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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 09/03/2025
Date Signed: 09/04/2025 03:49:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/28/2025 and conducted by Evaluator Ellen Lindstrom
COMPLAINT CONTROL NUMBER: 27-AS-20250528150925
FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:CINDY LICHTENHANFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:114CENSUS: DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lacy Vincent, AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Lack of supervision resulted in residents sustaining multiple falls
INVESTIGATION FINDINGS:
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On 9/02/2025, Licensing Program Analysts (LPA) Triel Ellen Lindstrom and Arielle Pascua arrived unannounced at the facility to deliver the findings on a complaint received on 5/1/2025. The LPA met with Administrator Lacy Vincent and explained the purpose of the visit. LPA Lindstrom had toured and made observations at the facility, reviewed records and work schedules, and interviewed residents, staff, and family members. This investigation was conducted during site visits on 5/5/25, 5/28/25, 6/9/2025 and 8/4/2025.

Allegation: Lack of supervision resulted in residents sustaining multiple falls
On 5/5/25, R6 stated that when the facility is inadequately staffed, staff do not respond timely to resident call buttons. R6 stated that when she was unable to reach her call button, she had to scream, and that it can take up to an hour to receive help. R7 stated that the facility is often short-staffed, and staff work a lot of overtime. R7 stated that typically the response time to her call button is 15 to 20 minutes, although
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 5
Control Number 27-AS-20250528150925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 09/03/2025
NARRATIVE
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sometimes it is 30 to 45 minutes. R7 stated that due to inadequate staffing, staff are unable to assist her when walking with her walker.

On 7/25/25, the Department received an incident report that stated a resident’s family member found this resident bent over his wheelchair and bleeding from his knee. Camera footage showed that the resident had vomited three times and run his wheelchair into a pillar hurting his knee. No care staff were nearby to witness the incident. On 8/2/25, the Department received an incident report that the resident was found on his floor by a care staff bleeding from his elbow. The resident stated he was walking without his walker when he slipped and fell. There were no care staff nearby to witness the fall. On 8/4/25, F1 stated that there was only one person working in memory care that morning. A review of the August Caregiver Work Schedule showed only one person working in memory care on the A.M. shift on August 7th, 13th, 14th, 19th, 20th, 25th, and 26..The current census shows that there are twenty-eight residents in memory care.

Between August 4th and August 22nd, 2025, the Department received twelve incident reports of unwitnessed falls. On 8/5/25, S7 stated in a text sent to staff to stop telling residents and family that the facility is short staffed. On 8/8/25, the Department received an incident report of an unwitnessed fall. R1 had been found on the floor of his room with his head in a pool of blood. On 8/8/25, F1 stated that R1 had another unwitnessed fall and was in the hospital with a brain bleed and fractured hip. On 8/15/25, the Department received an incident report of R8 found on the floor due to an unwitnessed fall. The resident was transported to hospital via EMS and returned with a splint and sling due to a fracture of her arm.

The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the allegation of lack of supervision resulted in residents sustaining multiple falls is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities is being cited on the attached LIC 9099D.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/28/2025 and conducted by Evaluator Ellen Lindstrom
COMPLAINT CONTROL NUMBER: 27-AS-20250528150925

FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:CINDY LICHTENHANFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:114CENSUS: DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lacy Vincent, AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff did not ensure residents had adequate clothing.
Facility staff are not properly addressing pests in the facility.
INVESTIGATION FINDINGS:
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On 9/02/2025, Licensing Program Analysts (LPA) Triel Ellen Lindstrom and Arielle Pascua arrived unannounced at the facility to deliver the findings on a complaint received on 5/1/2025. The LPA met with Administrator Lacy Vincent and explained the purpose of the visit. LPA Lindstrom had toured and made observations at the facility, reviewed records and work schedules, and interviewed residents, staff, and family members. This investigation was conducted during site visits on 5/5/25, 5/28/25, 6/9/2025 and 8/4/2025.

Allegation: Facility staff did not ensure residents had adequate clothing
LPA Lindstrom toured the facility on 5/5/25, 5/28/25, 6/9/25 and 8/4/25 and interviewed a total of fifteen staff, ten residents, and four family members. 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.
(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 5
Control Number 27-AS-20250528150925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 09/03/2025
NARRATIVE
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Allegation: Facility staff are not properly addressing pests in the facility
LPA Lindstrom toured the facility on 5/5/25, 5/28/25, 6/9/25 and 8/4/25 and interviewed a total of fifteen staff, ten residents, and four family members. 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.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250528150925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2025
Section Cited
CCR
87468.2(a)(4)
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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:
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Administrator refused to participate in developing a plan of correction.

The licensee will provide to the Department their plan to meet the regulation by the POC date
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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.
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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: Stephenie Doub
LICENSING EVALUATOR NAME: Lisa Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5