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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603509
Report Date: 12/05/2023
Date Signed: 12/05/2023 05:35:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2023 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20231002095754
FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:ROSSI, MARIAFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:105CENSUS: 71DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Michael Sokolowski, Executive DirectorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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- Staff did not meet training requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings of a complaint investigation regarding the above-mentioned allegation. LPA identified herself and was granted entry by Alyssa Antolin, concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Michael Sokolowski.

The Department’s investigation consisted of interviews with residents and staff, and records review of relevant documents pertinent to this investigation. On October 2, 2023, it was alleged that staff did not meet training requirements.

It was specifically alleged that staff #1 (S1) was inappropriately trained to provide medications to residents. Interview with S1 confirmed that they assisted with passing out medications, but there was always an assigned Medication Technician (Med Tech) dispensing the medications into a cup for the residents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
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 5
Control Number 08-AS-20231002095754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/05/2023
NARRATIVE
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S1 confirmed that they did not dispense the medications. The assigned Med Tech dispensed the medication into assigned cups that displayed the room number on the cup and onto a clipboard that had the same room number that matched the cup. There were no more than approximately 5 cups on the clipboard which S1 passed out along with the assigned Med Tech. Interview with staff #2 (S2) confirmed S1’s interview. LPA Lopez reviewed staff job descriptions, medication administration records (MAR’s), training logs, and Provider Information Notice (PIN). Records revealed that S1 did not have medication training, but the Med Tech who S1 assisted had records that showed they had medication training. S1’s job description say’s that S1 should have the ability to make independent decisions when circumstances warrant such action and to remain calm during emergency situations. A review of medication logs revealed that a Med Tech provided residents with their medications on 10/01/2023. There was no indication that S1 dispensed residents’ medications. S1’s training log showed active action towards their training for the months of June, July and September. In review of Med Tech's training log, it revealed that they were properly trained to dispense medications. In review of PIN 23-16-ASC, Residential Care Facilities for the Elderly Reference Guide to Administrator, Staff and Volunteer Training Requirements, the requirements that all staff require were fulfilled by S1 and S2 according to their training logs.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated.

The report was discussed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2023 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20231002095754

FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:ROSSI, MARIAFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:105CENSUS: 71DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Michael Sokolowski, Executive DirectorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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9
- Staff did not provide medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Alyssa Antolin, concierge. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Michael Sokolowski.

The Department’s investigation consisted of interviews with residents and staff, and records review of relevant documents pertinent to this investigation. It was alleged that staff did not provide medications as prescribed.

On October 2, 2023, it was specifically alleged that medications were provided to the residents late and incorrectly. Residents interviewed confirmed that medications have been administered to them late. They mentioned that there is insufficient staff and the facility had contracted an agency with workers who were unfamiliar with the facility to cover medications being administered to them. Residents said they have received their afternoon medications conjointly with their bedtime medications.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20231002095754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/05/2023
NARRATIVE
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 Although residents confirmed their medications were provided late, they did not confirm that the medications were incorrect. Staff interviews confirmed that medications were formerly provided to residents late due to agency staff cancelling their shifts on their assigned shift date. Staff said that they were redirected to fill-in the vacant areas to ensure residents had their morning medications dispensed. They confirmed that due to a late start in passing medications, some of the medications were dispensed late. Interview with the Executive Director confirmed that they worked with an agency to fill the vacant positions as needed.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during resident and staff interviews, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D.

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Executive Director Michael Sokolowski. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20231002095754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
87465(C)(2)
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87465 (C)(2) Incidental Medical and Dental Care … Once ordered by the physician the medication is given according to the physician's directions… this requirement was not met as evidence by:
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Facility will assign a lead staff to ensure agency staff are trained and there is an assigned staff who are responsible for proper medication distribution. Facility will submit a month's calendar of the assigned leads by POC due date, 12/22/23.
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Based on staff and resident interviews, facility did not provide the residents their medications as prescribed, at the appropriate timeframe. This posed a potential health risk to 4 of 71 [R1, R2, R3, & R4] 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: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5