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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004795
Report Date: 04/14/2022
Date Signed: 04/14/2022 10:50:26 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220103080936
FACILITY NAME:WESTMINSTER VILLAFACILITY NUMBER:
306004795
ADMINISTRATOR:PATTY OSUNAFACILITY TYPE:
740
ADDRESS:13881 DAWSON STREETTELEPHONE:
(714) 534-7880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:200CENSUS: 121DATE:
04/14/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Patty Osuna and and Alex JonesTIME COMPLETED:
11:08 AM
ALLEGATION(S):
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Staff gave resident discontinued medication
Staff refused to order resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Administrator Patty Osuna and explained the reason for the visit. Care Coordinator Alexis Jones was present as well.

During the investigation, LPA toured the facility, reviewed and obtained pertinent documentation such as medication administration records and hospital paperwork as well as interviewed staff and witness. Regarding the allegations that staff gave resident discontinued medication and staff refused to order resident's medication, the investigation revealed the following: R1 was hospitalized on 10/20/2021 for psychiatric evaluation and returned to the facility on 11/01/2021 with new medication orders. Per interviews with witness and facility staff, facility contacted the pharmacy with revised orders by fax on 11/01/2021 when resident returned. Facility provided proof of fax to LPA. Resident was sent back out to the hospital on 11/03/2021 and has not returned to the facility to date. Witness indicates an antibiotic medication for a dental infection was not filled by the facility however in interviews, CONT ON LIC 9099C DATED 04/14/2022
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
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 2
Control Number 22-AS-20220103080936
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WESTMINSTER VILLA
FACILITY NUMBER: 306004795
VISIT DATE: 04/14/2022
NARRATIVE
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witness cannot determine the timeline. Facility provided proof of medication order for a dental infection dated 08/24/2021 and medication administration record verifies resident was given the medication. Therefore the allegations are deemed UNFOUNDED, meaning the allegations are was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2