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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880776
Report Date: 02/15/2023
Date Signed: 02/15/2023 01:29:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220907102851
FACILITY NAME:WESTMONT VILLAGEFACILITY NUMBER:
331880776
ADMINISTRATOR:KEITH KASINFACILITY TYPE:
740
ADDRESS:17050 ARNOLD DRIVETELEPHONE:
(951) 697-2100
CITY:RIVERSIDESTATE: CAZIP CODE:
92518
CAPACITY:225CENSUS: DATE:
02/15/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Emerald Mobley, Memory Care Resident Services DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility does not provide adequate supplies to allow for proper hygiene practices
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to deliver findings to an investigation into the allegation listed above. LPA met with Memory Care Resident Services Director Emerald Mobley and explained the purpose of the visit and conducted a tour of the facility.

It was alleged that the facility did not have any paper towels, soap or hand sanitizer in any of the bathrooms in the memory care side of the building.

Continued on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220907102851

FACILITY NAME:WESTMONT VILLAGEFACILITY NUMBER:
331880776
ADMINISTRATOR:KEITH KASINFACILITY TYPE:
740
ADDRESS:17050 ARNOLD DRIVETELEPHONE:
(951) 697-2100
CITY:RIVERSIDESTATE: CAZIP CODE:
92518
CAPACITY:225CENSUS: DATE:
02/15/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Emerald Mobley, Memory Care Resident Services DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident developed a pressure injury while in care
Staff do not provide bathing assistance to residents in care
Facility air conditioning system is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to deliver findings to an investigation into the allegations listed above. LPA met with Memory Care Resident Services Director Emerald Mobley and explained the purpose of the visit and toured the facility.

It was alleged that Resident One (R1) has a pressure injury on their bottom that was bleeding about the size of a penny. It was unknown of the actual stage of the pressure injury.

Continued on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
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 18-AS-20220907102851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 331880776
VISIT DATE: 02/15/2023
NARRATIVE
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It was further not known if the resident was receiving Hospice or home health services. It was stated that R1 has all the medical supplies in their cabinet but none of the staff were alleged to be providing the proper care for pressure injury preventative care. Through observation, interview, and document review, LPA discovered that R1 had medical supplies in their cabinet to treat a recurring coccyx wound. At the time of the allegation made, R1 was not receiving treatment for a wound; however, R1 had been regularly seen for treatment for the recurring wound. Through document review, on 9/7/2022, Vitas Hospice began treating R1 for a coccyx wound once per week. Vitas Hospice began wound care and gave training to staff to care for the wound. Interviews with staff and outside witness revealed that R1 was being repositioned in-between treatments.

It was alleged that the residents are not being showered and some of the residents smelled bad. LPA conducted interviews with staff, and residents, and through observation determined that residents are being showered by staff.

It was alleged that the air conditioning system is in disrepair. Through interview with residents, staff, and observation, LPA found that the facility is cooled by a swamp cooler system that produces air via three large cooling systems. At the time of the allegation, one system had gone down; however, the facility was actively working on maintaining the air temperature through the remaining two cooling systems that were operational. Through interviews, LPA determined that there was not a complaint regarding the comfort of residents due to the one cooler undergoing maintenance.

Thus, these allegations were UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where a copy of this report was discussed with and provided along with a copy of the LIC811 (confidential names list).
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20220907102851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 331880776
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2023
Section Cited
CCR
87307(a)(3)(D)
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Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(D) Hygiene items of general use such as soap and toilet paper. This requirement was not being met as evidenced by:
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Licensee agrees to supply resident rooms with soap and provide proof of such to LPA by POC date. Licensee agrees to further conduct in-service training with staff on the cited regulation and provide proof of such to LPA by POC date.
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Based on LPA observation and interview, soap is not being provided to residents. This is a potential health and safety and/or personal rights risk to 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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220907102851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 331880776
VISIT DATE: 02/15/2023
NARRATIVE
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Through LPA observation during a tour of the facility, and through interviews conducted, LPA found that liquid soap and paper towels are currently not being provided to memory care residents. Thus, this allegation was SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

A Type B citation was issued per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted where a copy of this report was discussed with along with a copy of the LIC9099-D, and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5