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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601300
Report Date: 07/14/2020
Date Signed: 07/14/2020 12:25:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WESTMONT OF BRENTWOODFACILITY NUMBER:
075601300
ADMINISTRATOR:MOSES, CANDICEFACILITY TYPE:
740
ADDRESS:450 JOHN MUIR PKWYTELEPHONE:
(925) 516-8006
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:200CENSUS: DATE:
07/14/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Oreisha Morgan & Patrick Frazier TIME COMPLETED:
11:35 AM
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On 07/14/20 at 10:54 AM, Licensing Program Analysts (LPAs) Leslie Ibo and Luisa Fontanilla conducted tele-visit with Resident Services Director Oreisha Morgan and Patrick Frazier Operation Specialist. LPAs explained that the reason for the tele-visit is regarding an incident report submitted by the facility and received by LPAs on July 12, 2020. Due to COVID-19 shelter in place order issued on March 17, 2020 by the Governor, Administrator was not physically available to sign this report.

Resident Services Director stated the incident happened on 6/28/2020 where R1 fell on her right side and R1 was sent to the hospital.


LPAs advised resident services director that each incident needs to be reported to CCL within 24 hours and a written report (LIC 624) submitted within 7 days.

Deficiency cited for reporting requirements under Advisory Notes (LIC 9102 - Technical Violation).
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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