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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 10/29/2025
Date Signed: 10/29/2025 10:50:33 AM

Unsubstantiated


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
08/05/2025 and conducted by Evaluator Ellen Lindstrom
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250805162157
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: DATE:
10/29/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Emily Parker, Memory Care DirectorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Lack of Supervision led to resident sustaining serious injury from fall.
INVESTIGATION FINDINGS:
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On 10/29/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to deliver complaint findings. LPA Lindstrom identified herself, met with the Memory Care Director, and explained the purpose of the visit.

Allegation: Lack of Supervision led to resident sustaining serious injury from fall.
Resident 1 (R1) had an unwitnessed fall on 7/31/2025 that resulted in a laceration to the forehead. The resident was transported to the hospital for treatment and discharged on 8/1/2025. R1 had a second unwitnessed fall on 8/8/2025 that resulted in scalp wounds and shoulder and rib fractures. The resident was transported to the hospital for treatment. On 8/10/2025, the resident was placed on hospice care and on 8/12/2025, the resident was moved to another senior care facility. On 8/13/2025, the resident passed away. According to R1’s Death Certificate, the resident’s cause of death was respiratory failure and Alzheimer’s disease.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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 2
Control Number 27-AS-20250805162157
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: 10/29/2025
NARRATIVE
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R1’s Physician’s Report, dated 1/17/2024, stated that R1 was non-ambulatory based on mental condition, but that R1 could transfer independently to and from bed. Community Care Licensing Division (CCLD) personnel interviewed R1’s Responsible Party. The Responsible Party stated that R1 walked without assistance before moving to the facility in Spring 2025 and used a walker provided by staff after moving in. CCLD personnel interviewed four facility staff. Staff stated that R1 was able to walk unassisted with a walker and transfer from bed to the walker independently. Staff and R1’s Responsible Party stated that when R1 returned to the facility after the 7/31/2025 fall, R1 continued to be able to walk unassisted with a walker. Staff stated that there was no lack of supervision. Staff frequently saw R1 enjoying walking around the facility and observed R1 every two hours during rounds and approximately every thirty minutes during informal checks.

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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2