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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208908
Report Date: 07/28/2022
Date Signed: 07/28/2022 02:40:31 PM


Document Has Been Signed on 07/28/2022 02:40 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:WESTMONT OF FRESNOFACILITY NUMBER:
107208908
ADMINISTRATOR:HAMILTON, PAMELAFACILITY TYPE:
740
ADDRESS:7442 & 7468 N MILLBROOK AVETELEPHONE:
(858) 729-6720
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:155CENSUS: 88DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Erik V. SchukTIME COMPLETED:
02:22 PM
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On 07/28/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Erik Schuk. Facility has one central entry and exit and has implemented a sign in policy/symptom screening for visitors.

Facility tour conducted. Facility did not have obstructions blocking pathways, entrances, and exits. No fire clearance issues observed during this inspection. Staff observed to be wearing facial coverings. Residents encouraged to wear facial coverings in common areas and when out of the facility. High traffic areas are sanitized at least once a day. LPA observed signs promoting cough sneeze etiquette, hand-washing, and social distancing. LPA observed hand-sanitizer dispensers at the front entrance and elevator.

LPA observed hand-washing signs in facility bathrooms. LPA toured the following resident rooms: 105, 112, 117, 120, 134, 224, A3, B4, B8, E1, E8, and F8. Bedrooms at this facility are single occupant. In room 134, LPA observed medications and knives to be accessible in the apartment. LPA observed a 30 day supply of medications. LPA observed a supply of PPE and cleaning supplies. Staff records reviewed for good health. Residents files observed to have updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 08/11/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A) and Surety Bond

CONTINUED TO 809C

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: WESTMONT OF FRESNO
FACILITY NUMBER: 107208908
VISIT DATE: 07/28/2022
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Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, on the attached 809D.

An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Erik Schuk, whose signature on this form confirm receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2022 02:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: WESTMONT OF FRESNO
FACILITY NUMBER: 107208908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed medications in room 134 to be accessible to 2 residents in the apartment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for the above regulations are met to the Fresno CCL office by the POC due date.
Type A
Section Cited
CCR
87309(a)
87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed a small container of knives on a cabinet in room 134 accessible to 2 residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements of the above regulation are met to the Fresno CCL office by the POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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