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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 10/01/2025
Date Signed: 10/01/2025 11:05:15 AM

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
09/26/2025 and conducted by Evaluator Ellen Lindstrom
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250926085746
FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:LACY VINCENTFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:114CENSUS: 83DATE:
10/01/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Emily Parker, Memory Care DirectorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff dispensed medication to resident that was not prescribed.
INVESTIGATION FINDINGS:
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On 10/1/2035, Licensing Program Analyst (LPA) Triel Ellen Lindstrom visited the facility unannounced to open this complaint and deliver findings. LPA Lindstrom met with Emily Parker, Memory Care Director, and explained the purpose of the visit. The purpose of the visit was to open the complaint, interview staff, review records, and deliver findings.

Allegation: Staff dispensed medication to resident that was not prescribed.
LPA Lindstrom reviewed an Unusual Incident/Injury Report (LIC624) that was submitted to the Department by the Administrator on 9/25/2025. This report stated that a resident (R1) was administered a narcotic medication between 9/6/2025 - 9/17/2025 without a prescription order on file at the facility. According to the LIC 624, staff reported seeing a bottle of oxycodone in R1’s room on 9/4/2025. Staff (S1) removed it from R1’s room that day and gave it to staff (S2) to count the contents, create a ‘narc count sheet,’ confirm the doctor’s prescription, and store until then. On 9/6/2025, S2 started to administer the
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
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-20250926085746
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: 10/01/2025
NARRATIVE
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medication to R1. When asked why, S2 told S1 that there was an order and a paper medication administration record (MAR). Every Med Tech after 9/6/2025 also administered the medication, but they used the narc count sheet to track administration instead of the paper MAR. No other Med Tech saw a prescription order.

According to the LIC624, the administration of this medication came to the attention of management when S1 received a call from a pharmacy asking why staff requested a refill for a medication that was not on R1’s medication list. The internal investigation revealed that staff were alternating administration of R1’s pain medication between the prescribed pain medication that he was already on and the medication with no order. On 9/13/2025, S3 administered both pain medications at once, according to the narcotic count sheet and electronic MAR. When discovered by management, they informed R1’s family and doctors.

On 9/29/2025, LPA Lindstrom spoke with S1 about the incident reported in the LIC624. S1 stated that they asked S2 why they began to administer this pain medication. S2 reported that she had seen an order for the medication and so created a paper medication administration record. S1 has since reviewed the document that S1 referenced and determined that it was not an order. S2 told S1 that they contacted R1’s primary doctor, who confirmed that they had not written the prescription, and then contacted the doctor listed on the medication bottle, who did not respond. S1 stated that the found medication had been prescribed to R1 by a surgeon on 7/16/2025. S1 was unsure how the bottle came to be in R1’s room. The medication bottle contained fourteen tabs when it was removed from R1’s room. Staff administered these fourteen tabs to R1 between 9/6/2025 and 9/17/2025.

Based on the LPA’s interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted with Emily Parker and a copy of this report was provided, along with appeal rights.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250926085746
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: 10/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2025
Section Cited
CCR
87208(a)
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87208(a) Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation…The licensee shall operate the facility in accordance with the terms specified in the plan…
This requirement is not met as evidenced by:
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The Licenseee will discipline the staff involved in the improper administration of the narcotic;
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Based on interview & record review, staff did not follow facility’s Plan of Ops re: that caregivers receive training in proper handling of meds, that meds be centrally stored along w/ its record, that a physician order be on file, which poses an immediate health, safety and personal rights risk to residents in care.
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The Licensee will provide training for all Med Techs regarding administration of narcotics,and the procedures for handling medication without orders and for obtaining the needed orders.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
09/26/2025 and conducted by Evaluator Ellen Lindstrom
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250926085746

FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:LACY VINCENTFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:114CENSUS: 83DATE:
10/01/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Emily Parker, Memory Care DirectorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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3
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Staff did not seek timely medical attention for resident.
INVESTIGATION FINDINGS:
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On 9/30/3035, Licensing Program Analyst (LPA) Triel Ellen Lindstrom visited the facility unannounced to open this complaint. LPA Lindstrom met with Emily Park, Memory Care Director, and explained the purpose of the visit. The purpose of the visit was to open the complaint, interview staff, review records, and deliver findings.

Allegation: Staff did not seek timely medical attention for resident.
LPA Lindstrom reviewed an Unusual Incident/Injury Report (LIC624) that was submitted to the Department by the Administrator on 9/25/2025. This report stated that a resident (R1) was administered a narcotic medication between 9/6/2025 - 9/17/2025 without a prescription order. This medication had been found and removed from R1’s room by staff on 9/4/2025. At the time of its discovery, R1 was already taking a prescribed narcotic pain medication. When staff began to administer the medication found on 9/4/2025 as well, they alternated between the prescribed medication and the medication without an ord
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250926085746
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: 10/01/2025
NARRATIVE
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throughout the day. On 9/13/2025, staff (S3) administered both pain medications during the same medication pass.

On 9/29/2025, LPA Lindstrom interviewed two staff (S3 and S4) about the incident reported in the LIC624. S3 stated that they had never heard R1 indicate they felt unwell or symptomatic because of pain medication, nor had they ever thought that R1 needed medical attention for the side effects of pain medication. S3 stated that R1 could be a little sleepy and that they were very insistent about getting their pain medication. S4 stated that when R1 first moved in, they reported not liking how the pain medication made them feel, but then never mentioned it again. S4 stated that they never observed any negative side effects or heard R1 express anything negative about pain medication between 9/6/2025 – 9/17/2025.

Based on interviews, observations, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5