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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606597
Report Date: 02/16/2023
Date Signed: 02/16/2023 02:52:22 PM


Document Has Been Signed on 02/16/2023 02:52 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:WESTPORT HOMEFACILITY NUMBER:
197606597
ADMINISTRATOR:REX RETOLADOFACILITY TYPE:
740
ADDRESS:10252 EAST AVENUE STELEPHONE:
(661) 944-5779
CITY:LITTLEROCKSTATE: CAZIP CODE:
93543
CAPACITY:20CENSUS: 12DATE:
02/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Russel Cambiado - staffTIME COMPLETED:
03:00 PM
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On 2/16/2023, Licensing Program Analysts (LPAs) Melissa Ruiz and Angela Panushkina arrived at the facility to conduct an unannounced complaint investigation, control number 31-AS-20230208122607. Upon arrival, LPAs were greeted by staff and allowed entrance to the facility. The purpose of this Case Management – Deficiencies report is to address deficiencies observed by LPAs throughout the course of complaint investigations.

On 9/28/2022, LPA Ruiz conducted a visit for complaint investigation #31-AS-20220921115643. During that visit, facility was cited under Title 22 Regulation, Section 87458(b)(3), due to no LIC622 (physician report) on file for residents, specifically one resident (R2). On that report issued, the Plan of Correction indicated that updated LIC622’s were to be submitted by 9/30/2022 for all residents in care, including R2. On 2/1/2023, staff Dori Cambiado, on behalf of Licensee Roda Garabato faxed a LIC622 to the Woodland Hills Regional Office for R2, signed and dated by Doctor Abdul Rab Kahn on 9/25/2022.

On 2/15/2023, LPA spoke to Dr. Khan over the phone, where Dr. Khan confirmed that he had never seen the patient, nor completed and signed the LIC622. Additionally, Dr. Khan’s staff Lolita, told LPA that there was no patient with R2’s name in their database. Due to record review and interviews conducted, Licensee has made false claims or statements by submitting a false LIC622 report. Deficiency issued per CA Code of Regulations Title 22. Appeal rights issued, report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/16/2023 02:52 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: WESTPORT HOME
FACILITY NUMBER: 197606597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2023
Section Cited

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87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
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The licensee shall submit proof of scheduling a physician visit for R2 byt the POC due date. Additionally, Licensee to submit a LIC622 completed by the physician. Proof of POC is to be submitted by e-mail to MELISSA.RUIZ@DSS.CA.GOV
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Based on interviews and record review, the licensee did not comply with the section cited above due to filling out and signing a LIC622 for R2 which was false because R2 was never seen by the physician on LIC622 which poses an immediate health, safety or personal rights risk to persons in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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