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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880776
Report Date: 11/16/2022
Date Signed: 11/16/2022 11:20:00 AM


Document Has Been Signed on 11/16/2022 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAGEFACILITY NUMBER:
331880776
ADMINISTRATOR:KEITH KASINFACILITY TYPE:
740
ADDRESS:17050 ARNOLD DRIVETELEPHONE:
(951) 697-2100
CITY:RIVERSIDESTATE: CAZIP CODE:
92518
CAPACITY:225CENSUS: 154DATE:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Vivian Villegas, AdministratorTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Jesse Gardner conducted a subsequent case management visit in regards to complaint investigation 18-AS-20221026090245.

LPA observed administrator did not correct the deficiency for section 87468.1(a)(2) Personal Rights of Residents in all facilities which was cited on 11/2/2022. The deficiency had a due date of 11/11/2022 after receiving documents on 11/16/22, stated the training was completed on 11/7/22; however, the training was not submitted by the due date.

On 11/2/2022, LPA issued a second citation for the deficiency for section 87625(b)(2) Managed Incontinence. The training was stated to be conducted within the Plan of Correction (POC) parameter on 11/7/22; however, again, proof of the training was not submitted in time to clear the POC.

Both failure to submit proof of the POC result in (2) civil penalties of $500 each totalling $1,000 will be assessed.

An exit interview was conducted with Ms. Villegas a copy of this report along with (2) LIC421FC Civil Penalty Assessments and Appeal Rights were given.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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