374603509-9-18-2023-08-AS-CLOZ-CVT4QY-20230918191906

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603509
Report Date: 09/18/2023
Date Signed: 09/18/2023 07:19:35 PM

Document Has Been Signed on 09/18/2023 07:19 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
SAN DIEGO RO, 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: 78	DATE:	09/18/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Michael Sokolowski, Executive Director		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a complaint investigation and conjointly conducted a case management visit. LPA Lopez identified herself and was granted entry by Amanda DeLeon, concierge . LPA Lopez stated the purpose of the visit and reviewed the basic elements of the case management visit with Executive Director Sokoloski. Today's visit was in response to an Incident Report (LIC624), which was self submitted to the Community Care Licensing Division (CCLD) San Diego Regional Office, received on 09/15/2023. According to the LIC624, on 09/11/23, a Resident #1 (R1) reported that they were unable to find the monies they kept in their personal property. R1 stated they had a total of $100 bills in $20 dollar bills and $10 dollar bills in their belongings on 08/31/23. Facility staff confirmed the monies with R1's responsible party. During the visit, LPA Lopez toured the facility, spoke with staff and residents, and requested and obtained relevant documents. According to staff interviewed, the R1 had spoken to the Resident Service Director (RSD) to report the missing money. RSD contacted the residents RP who confirmed that resident did have the money within her belongings. RSD and staff did look for the missing money in the resident’s room to no avail. According to the RSD, they attempted to report the missing money to the police, but since it was less than $10,000, they would not come out to take the report. RSD also attempted to make the report online but was unable as the online prompt did not let RSD surpass a section that the resident needed to fill out. According to the RSD, the resident did not want to pursue the incident further. According to Staff #2 (S2), residents are not allowed to have money on them if they are in the assisted living. The residents’ representative’s usually take care of the resident’s cash resources. If a resident has a large amount of money they place it in their inventory sheet, but that was something unusual that a resident would have. According to S2, staff was unaware that R1 had their money on them but it was confirmed with their RP.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH	FACILITY NUMBER: 374603509
	VISIT DATE: 09/18/2023

NARRATIVE

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Per the Executive Director (ED), the facility conducted an internal investigation. Their investigation was inconclusive as the money was not found. Per the ED, the resident was reimbursed the monies that was lost/stolen.

The facility is currently licensed to serve a total of 105 residents, all of whom may be non-ambulatory and 12 of whom may be bedridden on the ground floor only; and hospice is approved for 12. Per R1’s latest LIC602 Physician’s Report (dated 05/10/2023), R1 is considered to be non-ambulatory. R1’s is able to follow instructions and is able to communicate their needs and manage their own cash resources.

During the records review, LPA observed that the facility had a Certificate of Liability Insurance with an expiration date of 09/2024. The facility did reimburse R1 the amount that was stolen/lost. There were no deficiencies issued during this visit.

An exit interview was conducted, with Executive Director Michael Sokolowski. A copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the documents were received.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC809 (FAS) - (06/04)

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