<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601300
Report Date: 02/16/2024
Date Signed: 02/16/2024 05:28:03 PM


Document Has Been Signed on 02/16/2024 05:28 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: 83DATE:
02/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Scott Shahade, Executive DirectorTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/16/2024 at 2:40pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived unannounced to conduct a Case Management visit for an incident that occurred on 2/16/2024. LPAs met with Scott Shahade, Executive Director (ED), and explained the purpose of the visit.

While LPAs were conducting a continuation for an annual visit LPAs were informed by the ED that an incident occurred at approximately 6:00am this morning between Staff 2 (S2) and Resident 1 (R1). ED stated S2 was trying to prevent R1 from eloping, words were exchanged, and S2 pushed R1's walker causing R1 to fall. R1 was taken to the Sutter hospital. S2 was suspended pending investigation. Around 2:30pm LPAs were informed that R1 sustained a fracture and had returned to the facility.

LPAs obtained a copy of the incident report, the SOC341, and discharge summary visit. For S2 LPAs obtained training records, application, and contact information. For R1 LPAs obtained admission agreement, hospice care plan, physician's report, identification and emergency contact, progress notes, and last assessment.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1