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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880776
Report Date: 04/19/2023
Date Signed: 04/19/2023 05:31:17 PM


Document Has Been Signed on 04/19/2023 05:31 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:WESTMONT VILLAGEFACILITY NUMBER:
331880776
ADMINISTRATOR:VIVIAN VILLEGASFACILITY TYPE:
740
ADDRESS:17050 ARNOLD DRIVETELEPHONE:
(951) 697-2100
CITY:RIVERSIDESTATE: CAZIP CODE:
92518
CAPACITY:225CENSUS: 172DATE:
04/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:48 PM
MET WITH:Resident Services Director Mayra AlfaroTIME COMPLETED:
05:35 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced case management visit to the facility. The purpose of the visit was to follow up on resident #1 (R1)s death. LPA met with Resident Services Director Mayra Alfaro and explained the purpose of today's visit.

During LPA's visit, LPA reviewed and obtained copies of pertinent documentation and conducted staff interviews regarding the death of (R1) whom passed away on either late Monday night 4/17/23 or early Tuesday morning 4/18/23. LPA interviewed Mayra and Resident Services Director of Memory Care Emerald Mobley for further information regarding the death of R1 and the events that led up to R1's death. LPA was informed by both Mayra and Emerald that R1 was a new admit and moved in on Saturday April 15, 2023. The last known reported activity by that they may have been watching TV, and that it was extremely loud volume. R1 was last seen around dinner time at 4:30pm asking dining where the dining room was located and had refused to go.

There preliminary cause of death was a self inflicted gun shot wound, an autopsy is being performed,. LPA advised Resident Services Director Mayra Alfaro, and Emerald Mobley to send a copy of the death certificate to the department as soon as it is available.

No deficiencies were cited during this visit.

An exit interview was conducted ,and a copy of this report (LIC 809) and LIC 811 (confidential names list, were provided to Resident Services Director Mayra Alfaro.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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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