331880776-8-31-2022-18-AS-CTUA-DYF9G5-20260930232054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880776
Report Date: 08/31/2022
Date Signed: 08/31/2022 01:20:03 PM

Substantiated

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
08/25/2022 and conducted by Evaluator Janira Arreola

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220825124947

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: 153	DATE:	08/31/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director, Keith Kasin		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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9

Facility has pests.

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit to the facility for the purpose of a complaint investigation. LPA met with Executive Director Keith Kasin who was informed of the purpose of the visit.

LPA conducted staff and resident interviews, records review and documented observations.

Regarding Allegation #1 "Facility has pests” LPA conducted a walk through of the facility and inspected (10) resident rooms and beds for bed bugs. LPA found no evidence of bed bugs except for (1) room, which was R1's room. LPA found through interview and observation that R1 has been moved to a different room. LPA also interviewed residents and found that residents pointed to R1's room being the only one with bed bugs. LPA observered R1's room that will be getting treatment to have plastic coverings and staff stated it was ready for treatment. LPA found that the facility has a scheduled treatment for the bed bugs that has been pushed back and staff interviews acknowledged the bed bugs at the facility. Therefore, the allegation is substantiated as the facility is actively taking steps to treat the pests.

A finding of substaniated means that the proponderance of the evidence standard has been met.

Defeciencies were cited on LIC9099-D and POC was documented by LPA.

An exit interview was conducted where this report, deficency page, and appeal rights were reviewed and provided to Executive director, Keith Kasin.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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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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
08/25/2022 and conducted by Evaluator Janira Arreola

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220825124947

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: 153	DATE:	08/31/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director, Keith Kasin		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not provide resident reliable internet and phones.
Facility is not providing care for the resident

INVESTIGATION FINDINGS:

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3
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5
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7
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13

Regarding allegation #1 "Facility does not provide resident reliable internet and phones.” Based on LPA observation there was a landline in resident #1 (R1) room, however the phone does not make calls except to the front desk. LPA gathered through staff interviews that residents can make phone calls from the front desk as well. Staff and resident interviews revealed that the facility does have internet. LPA also observed Wifi networks available to residents and guests at the facility. Based on staff and resident interview residents have access to phones and internet at the facility. Therefore the allegation is unsubstantiated.

Regarding allegation #2 "Facility is not providing care for the resident ” LPA interview with staff and R1's responsible party, found that the resident does not subscribe to a care plan from the facility and is independent. LPA reviewed R1's admissions agreement and found that this was coroberated. Therefore the allegation is unsubstantiated.

A finding of unsubstantiated means that although the allegation is valid, the prodonderance of the evidence standard has not been met.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 18-AS-20220825124947

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/10/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide LPA proof of the completed extermination, which is scheduled for September 6th. POC date will allow some days for Administrator to provide this proof to LPA.
	8 9 10 11 12 13 14	Based on LPA obervation, interviews conducted, and records review, the facility was found to have bed bugs. Staff stated that there were bed bugs, and LPA observed R1's room which was prepped for extermination. LPA aslo reviewed email correspondence of scheduled treatment.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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