306006195-1-16-2025-22-AS-MSTC-DDG64R-20250131192912

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006195
Report Date: 01/16/2025
Date Signed: 01/16/2025 03:54:49 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
10/11/2024 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241011163346

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: 111	DATE:	01/16/2025
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ashanti Minor-Administrative Services Coordinator, Carmen Galicia-Administrator		TIME COMPLETED:	04:09 PM

ALLEGATION(S):

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Facility staff failed to provide a resident with privacy
Residents are not accorded comfortable accommodations due to the use of air fresheners
Retaliation and/or punitive measures are taken against some residents
Facility call system is not answered in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on October 11, 2024. LPA was greeted and granted entry into the facility and met with Administrative Services Coordinator Ashanti Minor. Executive Director (ED) Carmen Galicia arrived shortly after. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that facility staff failed to provide a resident with privacy. Resident 1 (R1) was admitted to the facility on September 26, 2023. Documents reviewed included the Physician Report (LIC602) dated September 20, 2023 for R1. Per Physician report R1’s diagnosis is Stage 3 chronic kidney disease (CKD). Regarding the allegation that facility staff failed to provide a resident with privacy, the following was revealed: One of nine individuals interviewed confirmed the allegation. During the course of the interviews with residents, R2 reported that she has no issues with privacy. Per R3 staff provide the residents with privacy.
CONTINUED ON LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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-20241011163346

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: 01/16/2025

NARRATIVE

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R4 stated that staff always knock on his door before they enter his bedroom. During the course of the interviews with staff, Staff 1 (S1) reported that the facility staff always provide the residents with privacy. Per S2 residents are given privacy. During the course of the investigation LPA reviewed documents including the Relias training transcripts for S1 through S6. Per Relias transcripts for S1 through S6, S1-S6 have completed training on Resident Rights in Assisted Living.

Regarding the allegation that Residents are not accorded comfortable accommodations due to the use of air fresheners, the following was revealed: One of nine individuals interviewed confirmed the allegation. During the course of the interviews with residents, R3 reported that residents are accorded comfortable accommodations and stated that the air fresheners have a neutral smell. Per R4 the air fresheners make it smell better and stated that residents are accorded comfortable accommodations. During the course of the interviews with staff, S1 reported that no resident has complained about the air fresheners since she began working here. Per S2 the residents are being accorded comfortable accommodations since the air fresheners use natural essentials. LPA reviewed documents including the Aire-Master Scent Marketing and Odor Control. Per Aire-Master Scent Marketing and Odor Control under Scent Facts it states that the scents are made of a combination of natural and essential oils plus fine aromatics, no petroleum carriers or harsh propellants.

Regarding the allegation that retaliation and/or punitive measures are taken against some residents, the following was revealed: Five of nine individuals interviewed denied the allegation. During the course of the interviews with residents, R2 reported that staff do not retaliate against the residents and stated that the caregivers are nice. Per R4 staff do not retaliate or take punitive measures against the residents and stated that staff do a good job. During the course of the investigation LPA reviewed documents including the Westminster Terrace, LLC Employee Handbook. Per Employee Handbook on Section 3 under conduct it states the following are examples of conduct that are prohibited and will not be tolerated: being threatening, intimidating, coercing…, rude, discourteous condensing, unprofessional or otherwise socially unacceptable behavior toward a resident. During the course the interviews with staff, S1 reported that the facility does not retaliate against the residents and stated that staff have a good relationship with the residents.

CONTINUED ON LIC9099-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20241011163346

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: 01/16/2025

NARRATIVE

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Regarding the allegation that facility call system is not answered in a timely manner, the following was revealed: During the course of the investigation LPA reviewed documents including the Westminster Terrace call system past calls dated October 05, 2024 through October 10, 2024. Per call system past calls on average staff answer the call system between five minutes to 35 minutes. During the course of the interviews with residents, R2 stated that when she uses her call button that staff respond within 24 minutes. Per R4 he uses his call button all the time and reported that the average respond time is 30 minutes. During the initial visit on October 18, 2024 LPA tested the call system in random resident bedrooms. The average call system response time was between six to 25 minutes.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED.

For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations.

LPA conducted an exit interview with ED Galicia, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

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