<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606597
Report Date: 08/13/2023
Date Signed: 08/13/2023 09:39:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2022 and conducted by Evaluator Melissa Ruiz
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220623124134
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:0CENSUS: 0DATE:
08/13/2023
UNANNOUNCEDTIME BEGAN:
07:30 PM
MET WITH:Roda GarabatoTIME COMPLETED:
09:37 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect required a resident to be hospitalized while in care
Staff did not keep a resident free from bedbugs
Staff did not address a resident's hygiene needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/13/2023, Licensing Program Analyst (LPA) Melissa Ruiz drafted this report to address the allegations listed above for a subsequent complaint investigation. The facility has been closed as of June 8, 2023; therefore, the complaint report will be submitted to the Licensee, Roda Garabato by e-mail for electronic signature.

Allegation: Staff neglect required a resident to be hospitalized while in care.
It was alleged that around June of 2022, the Emergency Department staff and overseeing physician observed resident #1 to have signs of negligence such as bed bugs and feces on R1’s body. Additionally, R1 had an untreated UTI that led to the hospitalization of R1. During an initial complaint visit conducted by LPA Stamps on 6/24/2022, the designee Dori Cambiado was unable to provide R1’s complete file, such as physician reports (LIC602), appraisal needs and service plans, and or medication records. Additionally, the facility was cited on 9/28/2022 for complaint control #31-AS-20220921115643 for not having LIC622’s for at least one resident. Due to incomplete, missing, or outdated records for R1, that are relevant to R1’s daily care and health, the allegation listed above is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 31-AS-20220623124134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2023
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
1
2
3
4
5
6
7
Facility has closed as of June, 2023.
8
9
10
11
12
13
14
This requirement has not been met as evidenced by: The licensee failed to ensure staff provided adequate observation regarding R1’s change in condition, and adequate records pertaining to R1’s health and care which led to R1’s hospitalization. This poses as an immediate health and safety risk to the resident in care.
8
9
10
11
12
13
14
Type A
08/13/2023
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303(a) Maintenance and Operation:
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
1
2
3
4
5
6
7
Facility has closed as of June, 2023.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:

Based on interviews and observation, the facility has an infestation of bedbugs, which poses an immediate risk to the health and safety to the residents in care .
8
9
10
11
12
13
14
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: 08/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220623124134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2023
Section Cited
CCR
87307(a)(3)(D)
1
2
3
4
5
6
7
87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function…in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper.

1
2
3
4
5
6
7
Facility has closed as of June, 2023.
8
9
10
11
12
13
14
This requirement has not been met as evidenced by:

The licensee failed to ensure R1’s hygiene needs were met by not providing adequate assistance or items related to hygiene such as hand soap, paper towels, body soap, or shampoo. This poses a potential health and safety risk or personal rights risk to residents in care.

8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220623124134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 08/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegations:

Staff did not keep a resident free from bedbugs

Staff did not address a resident's hygiene needs

It was alleged that a resident (R1) was taken to the hospital, where bed bugs and feces were in their nails and feet. On 6/24/2022, LPA Stamps conducted an initial 24-hour visit and LPA Stamps was unable to gather documents relevant to this complaint investigation. On 9/29/2022, the facility was cited under complaint control #31-AS-20220927171106, where the allegation “Staff are not ensuring that the facility is free from bed bugs” was deemed substantiated. On that day, LPA conducted a physical plant tour and LPA observed bed bugs on beds and blankets. Additionally, on that day, Staff #1 (S1) admitted to having a bed bug problem for over 1 year and that they were trying to treat the bedbugs themselves. Regarding resident’s hygiene needs, on 6/24/2022, LPA Stamps conducted a physical plant tour and LPA Stamps did not see handwashing soap, paper towels, or body soap in two resident bathrooms. LPA Stamps observed one shampoo bottle in one of the bathrooms and it was almost empty, and the contents seemed to have been refilled with water. Due to the previous substantiated allegation on complaint #31-AS-20220927171106 and facility not providing adequate and or sufficient hygiene supplies to ensure resident’s hygiene needs are met, based on LPA’s observations, the allegations listed above are deemed substantiated.

Deficiencies issued, per CA Code of Regulations, Title 22. Report sent via e-mail for electronic signature. Appeal rights issues.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4