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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601300
Report Date: 04/06/2021
Date Signed: 04/06/2021 02:27:06 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: 108DATE:
04/06/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Kyle Ruth Islas & Robin Mendez TIME COMPLETED:
02:40 PM
NARRATIVE
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On 04/06/2021, Licensing Program Analysts (LPA) Leslie Ibo conducted a Case Management with Administrator Kyle Ruth- Islas and Residence Services Director Robyn Mendez, 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.

This is continuation of case management conducted on 03/30/2021, LPA conducted interview and records review, based on facility internal investigation document S1 admitted giving medication to R1, but based on medication records and Physician's order the medication was not prescribed to R1. Facility then provided one on one observation to R1 upon receiving the incident report from S2 & S3 . There was no reported side effect from the medication that was given to R1. Law enforcement, ombudsman & R1's family was informed about the incident. S1 was terminated from the facility effected 03/31/2021. Administrator will hire a third party company to provide training for all medication technician.

Deficiency was cited from the California Code of Regulations, Title 22. Repeat violation, civil penalty of $250.00 assessed today.

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: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2021
Section Cited

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87465 Incidental Medical and Dental Care:(c) ...facility staff designated by the licensee shall be permitted to assist the resident with self-administration...(2)Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidence by:
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Based on LPA interview and records review: S1 admitted giving medication to R1, but based on medication records and Physician's order the medication was not prescribed to R1. R1 was placed on one on one observation after the incident, no known side effect was noted to R1. This poses a potential threat to the health and safety of clients in care.
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 a copy of the training in-service will need to be submitted on before 04/09/2021. A $250.00 assess on this day.

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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2021
LIC809 (FAS) - (06/04)
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