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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880776
Report Date: 11/02/2022
Date Signed: 11/02/2022 03:08:04 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
10/26/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221026090245
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: 152DATE:
11/02/2022
UNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Vivian Villegas, Administrator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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7
8
9
Facility is not meeting residents laundering needs.
Residents are left in wet diapers for extended periods of time.
Facility is not meeting residents housekeeping needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit to the facility to initiate the investigation into the above allegations. LPA met with Administrator Vivian Villegas, and informed her of the purpose of the visit. LPA met with Resident Services Director Deserie Rodillo and conducted a tour of the facility.

LPA reviewed files, and obtained copies of pertinent documents, inspected 6 out of 6 memory care rooms, interviewed 2 Home Health caregivers (S1, S2), 5 staff (S3, S4, S5, S6, S7), and 3 residents (R1, R2, R3)

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: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
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 6
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
10/26/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221026090245

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: 152DATE:
11/02/2022
UNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Vivian Villegas, Administrator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff do not speak a language that resident(s) understand.
Facility does not have sufficient staff to meet the needs of the residents in care.
Facility is not ensuring that resident receives meals on a regular basis.
Facility does not provide a safe environment for residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit to the facility to initiate the investigation into the above allegations. LPA met with Administrator Vivian Villegas, and informed her of the purpose of the visit. LPA met with Resident Services Director Deserie Rodillo and conducted a tour of the facility.

LPA reviewed files and obtained copies of pertinent documents, inspected 6 out of 6 memory care rooms, interviewed 2 Home Health caregivers (S1, S2), 5 staff (S3, S4, S5, S6, S7), and 3 residents (R1, R2, R3).
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: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
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 6
Control Number 18-AS-20221026090245
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: 11/02/2022
NARRATIVE
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5
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7
8
9
10
11
12
13
14
15
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32
Regarding allegation, "Facility staff do not speak a language that resident(s) understand.", after interviews conducted, LPA determined that residents do not have difficulty in understanding staff/caregivers. Thus this allegation is UNSUBSTANTIATED.

Regarding allegation, "Facility does not have sufficient staff to meet the needs of the residents in care." It was alleged that caregivers were not able to be found when needed. Through interviews obtained from staff and residents, LPA determined that staffing concerns are not an issue. Residents do not have concerns. Thus this allegation is UNSUBSTANTIATED.

Regarding allegation, "Facility is not ensuring that resident receives meals on a regular basis." It was alleged that meals are not provided to residents if they are in their rooms. Through interviews conducted with staff and residents, LPA determined that staff ask residents if they want to eat in their room, or visit with other residents while they eat in the dining room. Even if residents have visitors in their rooms, residents are afforded meals if they wish inside of their rooms. Thus this allegation is UNSUBSTANTIATED.

Regarding allegation, "Facility does not provide a safe environment for residents in care." It was alleged that caregivers check on residents once every 12 hours. Through interviews conducted with staff and residents, LPA determined that residents are checked on at a maximum of every 1-2 hours. Most room checks are done within 15-20 minutes. Thus this allegation is 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 and copy of this report was discussed with and provided.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20221026090245
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: 11/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding allegation, "Facility is not meeting residents laundering needs.", it was alleged that a resident had urine soaked laundry that had been left and not done. After interviews conducted, LPA determined that laundry is not kept up with and is often missed for several residents. Therefore, the allegation is SUBSTANTIATED.

Regarding allegation, "Residents are left in wet diapers for extended periods of time." Through interviews conducted, LPA determined that 5/6 residents (R1, R2, R3, R4, R5) are incontinent and have not received proper help/assistance from staff/caregivers with changing of their diapers on many occasions. Therefore, the allegation is SUBSTANTIATED.

Regarding allegation, "Facility is not meeting residents housekeeping needs." It was alleged that there was a urine soaked floor that had not been mopped in a resident room. Through interviews conducted, LPA determined that urine is often left on the floor when staffing is short on those days. Therefore, the allegation is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

The facility was issued 3 citations via Title 22. An exit interview was conducted and copy of this report was discussed with along with copies of the LIC811, LIC811C, LIC9099D and appeal rights were provided.


SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20221026090245
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: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/11/2022
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not being met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to have a staff meeting and remind staff of the laundry schedule and expectations of when clothing requires washing. Proof is to be submitted to the Department by 5pm on the due date indicated.
8
9
10
11
12
13
14
Based on interviews, LPA found that several non-specific rooms the Licensee did not ensure that residents were accorded comfortable accommodations. This poses a potential health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
Deficiency Dismissed
Type B
11/11/2022
Section Cited
CCR
87625(b)(2)
1
2
3
4
5
6
7
Managed Incontinence: (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This was not being met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to conduct in-service training with all staff caring for incontinent residents and submit proof by POC date.
8
9
10
11
12
13
14
Based on LPA interviews, LPA found that the Licensee did not ensure 5/6 residents were being changed. This poses a potential health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20221026090245
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: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/11/2022
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
Personnel Requirements: Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs.
1
2
3
4
5
6
7
Licensee agrees to conduct In-service training on caring for residents, and providing for their needs. Licensee to submit proof to LPA by POC date.
8
9
10
11
12
13
14
Based on interview, LPA determined that staffing is often short where cleanliness isn't afforded to residents. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6