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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880776
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:20:33 PM


Document Has Been Signed on 01/06/2023 02:20 PM - 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: 163DATE:
01/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:BUSINESS OFFICE DIRECTOR, JOSEPHINE WILLIAMS.TIME COMPLETED:
02:30 PM
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On January 06, 2023, Licensing Program Analyst (LPA), Venus Mixson made an unannounced case management visit to the above facility for the purpose of follow-up on a recent death. LPA Mixson met with Business Office Director, Josephine Williams introduced self and stated the purpose of the visit.

There were 163 residents and 34 staff present at the time of the visit. LPA Mixson requested and received pertinent documents related to Resident 1 (R1)'s death. LPA Mixson toured the facility there were no deficiencies observed at the time of the visit..



LPA Mixson reviewed death report that was submitted by to the Department on 12/24/2022, by Deserie Rodillo, Resident Service Director, and completed the death report for CCL.



An exit interview was conducted a copy of this report, along with the LIC 811, was provided to the Business office Director.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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