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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601300
Report Date: 03/30/2021
Date Signed: 03/30/2021 04:58:04 PM

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:MOSES, CANDICEFACILITY TYPE:
740
ADDRESS:450 JOHN MUIR PKWYTELEPHONE:
(925) 516-8006
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:200CENSUS: DATE:
03/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kyle Ruth Islas TIME COMPLETED:
01:00 PM
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On 03/30/2021, Licensing Program Analysts (LPA) Leslie Ibo conducted a Case Management Health with Administrator Kyle Ruth- Islas, in relation to the incident report received on 03/26/2021, S1 gave R1 un-prescribed medication. LPA explained that due to Shelter in Place Order and directive from management to telework, inspection will be done via phone call.

During the interview with Administrator, S1 was placed on administration leave and facility is conducting internal investigation. Resident was placed on one on one observation for monitoring if there is any change in behavior, physician was notified, law enforcement was notified, and Ombudsman was notified. R1 is on stable condition.

LPA will need to conduct follow up visit, LPA requested for documents such as LIC602, MAR, documents regarding facility internal investigation. Administrator agreed to send the requested document via email.

Exit interview conducted. Appeal Rights and a copy of this report emailed.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
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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