374603509-4-12-2023-08-AS-DNGN-CQU2LN-20230412172950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603509
Report Date: 04/12/2023
Date Signed: 04/12/2023 05:29:57 PM

Document Has Been Signed on 04/12/2023 05:29 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	WESTMONT AT SAN MIGUEL RANCH		FACILITY NUMBER:	374603509
ADMINISTRATOR:	ROSSI, MARIA		FACILITY TYPE:	740
ADDRESS:	2325 PROCTOR VALLEY RD		TELEPHONE:	(619) 271-4385
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91914
CAPACITY:	105	CENSUS: 81	DATE:	04/12/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Director of Operations Maria Rossi		TIME COMPLETED:	05:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Regional Director of Operations Maria Rossi.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (RO) on 04-06-2023. Per the LIC624: On 04-02-2023 around 6:45 PM, Resident #1 (R1), who lives in the facility’s secured memory care neighborhood, was briefly AWOL (absent without leave). [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Staff #1 (S1), who was taking a break, saw R1 in the facility’s parking lot and escorted them back to the memory care neighborhood. R1 was unharmed/uninjured.

During today’s visit, LPA briefly toured the facility and performed a welfare check, verifying that R1 was indeed unharmed/uninured. LPA also tested the delayed egress exit doors associated with the facility’s memory care neighborhood, and verified their alarms were all operational. LPA also collected copies of pertinent administrative, care, and medical records, and interviewed relevant staff.

Due to R1’s baseline short-term memory loss, they had no recollection of the incident and were unable to participate as an interviewee. According to R1’s latest LIC602 Physician’s Report, dated 12-22-2022, R1 was diagnosed with “Mild Cognitive Impairment” and was “confused/disoriented.” R1’s doctor determined that they were not able to safely leave the facility unassisted, and that “exits must be alarmed.” Per R1’s LIC603 Pre-Placement Appraisal, dated 12-22-2022, their short-term memory was “very poor” due to past strokes.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH	FACILITY NUMBER: 374603509
	VISIT DATE: 04/12/2023

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[CONTINUED FROM LIC 809]

Staff interviews revealed: leading up to the incident, Staff #2 (S2) briefly disarmed and opened an egress door to allow a visitor to leave the memory care neighborhood and go into the main lobby. Not recognizing that R1 was a memory care resident, S2 allowed R1 to follow the visitor out. It was S2’s second day working alone in their job position, which was centered in the lobby (i.e., S2 did not ordinarily work inside the memory care neighborhood). Based on an after-action review of camera footage, licensee estimated that R1 was outside of the facility building for about 20 minutes, before S1 encountered them and escorted them back inside.

A preponderance of evidence exists to show that preceding the incident, Licensee did not equip S2 the knowledge and/or training they needed to visually recognize R1 as a memory care resident, which contributed to R1’s AWOL. Following the incident, licensee conducted an internal investigation, placed photos of its memory care residents in a confidential binder available for lobby staff to review and reference, and on 04-05-2023 conducted a missing resident drill and training for its staff.

One deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Rossi. A hard copy of this report, the LIC809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to licensee during today’s visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/12/2023 05:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH	FACILITY NUMBER: 374603509
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/12/2023 Section Cited	1 2 3 4 5 6 7	87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be…competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Per manager interviews, licensee placed photos of its memory care residents in a confidential binder available for lobby staff to review and reference. Per training records, on 04-05-2023, licensee conducted a drill and retraining for its staff on the topic of missing residents. Licensee agreed to add a sign to the inside of each of the memory care neighborhood’s four (4) egress doors, reminding staff to look behind them before exiting. Licensee agreed to E-mail LPA photos showing these signs installed on each of the four (4) doors, by the POC due date.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not ensure facility personnel (S2) was competent to provide the services necessary to meet the needs of 1 of 81 residents (R1), which posed a potential safety risk to persons in care.	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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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