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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601300
Report Date: 02/05/2025
Date Signed: 02/05/2025 04:49:05 PM

Document Has Been Signed on 02/05/2025 04:49 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/
DIRECTOR:		AGUSTIN SAMANIEGOFACILITY TYPE:
740
ADDRESS:450 JOHN MUIR PKWYTELEPHONE:
(925) 516-8006
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 200TOTAL ENROLLED CHILDREN: 0CENSUS: 101DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Scott Shahade, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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On 02/025/2025 at 1:00PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and C. Fowler, arrived unannounced to continue the 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 approved for 190 non-ambulatory and 10 bedridden residents. Facility has hospice waiver for 20 residents.

LPAs toured the facility with Administrator including but not limited to apartments, bathrooms, kitchen, common area and outside. LPAs toured apartments #002, #015, #113, #117 and #145. All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/24/2024. Emergency disaster plan last updated 02/01/2024. First aid kit was observed to be complete. Fire drill was last conducted on 01/15/2025.

Continued LIC809C.
Harpreet HumpalTELEPHONE: (510) 285-3928
Tonica Syess-GibsonTELEPHONE: (510) 414-0641
DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WESTMONT OF BRENTWOOD
FACILITY NUMBER: 075601300
VISIT DATE: 02/05/2025
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Continued from LIC809.


LPAs reviewed five (5) staff records, five (5) resident record and they were complete.

LPA requested the following documents to be submitted to CCLD by 02/12/2025.

· 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 visit.

Exit interview conducted. A copy the appeal rights and the report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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