306006195-5-6-2024-22-AS-SSAS-DD93SH-20250124173022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006195
Report Date: 05/06/2024
Date Signed: 05/06/2024 12:15:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/01/2024 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240501112436

FACILITY NAME:	WESTMINSTER TERRACE		FACILITY NUMBER:	306006195
ADMINISTRATOR:	CRISTINA MILLER		FACILITY TYPE:	740
ADDRESS:	7571 WESTMINSTER BLVD		TELEPHONE:	(714) 891-6608
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	152	CENSUS: 102	DATE:	05/06/2024
		UNANNOUNCED	TIME BEGAN:	08:11 AM
MET WITH:	Facility Administrator - Carmen Galicia		TIME COMPLETED:	12:36 PM

ALLEGATION(S):

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Residents are afraid to express themselves due to retaliation
Facility is understaffed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for the complaint and to deliver the findings. LPA De Perio explained the purpose of today's visit and was greeted by Facility Administrator (AD) Carmen Galicia.

During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed.

It was alleged that residents are afraid to express themselves due to retaliation. LPA De Perio conducted a total of 7 resident interviews, of which 7 out of 7 resident interviews did not corroborate with the allegation and denied of any forms of retaliation. 3 of the resident interviews specified that there is a resident council meeting held monthly, to present to facility management regarding concerns.

Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240501112436

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WESTMINSTER TERRACE	FACILITY NUMBER: 306006195
	VISIT DATE: 05/06/2024

NARRATIVE

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1 out of 1 interview conducted with staff (S1) stated that resident 1 (R1) was talking negatively about other residents, to either staff or other residents, and that S1 advised R1 to go directly to the facility administrator if there were any resident health and safety concerns.

It was alleged that facility is understaffed. LPA De conducted a total of 7 resident interviews, of which 7 out of the 7 interviews did not corroborate with the allegation by stating that staffing is adequate enough to suffice the needs of residents. 2 out of 2 staff interviews stated that for the morning and evening shift, there are a total of 4 caregivers, and 2 med-tech hybrids (med-techs who are trained to care give) per shift, and for the noc shift, there are a total of 2 caregivers and 1 med-tech hybrid. LPA De Perio conducted a record review of the April 2024 staff schedule and verified this information. It was also observed via staff schedule that facility utilizes Great Comfort, which is a staffing agency to ensure that there is an adequate amount of direct care staff present, and that if facility is unable to find coverage, either AD Galicia or Health and Wellness Director will cover the shift.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, these allegations are deemed UNSUBSTANTIATED.

An exit interview was conducted with AD Galicia.

A copy of this report was provided and explained.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

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