075601300-9-2-2022-15-AS-KHOS-CKAQM4-20221017121655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601300
Report Date: 09/02/2022
Date Signed: 09/02/2022 04:22:16 PM

Unsubstantiated

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
09/20/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210920110908

FACILITY NAME:	WESTMONT OF BRENTWOOD		FACILITY NUMBER:	075601300
ADMINISTRATOR:	KYLE RUTH-ISLAS		FACILITY TYPE:	740
ADDRESS:	450 JOHN MUIR PKWY		TELEPHONE:	(925) 516-8006
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	200	CENSUS: 96	DATE:	09/02/2022
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	AGUSTIN SAMANIEGO, Executive director		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff did not respond to resident's signal system in a timely manner resulting in resident falling.
Staff did not follow resident's care plan.
Staff did not meet resident’s needs.

INVESTIGATION FINDINGS:

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On 5/2/2022 at 9:30AM, Licensing Program Analysts (LPA) L. Ibo arrived unannounced to complete investigation regarding the allegations above. LPA meet with Executive director Agustin San Maniego and explained the purpose of the visit.

During the investigation, LPA conducted interview and records review. LPA obtained and reviewed resident's file including but not limited to; physician's report, medication administration report, hospice records and physician’s communication log.

Staff did not respond to resident's signal system in a timely manner resulting in resident falling.
Based on interview and records review, staff response time is between 5-10mins. Based on records review, staff responded to resident (R1) pendant call on a reasonable time with an average response time of 6 minutes.
…Continue to LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

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-20210920110908

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: 09/02/2022

NARRATIVE

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Staff did not follow resident's care plan.
During the course of investigation, on August 2021, R1 had a change of condition, a new care plan was generated with higher level of care, based on interview with the staff, as soon as R1 had changed of condition the management team inform all the staff to make sure that staff follows the new care plan. Staff was also informed via communication log on what is the new care plan for R1.

Staff did not meet resident’s needs.
During investigation, staff was in constant communication with R1’s medical team and hospice agency for any change in condition. Based on staff interview and records review, staff was constantly checking R1 at least every two hours, staff were repositioning R1 at least every two hours, staff also documented every time staff assisted her to the bathroom and R1’s meal intake record was also documented to ensure R1’s needs are being met.

LPA cannot interview R1 regarding the allegations above.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC9099 (FAS) - (06/04)

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