075601300-12-22-2021-15-AS-HHUL-CA5N88-20211228091352

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601300
Report Date: 12/22/2021
Date Signed: 12/22/2021 12:03:25 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
04/08/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200408113511

FACILITY NAME:	WESTMONT OF BRENTWOOD		FACILITY NUMBER:	075601300
ADMINISTRATOR:	MOSES, CANDICE		FACILITY TYPE:	740
ADDRESS:	450 JOHN MUIR PKWY		TELEPHONE:	(925) 516-8006
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	200	CENSUS: 108	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Agustin Samaniego, Administrator		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Resident sustained unexplained bruising and wounds

Resident was left in a wheelchair for long periods of time

INVESTIGATION FINDINGS:

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On 12/22/2021 at 10:25AM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the above allegations. LPA met with Agustin Samaniego, Administrator and explained the reason for the visit.

During the course of the investigation, LPA Y. Flores-Larios interviewed staff and witness, obtained and reviewed documents. On the allegation resident sustained unexplained bruising and wounds. LPA L. Hall reviewed Resident’s 1 (R1’s) visits to the doctor from 09/11/2019 to 10/09/2019 and four (4) of the visits were related to R1’s lower leg. LPA reviewed documentation for R1’s physician communication and narrative charting.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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-20200408113511

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: 12/22/2021

NARRATIVE

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Continued from LIC9099.

Documentation was sent to R1’s physician on 11/05/2019 from staff regarding a cut, bruising, and redness that was forming on R1’s leg. On 01/17/2020 the narrative charting indicated R1 had some unopened wounds on legs, but wounds were red and inflamed and on 02/17/2020 charting indicated redness on both legs.

On the allegation resident was left in a wheelchair for long periods of time. LPA reviewed medical documentation that indicated R1 had a pre-existing condition before being admitted to the facility. R1’s physician was contacted by staff and R1 was prescribed medication to better her diagnosis.

During visit LPA collected the following documents: resident roster and physician's report.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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