075601300-12-22-2022-15-AS-KHOS-CMKP9P-20221229100729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601300
Report Date: 12/22/2022
Date Signed: 12/22/2022 03:55:34 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
06/03/2020 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20200603114825

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: 96	DATE:	12/22/2022
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Agustin San Maniego, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not ensure resident feels safe in the facility.
Staff did not protect resident from sustaining injury.
Staff did not seek emergency medical services for resident.
Staff did not provide proper care for resident.

INVESTIGATION FINDINGS:

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On 12/22/2022, Licensing Program Analyst (LPA) L.Ibo arrived unannounced to deliver findings for the above allegations and met with Administrator Agustin San Maniego. LPA explained to Administrator the purpose of visit.

On 06/12/2020, LPA Grace Luk conducted initial 10-day visit, obtained records and interviewed Staff 1 (S1). On 08/01/2022, complaint was reassigned to LPA L. Fontanilla.

During the course of investigation, LPA L. Fontanilla did the following: reviewed records including but not limited to resident assessment/reassessment, Service Plan, admission agreement, incident reports, Physician’s Report and interviewed 4 out of 8 staff.

...Continued to LIC9099....

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200603114825

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: 12/22/2022

NARRATIVE

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Staff did not ensure resident feels safe in the facility.

Based on interviews conducted, Resident 1 (R1) was moved from Assisted Living to Memory Care Unit (Compass Rose) due to Dementia diagnosis

Staff interviewed state R1 and R1’s husband who were living in the same apartment in the assisted living argued a lot due to R1’s behavior. Staff 3 (S3) state there was an incident when R1’s husband pushed R1 during an argument.

LPA obtained a copy of an undated letter from former Executive Director Candice Moses and Physician’s Report addressed to R1’s husband. The letter states that due to R1’s diagnosis of Dementia, R1 needed to be moved to the Memory Care because R1 needed specialized care in a safe environment. The letter also states. “I assure you that she is happy and content and is getting all the attention that she needs and deserves.”

LPA L. Fontanilla reviewed R1’s Service Plan dated 04/23/2020. Service Plan indicates, “Psycho/social – additional support at night. Resident requires additional support at night due to disturbed sleep or other needs. Support at night needed.”

A review of SOC 341 filed by formed Director state R1 was screaming for help. When staff responded, staff noted, “R1 was backed up to the wall on the bed and R1’s husband was standing over R1 screaming. R1’s husband took away R1’s pendant and did not allow R1 access to wheelchair.” Brentwood Police Department was notified.

... Continue LIC9099C...

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200603114825

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: 12/22/2022

NARRATIVE

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Staff did not protect resident from sustaining injury.

LPA interviewed 4 out of 8 staff who worked with R1 in assisted living and Memory Care unit. Staff interviewed state R1 had fall incidents due to R1 trying to transfer without asking staff for assistance. S4 states R1 would scream for help but when staff arrives, R1 would tell staff to go away.

A review of incident reports for April and May 2020 indicates R1 slipping out of bed/wheelchair or trying to get a pet from the floor as reasons for the falls. The reports indicate R1 did not sustain injury.

R1’s Needs and Services Plan dated 04/30/2020 show that R1 was assessed as Moderate Risk for Falls and would need assistance with bathing, transferring, grooming, dressing and stand-by assistance with transfers to and from bed, chair, toilet as needed.

Staff did not seek emergency medical services for resident.

Staff interviewed state since R1 was on hospice, the hospice agency was notified for any incident regarding R1.

Internal incident reports reviewed indicate R1’s doctor, hospice nurse and son were notified for the fall incidents that occurred between April and May 2020.

Staff did not provide proper care for resident.

LPA reviewed R1’s Service Plan dated 4/23/2020. Service Plan shows that R1 was assessed as Moderate Risk for Falls and would need assistance with bathing, transferring, grooming, dressing and stand-by assistance with transfers to and from bed, chair, toilet as needed.

Staff interviewed state that R1 was assisted with activities of the daily living (ADLS) as indicated in the Needs and Services Plan.

Based on interviews conducted and records reviewed, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

There is no deficiency noted. A copy of this report was provided to Administrator Agustin San Maniego.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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