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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601300
Report Date: 04/03/2024
Date Signed: 04/03/2024 12:47:17 PM


Document Has Been Signed on 04/03/2024 12:47 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
OAKLAND ASC, 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: 93DATE:
04/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Scott Shahade Executive DirectorTIME COMPLETED:
01:00 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 04/03/2024 at 12;00PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 03/28/2024. LPAs met with Executive Director, Scott Shahade and informed him of the reason for the visit.

Based on the incident report received on 03/28/2024, resident (R1) tested positive for MRSA. Facility obtained documents regarding (R1) test results and (R1) is no longer infectious.

During visit, LPAs obtained (R1) medical documents, test results and progress notes which indicates (R1) is not infectious. Facility provided precautionary policy and procedures.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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