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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601300
Report Date: 02/02/2024
Date Signed: 02/02/2024 05:03:19 PM


Document Has Been Signed on 02/02/2024 05:03 PM - It Cannot Be Edited

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:AGUSTIN SAMANIEGOFACILITY TYPE:
740
ADDRESS:450 JOHN MUIR PKWYTELEPHONE:
(925) 516-8006
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:200CENSUS: 97DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Scott Shahade, Executive DirectorTIME COMPLETED:
05:10 PM
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On 2/2/2024 at 3:10pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson, arrived unannounced to conduct 1-Year Annual Required inspection visit. LPAs met with Executive Director (ED), Scott Shahade, and explained the purpose of the visit. The facility’s fire clearance was 190 non-ambulatory and 10 bedridden residents. Facility has hospice waiver for 18 residents.

LPAs reviewed 10 staff files.

LPA requested the following documents to be submitted to CCLD by 2/9/2024.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

No deficiencies cited during today's visit.

LPAs explained to ED that the inspection will have to be continued at a later date.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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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