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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604079
Report Date: 10/16/2025
Date Signed: 10/16/2025 06:53:30 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
07/10/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20250710080946
FACILITY NAME:WESTMONT OF LA MESAFACILITY NUMBER:
374604079
ADMINISTRATOR:GARCIA, KIMBERLYFACILITY TYPE:
740
ADDRESS:9000 MURRAY DRTELEPHONE:
(619) 369-9700
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:164CENSUS: 123DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Wes HebnerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are mismanaging residents' medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Wes Hebner. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

On July 10, 2025 it was alleged that staff are mismanaging residents’ medication. More specifically, It was alleged that staff provided medication intended for one resident to another. Staff interviews with Staff #1 and Staff #2 revealed that prescribed medication (fiber powder) intended for Resident #2 (R2) was mistakenly administered to resident #1(R1). The incident occurred in the medication room while staff were preparing medications for the resident’s temporary off-site stay, following notification from Outside Source 1 (OS1) and the RP would be leaving the facility for several days. Staff reported that the short notice contributed to the medication error and immediately conducted a in-service training with all med-techs.
(continued on LIC9099)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
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 4
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
07/10/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20250710080946

FACILITY NAME:WESTMONT OF LA MESAFACILITY NUMBER:
374604079
ADMINISTRATOR:GARCIA, KIMBERLYFACILITY TYPE:
740
ADDRESS:9000 MURRAY DRTELEPHONE:
(619) 369-9700
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:164CENSUS: 123DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Excecutive Director Wes Hebner TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not following resident’s care plan
Staff falsified resident records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Wes Hebner. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.
On July 10, 2025 it was alleged that staff are not following the resident’s care plan and staff falsified resident records. More specifically, the facility now charges for medication management even though they believe they do not need medication management and the facility marked that they have MCI and dementia. The facility’s decision to begin medication management is supported by updated physician documentation, a signed service plan, and language in the Admission Agreement allowing for changes in care based on safety and legal requirements. The department conducted a records review and found no evidence of falsified records and is following the resident's care plan. Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred; therefore, the allegation is UNSUBSTANTIATED.
An exit interview was conducted with Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20250710080946
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 OF LA MESA
FACILITY NUMBER: 374604079
VISIT DATE: 10/16/2025
NARRATIVE
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(Continued from LIC9099)

The Reporting Party revealed concerns about receiving another resident’s medication and expressed frustration with the facility’s handling of the medication release process. The Department records review revealed that an annual visit was conducted on July 15, 2025, and the October 9, 2025, audit confirmed current compliance with medication management practices, except for this singular incident.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with executive Director Wes Hebner, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.



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SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20250710080946
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 OF LA MESA
FACILITY NUMBER: 374604079
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement has not been met as evidenced by:
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Resident Service Director stated that an in-service medication training was conducted on 8/28/2025 after the incident. RSD submitted proof of training to the department on 10/15/2025 while at the facility.
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Based on interviews, the Licensee did not ensure that staff correctly assisted residents with medication administration, which poses a potential health risk for 1 of 123 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.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4