306005908-11-1-2022-22-AS-KSGH-CKRQG2-20221101120848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005908
Report Date: 11/01/2022
Date Signed: 11/01/2022 12:08:59 PM

Document Has Been Signed on 11/01/2022 12:08 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:	WESTMONT OF CYPRESS		FACILITY NUMBER:	306005908
ADMINISTRATOR:	PATRICK FRAZIER		FACILITY TYPE:	740
ADDRESS:	4889 & 4775 KATELLA AVE.		TELEPHONE:	(858) 729-6720
CITY:	LOS ALAMITOS	STATE: CA	ZIP CODE:	90720
CAPACITY:	152	CENSUS: 133	DATE:	11/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Patrick Frazier, Executive Director		TIME COMPLETED:	12:25 PM

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	Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Alvaro Ramirez Jr made an unannounced visit to the facility in order to conduct a required annual investigation focusing on Infection Control procedures. LPAs arrived at facility and were greeted and granted entry by Patrick Frazier, Executive Director after explaining the purpose of the visit and undergoing the facility's COVID-19 screening procedure at the front desk. At 9:45 AM, LPAs toured the facility with Executive Director. Facility has 133 residents in care including 21 in the Memory Care Unit. Facility consists of two separate buildings for both Assisted Living and Memory Care, respectively 3 levels and 2 levels. LPAs observed a cafe area, dining room, library, fitness room, activities room, salon and movie room in the main building. The fitness room is also used for outpatient occupational, physical and speech therapy if request by the residents. The activity program is displayed in multiple locations throughout the facility and tailored to the needs of independent and memory care residents respectively. LPAs observed residents relaxing in the facility's common areas or in their respective bedrooms. All residents appeared happy and well taken care of. Facility appears clean and sanitary in all areas inspected. LPAs observed the facility's central kitchen and observed it to be sanitary and fully stocked. Special diets are observed to be documented in the kitchen for any residents with special dietary needs. LPAs observed multiple outside visitation areas serving both buildings. The central swimming pool is observed to be adequately fenced and accessible to residents not on wander guard. Residents identified as at risk of elopement are equipped with bracelets that notify staff of their identity as well as the exit used when they exit the building. The bracelets and exits are regularly monitored to ensure they are functional. The Memory Care unit is equipped with a central patio with no means of egress for the unit's residents and their visitors. The building itself is equipped with delayed egress consistently with the facility's license. CONTINUED ON FORM LIC809C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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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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: WESTMONT OF CYPRESS	FACILITY NUMBER: 306005908
	VISIT DATE: 11/01/2022

NARRATIVE

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All resident rooms had the required elements as well as restrooms stocked with soap/sanitizer. Rooms are a combination of studio, one bedroom and two bedroom apartments in Assisted Living. Memory Care rooms are a combination of private studios and companion rooms organized around a shared hallway and bathroom. Bathroom are observed to be clean and without obstructions. The walk-in shower are equipped with anti-slip floors and handrails. A fixed resident call system is observed in the bathrooms. Residents can additionally opt for a pendant system for an additional fee. All units are equipped with individual climate control and are within a comfortable temperature range.

Facility screens all visitors to the facility and LPAs observed the screening/ sanitizing station in the facility. Facility utilizes an electronic visitor sign in sheet. Facility takes resident and staff temperatures daily and documents. An ample supply of available and stored PPE was observed, as well as pre-packed PPE supplies to be set up at the entrance of any unit for residents having to be placed on isolation. Facility experienced active cases of COVID recently but all residents involved are cleared at the time of the visit.

LPAs observed the medication room while MedTech staff was preparing the cart. Two secure carts are observed and equipped with key locks. The overflow cart is observed to be locked at the time of the visit. Medication scheduled for destruction are observed in the medication room, which is locked when not directly attended by staff.

LPAs requested and obtained the facility's fire panel inspection during the visit. Facility requested the report from the fire department and will provide it to the Department for review by Completion of Business on 11/04/022. A staff roster and updated proof of liability insurance were also requested and obtained for the purpose of updating the facility's regional office file.

A exit interview was conducted with the facility representative and a copy of the report was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC809 (FAS) - (06/04)

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