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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004795
Report Date: 11/06/2024
Date Signed: 11/26/2024 03:05:06 PM

Document Has Been Signed on 11/26/2024 03:05 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WESTMINSTER VILLAFACILITY NUMBER:
306004795
ADMINISTRATOR/
DIRECTOR:		PATTY OSUNAFACILITY TYPE:
740
ADDRESS:13881 DAWSON STREETTELEPHONE:
(714) 534-7880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 200TOTAL ENROLLED CHILDREN: 0CENSUS: 113DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Alexis JonesTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Eboni Bentley made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs met with Assistant Administrator (AAD) Alexis Jones and explained the purpose of the inspection.

During the inspection, LPA Gutierrez and Staff Monserrat Pasillas conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and observed the following:

This is a two-story building, licensed for one hundred non-ambulatory and one hundred ambulatory with a hospice waiver for ten. Evacuation chairs were observed at every stairway. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. There are two separate courtyard areas that include shaded sitting areas. LPA observed residents socializing in common areas and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 106.3 – 117.3 degrees Fahrenheit. LPA observed the facility has an excess of 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers located throughout the facility were observed to be fully charged with service tags dated March 5, 2024. Appliances were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents.

Medication was observed to be locked within the medication room. LPAs selected eleven residents’ medication for review and observed medication and medication records to be accurate. LPAs reviewed eleven resident files and four staff files. Staff files did not contain any documentation for hands-on staff training and AAD was unable to provide LPAs with documentation of hands-on staff training conducted; a Deficiency was cited on today’s date. (LIC809-C)
Armando J LuceroTELEPHONE: (714) 703-2840
Claudia GutierrezTELEPHONE: 714-703-2840
DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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Document Has Been Signed on 11/26/2024 03:05 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: WESTMINSTER VILLA
FACILITY NUMBER: 306004795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on AAD interview and record review, the licensee did not comply with the section cited above in four of four staff files, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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AAD stated that for on-the-job training, documentation will consist of a statement or notation, made by the trainer, of the content covered in the training and proof provided to LPA via email by POC date.
Section Cited
(1) The department shall adopt regulations to require staff members... who assist residents with personal activities of daily living to receive appropriate training... A staff member shall complete 20 hours, including six hours specific to dementia care... four hours specific to postural supports, restricted health conditions, and hospice care... before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment.... The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on AAD interview and record review, the licensee did not comply with the section cited above in three of four staff files which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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AAD stated they will document hands-on shadowing training completed and a copy provided to LPA via email by POC 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.
Armando J LuceroTELEPHONE: (714) 703-2840
Claudia GutierrezTELEPHONE: 714-703-2840

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WESTMINSTER VILLA
FACILITY NUMBER: 306004795
VISIT DATE: 11/06/2024
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On-the-job training documentation also did not include a statement or notation, made by the trainer, of the content covered in the training; a Deficiency was cited on today’s date. LPAs interviewed ten residents and four staff.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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