075601300-2-27-2025-15-AS-BFOG-DEG6QC-20250304200030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601300
Report Date: 02/27/2025
Date Signed: 02/27/2025 02:24:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2025 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20250221145851

FACILITY NAME:	WESTMONT OF BRENTWOOD		FACILITY NUMBER:	075601300
ADMINISTRATOR:	AGUSTIN SAMANIEGO		FACILITY TYPE:	740
ADDRESS:	450 JOHN MUIR PKWY		TELEPHONE:	(925) 516-8006
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	200	CENSUS: 103	DATE:	02/27/2025
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Jennifer Lawson/Business Office Director and Scott Shahade/Executive Director		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Staff do not ensure reporting requirements are followed.

INVESTIGATION FINDINGS:

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On this day, 2/27/25, at 11:45 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an investigation of the above allegation. LPA met with Business Office Director Jennifer Lawson, and informed the purpose of visit. Executive Director (ED) Scott Shahade arrived at around 12:00 noon.

Allegation: Staff do not ensure reporting requirements are followed.
Reporting party (RP) stated that the facility failed to report elder abuse timely to various agencies. Ombudsman was not given SOC341 elder abuse reports within the last several months relating to resident, R1. RP also stated that the facility did not report the other abuse to local law enforcement relating to another resident (R2).

....continued on 9099C (page 2)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 15-AS-20250221145851

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 02/27/2025

NARRATIVE

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Page 2

During the course of investigation, LPA obtained copy of resident roster and conducted interviews. LPA also reviewed the Unusual Incident Report (UIRs) and SOC341s submitted by the facility to Community Care Licensing (CCL) for R1 and R2 which showed the abuse were reported to CCL past the required timeline of 48 hours and not reported to the Ombudsman and local law enforcement. These were discussed with the ED.

ED stated the other alleged abuse incident relating to resident (R3) was reported to CCL on which a copy of SOC341 was provided by ED on this same day, 2/27/25. LPA and ED spoke to staff (S1) who stated she did not submit the LIC624 for R3 to CCL.

LPA interviewed the Ombudsman (OMD) on 2/21/25. OMD stated not receiving copies of SOC341s for R1 and R2.

Based on interviews and review of documents, the preponderance of evidence has been met, therefore, the allegation of staff do not ensure reporting requirements are followed is substantiated.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the ED.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20250221145851

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/27/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/13/2025 Section Cited CCR 87211(c)	1 2 3 4 5 6 7	87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24)hours as required by Welfare and	1 2 3 4 5 6 7	Executive Director agreed to do the following and submit proof by 3/13/25: 1. Complete the LIC624. 2. Submit the SOC341s to the local law enforcement and ombudsman. 3. In-service the staff and ensure reporting requirements are followed.
	8 9 10 11 12 13 14	Institutions Code Section 15630(b)(1)....a written report shall be sent...within two working days. -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above in not submitting the written report to the agencies within the time frame.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC9099 (FAS) - (06/04)

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