079200801-5-23-2023-15-AS-HHUL-CTXPB2-20230721110937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:04:54 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
02/17/2022 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220217095906

FACILITY NAME:	WESTMONT OF PINOLE		FACILITY NUMBER:	079200801
ADMINISTRATOR:	JOSEPHINE DAVIS		FACILITY TYPE:	740
ADDRESS:	2850 ESTATES AVE		TELEPHONE:	(510) 758-1122
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY:	100	CENSUS: 61	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Benjie Doctolero, Executive Director		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Resident sustained an injury while in care.
Staff handled resident in a rough manner.
Resident left in soaked diaper for an extended period of time.
Staff did not ensure resident is fed.
Staff do not safeguard resident's personal items.

INVESTIGATION FINDINGS:

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On 5/23/2023 at 9:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Executive Director, Benjie Doctolero.

During the course of investigation, LPA interviewed 3 residents, 8 staff, 2 witnesses, and complainant. LPA also obtained and reviewed incontinence care procedure, physician's report, service plan, emergency information, and care notes.

Resident sustained an injury while in care.
Interview with staff revealed there were no injuries observed on R2. Service plan dated 11/19/2021 indicates that R2 overall skin condition was normal.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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-20220217095906

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 PINOLE	FACILITY NUMBER: 079200801
	VISIT DATE: 05/23/2023

NARRATIVE

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Staff handled resident in a rough manner.
Interview with staff revealed no one witnessed resident being handled in a rough manner. There were no incident reports or care notes supporting resident was handled in a rough manner.

Resident left in soaked diaper for an extended period of time.
Service plan dated 11/19/2021 indicates that R2 will be checked every 2 hours for toileting needs. Interview with staff revealed that residents are checked 1-2 hours for incontinence care. Staff stated there were no incidents where R2 was left in soaked diapers for an extended period of time.

Staff did not ensure resident is fed.
Service plan dated 11/19/2021 indicated that R2 does not require assistance with meal consumption. Interview with staff revealed that R2 eats slow and staff would encourage R2 to eat. Staff stated that R2 was always fed.

Staff do not safeguard resident's personal items.
Residents and family were instructed to put names on the clothing and on the inventory list. However, it has been observed that some resident's clothes does not have their name on it. R2 did not have an inventory list on file.

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

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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