director Jessica Zepeda.

An exit interview was conducted with Executive Director Jessica Zepeda. A copy of this report, the LIC 9099-D, the Licensee Appeal Rights (LIC 9058), and LIC 811 were provided electronically at the conclusion of the virtual visit.

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SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 08-AS-20250218125138
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2026
Section Cited
CCR
87468.2(a)(19)
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CCR 87468.2(a)(19)Additional Personal Rights of Residents ...Residents have the right to prompt access to review all records ...shall be provided within two business days ... This requirement was not met as evidenced by:
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ED agreed to provide all outstanding facility-maintained resident records required for release, implement a written records-request procedure addressing the two-business-day requirement, and train staff responsible for records requests. Proof of correction will be submitted to CCL by the POC deadline.
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Based on records review and interviews, the licensee did not comply with the section cited above. R1's authorized representative submitted written requests for facility-maintained resident records, and the facility did not provide documentation establishing that the requested resident records were made available or provided within the required timeframe. This posed a potential personal-rights risk to R1 and (92) other residents in care.
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Type B
10/16/2026
Section Cited
CCR
87468.2(a)(20)
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CCR 87468.2(a)(20)Additional Personal Rights of Residents... have the right to be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict a resident for reasons other than those permitted by law ...This requirement was not met as evidenced by:
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ED agreed to implement a written involuntary-transfer/eviction procedure consistent with CCR 87468.2(a)(20), prohibit coercive eviction threats outside the permitted process, and train management staff involved in transfer or eviction decisions. Proof of correction will be submitted to CCL by the POC deadline.
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Based on records review and interviews, facility management communicated that R1's move to a higher level of care was necessary and that eviction proceedings would be pursued if cooperation with the proposed transfer was not received. Although a completed physical eviction did not occur before R1's death, the written communication constituted an improper licensee-initiated involuntary-transfer/eviction action and posed a potential personal-rights risk to R1 and (92) other 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.
SUPERVISOR'S NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 9
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
02/18/2025 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20250218125138

FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:ZEPEDA, JESSICAFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE:CAZIP CODE:
91914
CAPACITY:105CENSUS: 93DATE:
09/16/2026
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director, Jessica ZepedaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not treat a resident with dignity
INVESTIGATION FINDINGS:
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On September 16, 2026, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings regarding the above-referenced allegation. LPA explained the purpose of the visit, and met with Executive Director Jessica Zepeda. The investigative findings were discussed.

The Department's investigation consisted of a review of R1's resident records and Service Care Plans, facility and family correspondence, memorial-practice information, information received by Community Care Licensing (CCL), and interviews with facility staff and outside sources.

An LIC 811 identifying R1 was provided to facility management.
Page 1 of 3 (continue at LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 08-AS-20250218125138
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: 09/16/2026
NARRATIVE
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(continue from LIC9099A)

The complaint alleged that R1 was not treated with dignity and respect. The concerns focused primarily on facility management's conduct immediately after R1's death, including an alleged lack of condolences or personal acknowledgment, the absence of a memorial photograph or tribute, and concerns regarding facility social-media postings.

LPA reviewed R1's Service Care Plans and resident records. The records reflected significant cognitive and functional impairment, Level 7 care, full assistance with activities of daily living, and continued coordination of care through the end of R1's residency. The records reviewed and interviews conducted did not document degrading, humiliating, retaliatory, or intentionally disrespectful treatment of R1 while R1 resided at the facility.

During an outside-source interview, it was reported that direct-care staff expressed sympathy and respect after R1 died, while facility management did not personally acknowledge the family or offer condolences during the period the family remained at the facility waiting for the mortuary. The outside source stated that a private religious observance did not occupy the entire waiting period. The concern was also raised in writing on February 18, 2025, the day after R1's death.

Facility documentation included written correspondence following R1's death that expressed condolences and addressed administrative matters. This was considered as evidence that the facility provided a written expression of sympathy, although the correspondence did not establish whether facility management personally acknowledged the family while present at the facility.

During a follow-up interview, facility management stated that R1's family remained in R1's room while waiting for the funeral home and engaged in a private religious observance. Facility management stated that staff entered the room as needed but otherwise allowed privacy. The response did not establish whether verbal condolences were expressly offered by facility management.

Facility management also stated that the facility had no formal or consistent protocol requiring a memorial photograph or tribute following every resident death and described memorial displays as a courtesy when a family expressed interest. Page 2 of 3 (continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 08-AS-20250218125138
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: 09/16/2026
NARRATIVE
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Facility management reported that 13 residents died at the facility between November 2024 and February 2025, but the facility did not maintain a log identifying which residents received memorial displays or who initiated each request. Records reviewed did not establish that a memorial photograph or tribute for R1 was requested and refused.

The Department finds the concerns regarding management's post-death interaction credible and supported by records and interview information. The evidence supports that the family perceived management's response as lacking personal compassion and acknowledgment. However, the strongest evidence concerns management's interaction with the family after R1's death, rather than degrading, disrespectful, or undignified treatment of R1 while R1 was a resident.

The investigation did not establish that R1 was intentionally excluded from activities, denied care because of disrespect, subjected to degrading comments or conduct, or otherwise treated in a manner inconsistent with R1's personal dignity. Although compassionate personal acknowledgment and condolences are appropriate when a resident dies, the evidence obtained did not establish by a preponderance that facility staff violated R1's personal right to dignity and respect.

Based on records reviewed, interviews conducted, and all information obtained during the investigation, the Department determined that 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.

An exit interview was conducted with Executive Director Jessica Zepeda. A copy of this report, the Licensee Appeal Rights (LIC 9058), and LIC 811 were provided electronically at the conclusion of the virtual visit.

page 3 of 3
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 9