075601300-10-12-2021-15-AS-KHOS-C86JW8-20211026072419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601300
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:05:22 PM

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
11/14/2019 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20191114160548

FACILITY NAME:	WESTMONT OF BRENTWOOD		FACILITY NUMBER:	075601300
ADMINISTRATOR:	LYDIA J HERTZLER		FACILITY TYPE:	740
ADDRESS:	450 JOHN MUIR PKWY		TELEPHONE:	(925) 516-8006
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	200	CENSUS: 108	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Tasha Santiago/Community Relations Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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-Insufficient staff to meet residents' needs.

-Staff not meeting residents diapering needs.

-Facility failed to provide laundry service in timely manner.

-Staff not administering medications to residents in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegations. LPA met with Community Relations Director Tasha Santiago. LPA also spoke with Operations Specialist/Interim Executive Director Patrick Frazier over the phone. LPA informed both of them the purpose of LPA's visit.

It was alleged that the facility was short staffed resulting to staff unable to meet residents' needs such as assistance with activities of daily living (ADLs) and laundry needs. It was further alleged that due to short-staffing, staff were not meeting residents' diapering needs. Staff in a particular work shift were not able to administer medications in a timely manner to residents.

During the course of investigation, the Department obtained copies of staff schedule, resident roster, reviewed resident records and conducted interviews.
..........continued on 9099C

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: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20191114160548

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: 10/12/2021

NARRATIVE

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Six out of 9 staff indicated facility was short-staffed. Five out of 9 staff stated residents were wet/soaked with urine, 5 out of 9 staff said resident needs such as assistance with ADLs and laundry, shower were not met as a result of short-staffing. Three of the staff interviewed who were med-techs indicated the residents’ medications were not administered in timely manner.

Based on information gathered, the allegations are substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Patrick Frazier over the phone and with Tasha Santiago.

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: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20191114160548

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: 10/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/26/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings..... and grounds......	1 2 3 4 5 6 7	Executive Director (ED) to ensure sufficient staffing. ED to have the following submitted by 10/26/2021: 1. LIC500 Personnel Report 2. Staff schedules for assisted living and memory care units,
	8 9 10 11 12 13 14	-This requirement is not met as evidenced by: -Based on intervews, the licensee did not comply with the section above for not having sufficient staff to meet residents' needs such as assistance with ADLs, laudry and diapering needs which posed potential health and personal rights risks to persons in care.	8 9 10 11 12 13 14
Type B 10/26/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) .....(5) The licensee shall assist residents with self-administered medications as needed. -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director to ensure residents' medications are administered timely. In addition, ED to in-service the staff and submit copy of training topics with attendees signatures by 10/26/2021.
	8 9 10 11 12 13 14	-Based on interviews, the licensee did not comply with the section above for not having residents' medications administered in a timely manner which posed potential health risks to persons in care.	8 9 10 11 12 13 14

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: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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