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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601300
Report Date: 09/30/2020
Date Signed: 10/01/2020 10:31:05 AM

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: 119DATE:
09/30/2020
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Patrick Frazier, Robyn Mendez & Kyle Ruth- Islas TIME COMPLETED:
12:00 PM
NARRATIVE
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On September 30, 2020 at 10:15am, Licensing Program Analyst (LPA) Leslie Ibo conducted an announced tele-visit Case Management visit regarding 3 different incidents reported to CCLD. Due to governor’s shelter in place order, a tele visit via Facetime was conducted. LPA spoke with Patrick Frazier, Robyn Mendez (nurse) and Kyle Ruth-Islas the Executive Director and explained the purpose of the tele-visit.

On 9/18/2020, an unusual incident report was received at the CCL office regarding medication error. R1 was given R2’s medication. During the televisit, Administrator confirmed with LPA the error committed by S1. R1 was sent to the hospital for observation and notified R1’s family and primary doctor. Per facility nurse Robyn Mendez, R1 is doing good and no reaction from medication error. S1 was retrained on medication administration and preventing medication errors.

On 8/20/2020, R3 was in his apartment when the spouse contacted the staff and found the resident lying on the floor, resident stated that he stood up and lost his balance and fell backwards. Staff assessed resident and called 911 to transport to emergency room. R3 is back in the facility after staying at rehabilitation facility from pelvic fracture.

On 9/14/2020, R4 was found on the floor by the staff with skin tear to right of her leg, R4 complained of pain. The staff called 911 to transport the resident and now back to the facility. Facility nurse Robyn reassessed the resident and implemented a standard fall prevention plan.

The following deficiency was cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WESTMONT OF BRENTWOOD
FACILITY NUMBER: 075601300
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2020
Section Cited

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Incidental and Dental Care:(c) ...facility staff designated by the licensee shall be permitted to assist the resident with self-administration...(2)Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidence by:
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Based on LPA interview and records review: S1 gave the wrong medication to R1, the resident was sent to the hospital for observation and no known side effect from the medication error.
This poses a potential threat to the health and
safety of clients 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2020
LIC809 (FAS) - (06/04)
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