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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880776
Report Date: 09/15/2023
Date Signed: 09/15/2023 02:07:06 PM

Unsubstantiated


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
11/04/2020 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 18-AS-20201104115823
FACILITY NAME:WESTMONT VILLAGEFACILITY NUMBER:
331880776
ADMINISTRATOR:KURT KNAUERFACILITY TYPE:
740
ADDRESS:17050 ARNOLD DRIVETELEPHONE:
(951) 697-2100
CITY:RIVERSIDESTATE: CAZIP CODE:
92518
CAPACITY:225CENSUS: 179DATE:
09/15/2023
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Monya Henry, Executive DirectorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Due to lack of care and supervision resident sustained an injury from a fall while in car
Staff failed to seek timely medical attention for a resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conclude a complaint investigation for the above-mentioned allegations. LPA Prieto met with Monya Henry.

Regarding the allegation that due to lack of care and supervision resident sustained an injury from a fall while in car, resident #1 (R1) had an un-witnessed fall, sustaining an injury. The fall was addressed by facility staff and R1 was sent to the hospital for medical care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
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 2
Control Number 18-AS-20201104115823
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: 09/15/2023
NARRATIVE
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Regarding the allegation that staff failed to seek timely medical attention for a resident while in care, R1 was addressed by facility staff after an un-witnessed fall and sent to the hospital for medical treatment on the same day the incident occurred.

Based on the information obtained there is not enough evidence that due to lack of care and supervision resident sustained an injury from a fall while in care and staff failed to seek timely medical attention for a resident while in care . Therefore, the allegations are deemed UNSUBSTANTIATED at this time.

A copy of this report was signed by LPA Prieto and Monya Henry and I copy was left with the facility.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2