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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880776
Report Date: 01/10/2023
Date Signed: 01/10/2023 03:55:15 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
01/05/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230105121045
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: 164DATE:
01/10/2023
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Vivian Villegas, Administrator TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not properly trained regarding an indwelling catheter
Staff inappropriately restrained a resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to investigate the above allegations. LPA met with Administrator Vivian Villegas and Memory Care Resident Services Director Emerald Mobley and toured the facility.

LPA interviewed Resident One (R1), Caregiver Julio Ramirez-Mercado, Melvina Vega and Mobley. LPA reviewed documents provided by Licensee, and gathered pertinent documentation related to the complaint.

Regarding allegation, "Staff are not properly trained regarding an indwelling catheter." It was alleged that there were numerous incidents with R1 having a broken/torn foley, and that due to this, staff had not been properly trained.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20230105121045
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
VISIT DATE: 01/10/2023
NARRATIVE
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Through documents provided to LPA by the Licensee, LPA found that the last training done on catheter care was on June 9, 2022. LPA reviewed the training for the caregivers on the day of the incident (December 28, 2022) and found that during the incident, Caregivers Erniwati Keeling and Melvenia Vega had the most recent catheter training and were 2/3 caregivers on the schedule for their shift. Julio Ramirez-Mercado (3/3 caregivers) did not have the training. Caregiver Ramirez-Mercado was hired July 21, 2022 after the last catheter care was conducted. LPA reviewed Ramirez-Mercado's training that was conducted, and found no catheter care documented. Upon interview, Ramirez-Mercado further stated that they had no official catheter care training. Thus, this allegation was SUBSTANTIATED.

Regarding the allegation, "Staff inappropriately restrained a resident while in care." It was alleged that staff restrained R1 to their bed utilizing their bed sheets. LPA interviewed R1, Memory Care Resident Services Director Emerald Mobley, Caregiver Melvina Vega, and Caregiver Ramirez-Mercado. Through interviews conducted, LPA found that R1 had been restrained to their bed utilizing their sheets. Caregiver Ramirez-Mercado stated that they felt that R1 would cause injury to themselves and needed to be restrained. Thus, this 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.

LPA issued (2) citations per Title 22 in reference to the allegations.

An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811 (Confidential-Names List), LIC9099-D, LIC9099-C, and Appeal Rights were provided.


SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
01/05/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230105121045

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: 164DATE:
01/10/2023
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Vivian Villegas, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff is unable to communicate effectively with a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to investigate the above allegation. LPA met with Administrator Vivian Villegas and Memory Care Resident Services Director Emerald Mobley. LPA toured the facility, and interviewed Resident One (R1) and Caregiver Julio Ramirez-Mercado.

Regarding allegation, "Staff is unable to communicate effectively with a resident", it was alleged that Mercado was reported to not speak and/or understand English very well, which is primary language of R1. Through interviews conducted, LPA was not able to confirm that there was a language barrier between Mercado and R1 that prevented care. R1 appeared to not have difficulty speaking and understanding staff.

Thus, this allegation was UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that 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.

An exit interview was conducted where a copy of this report was discussed with and provided along with a copy of the LIC811.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
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 4
Control Number 18-AS-20230105121045
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: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2023
Section Cited
CCR
87623(b)(2)(B)
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Indwelling Urinary Catheter:(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(2) Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance.(B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed. This was not being met as evidenced by:
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Licensee agrees to conduct in-service training by all caregivers and submit to LPA by POC date.
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Based on interview, and documentation, R1 was not being provided care by trained staff. This presents a potential health and safety and personal rights risk to residents in care.
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Type B
01/24/2023
Section Cited
HSC
1569.269(a)(10)
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Enumerated rights; severability:(a) Residents of residential care facilities for the elderly shall have all of the following rights:(10)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This was not being met as evidenced by:
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Licensee agrees to conduct in-service training by all caregivers and submit to LPA by POC date.
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Based on interview, R1 was restrained by staff. This presents a potential health and safety and personal rights risk to residents in care.
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4