331880776-9-11-2023-18-AS-RSTS-CWKUQ6-20231013154634

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880776
Report Date: 09/11/2023
Date Signed: 09/11/2023 12:43:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
07/10/2023 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230710160707

FACILITY NAME:	WESTMONT VILLAGE		FACILITY NUMBER:	331880776
ADMINISTRATOR:	PATRICK FRAZER		FACILITY TYPE:	740
ADDRESS:	17050 ARNOLD DRIVE		TELEPHONE:	(951) 697-2100
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92518
CAPACITY:	225	CENSUS: 73	DATE:	09/11/2023
		UNANNOUNCED	TIME BEGAN:	11:34 AM
MET WITH:	Monya Henry, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not distribute resident's medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to initiate an investigation into the above allegation. LPA met with Executive Director Monya Henry who was informed of the purpose of the visit. LPA collected documentation, and conducted a tour of the facility. LPA interviewed several residents, reviewed several resident records, and conducted staff interviews.

It was alleged that the facility was not dispensing Resident One's (R1) medications. LPA requested a copy of R1’s medication list for review from the facility.

-Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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-20230710160707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WESTMONT VILLAGE	FACILITY NUMBER: 331880776
	VISIT DATE: 09/11/2023

NARRATIVE

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Upon review of R1's Medication Administration Record (MAR), medication #1 (M1) was not noted on R1's medication list; however, additional documentation was received by a relevant party that presented R1 was to consume M1 per written prescription orders during the month of 3/2022.

Record review provided by the facility did not include M1 on the Medication Administration Record (MAR) for the month of 3/2022. Additionally, the facility provided a "medication release" form dated 3/25/2023 for a "home visit", and, upon review, did not include the medication M1, that R1 was supposed to be consuming per written prescription orders.

Further, the Department conducted a review of several other resident's medication records and found no discrepancies. LPA then conducted resident interviews and found that resident's are getting their medications as prescribed.

Thus, as a result of the evidence obtained, the Department found that the 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.

An exit interview was conducted where a copy of this report was discussed with and provided to Executive Director Monya Henry along with copies of the LIC811, LIC9099C, LIC9099D, and Appeal Rights.

This is an amended version of the original report dated 7/11/2023.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC9099 (FAS) - (06/04)

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