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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006195
Report Date: 04/25/2025
Date Signed: 04/25/2025 05:36:44 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
01/13/2025 and conducted by Evaluator Michael Tea
COMPLAINT CONTROL NUMBER: 22-AS-20250113124540
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: 110DATE:
04/25/2025
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Carmen GaliciaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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- Staff are mismanaging resident's medications
- Staff do not ensure resident's room is clean and sanitized
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude the investigation and to deliver findings for the allegations mentioned above. LPA Tea was greeted and granted entry into the facility by Executive Director (ED) Carmen Galicia and explained the reason for the visit.

It was alleged that staff are mismanaging resident’s medication. During the investigation LPA interviewed residents and facility staff, checked and review resident files and charting. The investigation determined the following: It was reported that staff are not following the medication orders and directions prescribed for Resident 1(R1). Witnesses have stated that they know when R1 is not given their medication because R1 stays up at night, watching television and eating. ED Galicia and Wellness Director (WD) Brittainy Prieto explained to R1’s family that R1 has advanced dementia, and their health is gradually declining. They explain that R1 needs a higher level of care, suggesting maybe a board and care or memory care facility will provide the care R1 needs. The family of R1 believe she could be at a big facility like

Continuation of Report on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
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 2
Control Number 22-AS-20250113124540
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: 04/25/2025
NARRATIVE
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Westminster Terrace, and nothing was wrong R1’s health. WD Prieto stated the family had asked for a chemical restraint for R1 from the Psychiatric doctor who manages R1’s psych medication. She also said the family of R1 also wanted them to place R1 on medication that is high risks with adverse reactions. Per interviews, 2 out of 2 Medtech staff said there were no mismanaging of medications. Meditech 1 (M1) interviewed said they follow the family’s directive order to crush the medication and have her take it at the specific time requested. LPA observed the signs in the medtech room addressing medication orders specifically for R1 posted on the wall. LPA reviewed R1’s Medication Administration Record (MAR) and discovered no discrepancies, medication was given as prescribed. All medications were accounted for and checked. Any discontinuation of medication and resident refusal was noted and documented correctly. Medtech 2 (M2) has said that they give medication as prescribed and indicated in the MAR, they go only by the MAR itself. LPA interviewed residents, 9 out of 11 residents interviewed agreed that medication was given as prescribed and felt the staff did not mismanage their medications. Some residents felt they were on top of their medication and always on time when giving their medication.

It was alleged that staff do not ensure resident’s room is clean and sanitized. The investigation determined the following: It was reported that no one cleans R1’s room, witnesses have said that housekeeping does not clean the room and bathroom. They never cleaned the diarrhea on the carpet and the fecal matter left on the toilet. During the initial investigation LPA did visit R1’s room and found it to be neat and tidy and organized. There were a few small torn scraps of paper on the carpet. LPA did not observe diarrhea stains on the carpet. Bathroom was clean and the toilet had no fecal residue in or around the toilet at the time of the visit. All staff interviewed stated the housekeeping was done once a week for residents and as needed afterwards. The facility changes the resident’s sheets on a weekly basis. Maintenance Director Daniel Guerrero said he walks around the building and attend to any housekeeping calls. He stated some rooms are more demanding than others. He also explained they do random inspections to make sure rooms are clean. Per interviews, 8 out of 11 residents felt the facility did a good job cleaning their rooms. Some residents praised the facilities for sanitizing well, giving extra linens and footpads as requested and frequently changing the beddings.

Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations that staff are mismanaging resident’s medication and staff do not ensure resident’s room is clean and sanitized has been determined to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies cited at this time and an exit interview was conducted with ED Carmen Galicia. A copy of the report and confidential names list was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2