331880776-9-19-2023-18-AS-KCLS-CVZTK5-20230925144723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880776
Report Date: 02/16/2021
Date Signed: 09/19/2023 01:56:24 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
02/03/2021 and conducted by Evaluator Javier Prieto

COMPLAINT CONTROL NUMBER: 18-AS-20210203114628

FACILITY NAME:	WESTMONT VILLAGE		FACILITY NUMBER:	331880776
ADMINISTRATOR:	KURT KNAUER		FACILITY TYPE:	740
ADDRESS:	17050 ARNOLD DRIVE		TELEPHONE:	(951) 697-2100
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92518
CAPACITY:	225	CENSUS:	DATE:	02/16/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Monya Henry, Executive Director		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Due to neglect, resident was physically assaulted by another resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to concluded a complaint investigation regarding allegations that due neglect, resident was physically assaulted by another resident while in care. LPA Prieto met with Executive Director Monya Henry. In regards with the allegation, Resident #1 (R1) was found on the floor (un-witnessed) by staff, with resident #2 (R2) hitting R1 with cloth slipper on R1's ankle area. Both R1 and R2 were assessed for injuries. No injuries found. R1 was taken to medical facility as precaution, was evaluated, and returned to facility same day with no new orders and no medical findings.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

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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Control Number 18-AS-20210203114628

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: 02/16/2021

NARRATIVE

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Based on information obtained, the facility could not have prevented the fall of R1 and R2 could not have caused injury with cloth slipper on ankle area of R1. The facility staff took immediate action, once aware of the incident, and took precautionary measures to assure residents safety and protection.

Based on the information obtained there is not enough evidence that due to neglect, resident was physically assaulted by another resident while in care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and MS Henry and a copy of the report was left a the facility.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

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