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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601300
Report Date: 12/22/2022
Date Signed: 12/22/2022 03:51:05 PM


Document Has Been Signed on 12/22/2022 03:51 PM - It Cannot Be Edited

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:AGUSTIN SAMANIEGOFACILITY TYPE:
740
ADDRESS:450 JOHN MUIR PKWYTELEPHONE:
(925) 516-8006
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:200CENSUS: 96DATE:
12/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:AGUSTIN SAMANIEGO, Administrator TIME COMPLETED:
03:15 PM
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On 12/22/2022, Licensing Program Analysts (LPA) Leslie Ibo conducted a Case Management with Administrator Agustin San Maniego, in relation to the incident report received on 12/13/2022, R1 was sent out via 9-1-1 when staff member observed an open wound on coccyx area.

Based on interview and records review, R1 was independent resident no care was being provided by staff not until 12/08/2022 when R1 had change of condition. R1 currently at a rehabilitation facility and currently no update. LPA requested from Administrator to submit new LIC602 and other documentation regarding the open wound.

Due to insufficient information at this time, LPA will conduct additional interviews and documents reviews. LPA will return to the facility.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
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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