331880776-7-12-2025-18-AS-UCOL-DKL24M-20250815170409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880776
Report Date: 07/12/2025
Date Signed: 07/12/2025 03:10:14 PM

Unsubstantiated

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
11/19/2021 and conducted by Evaluator Regina Cloyd

COMPLAINT CONTROL NUMBER: 18-AS-20211119094333

FACILITY NAME:	WESTMONT VILLAGE		FACILITY NUMBER:	331880776
ADMINISTRATOR:	KEITH KASIN		FACILITY TYPE:	740
ADDRESS:	17050 ARNOLD DRIVE		TELEPHONE:	(951) 697-2100
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92518
CAPACITY:	225	CENSUS: 197	DATE:	07/12/2025
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Alicia Ballard		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Resident has not received treatments that were ordered by her doctor.

INVESTIGATION FINDINGS:

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On 11/23/2021, Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to conducted an investigation and met with Administrator Keith Kasin. On 07/12/25, LPA Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Memory Care Director Alicia Ballard and the purpose of the visit was explained.

Investigation consisted of the following: On 11/23/21, LPA Delgado interviewed one staff and one resident, requested and obtained copies of pertinent documentation, and toured the facility. On 07/12/25, LPA received Register of Residents and Resident #1 (R1)’s record and interviewed seven staff (S1 – S7) and nine residents. NOTE: LPA was unable to interview Resident #1 due to R1 passing away in February 2022.

Continue to LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2025

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-20211119094333

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: 07/12/2025

NARRATIVE

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Regarding the allegation, “Resident has not received treatments that were ordered by her doctor,” it is being alleged that Resident #1 (R1) is being neglected by staff because R1 did not receive R1’s medication infusion. Record Review of R1’s Admission Orders (dated 09/02/21) does not include the medication infusion. R1’s Hospice Care Plan (dated 01/21/22) does not include medication infusion. R1’s Medication Destruction Record (dated 02/24/22) does not include medication infusion. Interview with Witness #1 indicated that R1 received medication infusion through a Home Care agency. Witness #2 indicated that there were multiple orders, including in November and in December. Seven out of seven staff interviews (S1 – S7) indicated they have not received resident complaints about being neglected for not receiving home health services such as infusions. Four out of four residents (R2 - R3, R7 - R8) indicated they receive their home health and/or hospice services and have no complaints about services. R4 indicated that they were independent and manage their own medication. R10 indicated that R10 receives non-medical care services according to the agreement but manages own medication. Three out of three residents (R5 - R6, R9) indicated that they do not receive home health and/or hospice services but receive their medication as prescribed by the doctor.

Regarding the allegation, “Resident has not received treatments that were ordered by her doctor” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

No deficiencies cited.

An exit interview was conducted and a copy of this report was provided to the Memory Care Director Alicia Ballard.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2025

LIC9099 (FAS) - (06/04)

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