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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005908
Report Date: 01/13/2026
Date Signed: 01/13/2026 10:01:29 AM

Document Has Been Signed on 01/13/2026 10:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WESTMONT OF CYPRESSFACILITY NUMBER:
306005908
ADMINISTRATOR/
DIRECTOR:		NANCY RODRIGUEZFACILITY TYPE:
740
ADDRESS:4889 & 4775 KATELLA AVE.TELEPHONE:
(858) 729-6720
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY: 152CENSUS: 135DATE:
01/13/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:10 AM
MET WITH:Executive Director Nancy RodriguezTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management visit to follow up on an incident report Department received. LPA discussed purpose of visit with Executive Director (ED) Nancy Rodriguez.

On January 6, 2026, department received an incident report with elopement incident that occurred on December 25, 2025. According to incident report Resident 1 (R1) had left facility and around 6:19 AM facility staff received a call by nearby Hotel that R1 was in their hotel lobby. Report stated that resident was last checked in their room during 5:00AM rounds. LPA Tirre discussed incident with ED Rodriguez who stated that R1 resided in second building located at 4775 Katella to which R1 would come back and forth to main building steps away (located 4889 Katella) to eat in dining area. R1 was able to exit building but apparently did not have key Fob to get back in facility that morning, prompting R1 to walk over next door to nearby hotel. Main building doors are locked to the public from 8PM to 7AM, residents and staff have access with Key Fobs or pass code.

LPA Reviewed R1’s recent Physician’s Report dated 7/30/2025, has R1 with diagnosis of Encephalopathy unspecified with abnormalities of gait mobility, muscle weakness, mild cognitive impairment, history of falling and hyperlipidemia. R1’s Physicians Report under capacity for self care is marked not able to leave facility unassisted. R1’s Care Plan states Resident is independent and needs no assistance with care.

Based on information gathered, facility did not adequately supervise resident and the following is being cited on 809 D-page per California Code of Regulations (title 22 Division 6 Chapter 8).

An exit interview was conducted with Executive Director Rodriguez. A copy of report and Appeal Rights were provided to facility Representative.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jenifer Tirre
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/13/2026 10:01 AM - It Cannot Be Edited


Created By: Jenifer Tirre On 01/13/2026 at 09:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WESTMONT OF CYPRESS
FACILITY NUMBER: 306005908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2026
Section Cited
CCR
87464(f)(1)

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(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code and Health and Safety Code Section 1569.2(c). This requirement is not being met as evidenced by:
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Licensee to submit a Inservice training on ensuring residents are unable to elope out of facility. Licensee to forward proof to LPA by POC due date 1/20/26
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Based on interview conducted and records reviewed Licensee failed to ensure care and supervision were provided to R1. R1 eloped out of facility on 12/25/25 and was found in a nearby Hotel Lobby This poses a potential health and safety risk to residents 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jenifer Tirre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2026


LIC809 (FAS) - (06/04)
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