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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006195
Report Date: 09/04/2024
Date Signed: 09/04/2024 02:20:35 PM

Substantiated


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
06/07/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240607161443
FACILITY NAME:WESTMINSTER TERRACEFACILITY NUMBER:
306006195
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:7571 WESTMINSTER BLVDTELEPHONE:
(714) 891-6608
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:152CENSUS: 112DATE:
09/04/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carmen Galicia, Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Residents are not being provided with clean linen.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to follow up on the investigation into the six allegations listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Carmen Galicia was present to assist.

An initial visit wa conducted on June 13, 2024. LPA requested and obtained the facility's current resident census, conducted a tour of the facility, including the dining hall, kitchen, activities room, private dining and TV room in addition to a sample of eighteen different living units throughout the three levels. LPA conducted a total of eight resident interviews during the visit. Administrator provided LPA with pest control reports dated March 8, 2024 and June 12, 2024.
During the follow up visit, an additional tour of the facility's dining hall was conducted as well as 8 staff interviews.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
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 5
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
06/07/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240607161443

FACILITY NAME:WESTMINSTER TERRACEFACILITY NUMBER:
306006195
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:7571 WESTMINSTER BLVDTELEPHONE:
(714) 891-6608
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:152CENSUS: 112DATE:
09/04/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carmen Galicia, Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Residents are left soiled.

Facility is not addressing pest infestations.

Residents are not treated with respect and dignity.

Dining areas are not maintained clean.

Residents are not being provided with a way to activate the facility's call system.
INVESTIGATION FINDINGS:
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5
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7
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to follow up on the investigation into the six allegations listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Carmen Galicia was present to assist.

An initial visit wa conducted on June 13, 2024. LPA requested and obtained the facility's current resident census, conducted a tour of the facility, including the dining hall, kitchen, activities room, private dining and TV room in addition to a sample of eighteen different living units throughout the three levels. LPA conducted a total of eight resident interviews during the visit. Administrator provided LPA with pest control reports dated March 8, 2024 and June 12, 2024.
During the follow up visit, an additional tour of the facility's dining hall was conducted as well as 8 staff interviews.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20240607161443
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: 09/04/2024
NARRATIVE
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CONTINUED FROM FORM LIC90990-A
Regarding the allegation that Residents are left soiled, the following has been concluded: Based on interviews conducted with staff and residents as well as observations conducted, it has been witnessed on multiple occasions that staff was attending to residents having soiled themselves or their bedding. Additional staff and residents interviews did not provide any evidence of staff neglecting to attend residents in need of assistance with toileting care in a timely manner. It cannot therefore be corroborated that on any instances residents were left unattended after having become soiled.

Regarding the allegation that Facility is not addressing pest infestations, the following has been concluded: Upon follow-up visit there has been no evidence of continuing issues with pest at the facility. Staff interviews did not confirm any ongoing infestation either. Based on documents and evidence provided by facility staff during the initial visit, it can be confirmed that any occurrences of pests have been addressed timely.

Regarding the allegation that Residents are not treated with respect and dignity, the following has been concluded: Based on observations conducted in the facility as well as interviews with residents, no residents' statements indicated that they felt they were not receiving adequate treatment in respect of their personal rights.

Regarding the allegation that Dining areas are not maintained clean, the following has been concluded: Based on two visits of the facility's physical plant, it was observed that the dining areas were being cleaned during and/or after the meal service had been provided.

Regarding the allegation that Residents are not being provided with a way to activate the facility's call system, the following has been concluded: Based on observations conducted during the visits of the physical plant as well as interviews with staff and residents, it was determined that a majority of residents were aware of having been provided with a pendant and of the location of pull cords throughout their units. It cannot be corroborated that any incidents have occurred as a consequence of any resident not being provided with an adequate way of activating the call system.

As a result, the five allegations listed above are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240607161443
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: 09/04/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099

Regarding the allegation that Residents are not being provided with clean linen, the following has been concluded: During the initial visit, eighteen living units were visited and reviewed. While a majority of units were observed to have linens that appeared to be clean, two units were observed to have visibly stained and/or dirty linen that had not been replaced and one additional unit was found to have no linen present altogether during the visit. Upon follow-up visit, one staff interview corroborated occasional complaints from families visiting residents about bedding being soiled or wet during their visits and not having been replaced in a timely manner.

As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B citation is issued on the attached LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240607161443
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2024
Section Cited
CCR
87307(a)(3)(C)
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Per CCR 87307(a)(3)(C) "the licensee shall assure provision of: Clean linen(...). The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. " This requirement is not met as evidenced by:
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Licensee conducted an in-service regarding weekly changes of linen with housekeeping staff. A similar training either has or will be provided to caregiving staff as well before the Plan of Corrections due date.
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Based on interviews conducted and a tour of the facility's physical plant, it was observed that multiple living units had either soiled linen or absent linen altogether. This constitutes a potential risk to the health, safety and personal rights of 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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5