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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880776
Report Date: 08/04/2021
Date Signed: 09/19/2023 01:37:00 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
07/29/2021 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210729085123
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: 95DATE:
08/04/2021
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Monya Henry, Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained a fall while in care
Facility staff did not notice a change in the resident's condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conclude a complaint investigation regarding the above-mentioned allegations. LPA met with Executive Director Henry. Regarding the allegation of resident sustaining a fall while in care, resident #1 (R1), in question, was assessed as a fall risk and the incident occurred at 0110 hours during routine care check which was unwitnessed. 911 was called and R1 was treated for a injury. Although R1 fell at facility staff followed proper care procedures for prevention of falls and resident care. Regarding the allegation of not noticing a change of conditions, staff assessed R1's medical condition, which was documented. Home health services were obtained for R1 related to change of condition and addressed appropriately.
Based on the information obtained there is not enough evidence that facility resident sustained a fall while in care and facility staff did not notice a change in the resident's condition. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. A copy of this report was signed by LPA Prieto and Executive Director Henry and a copy was left at the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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