374603509-1-19-2024-08-AS-LSIA-CZMPAM-20240119100858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603509
Report Date: 01/19/2024
Date Signed: 01/19/2024 10:12:17 AM

Document Has Been Signed on 01/19/2024 10:12 AM - 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:	MICHAEL SOKOLOWSKI		FACILITY TYPE:	740
ADDRESS:	2325 PROCTOR VALLEY RD		TELEPHONE:	(619) 271-4385
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91914
CAPACITY:	105	CENSUS: 71	DATE:	01/19/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Executive Director Michael Sokolowski		TIME COMPLETED:	10:30 AM

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 Analysts (LPAs) Liliana Silveira and Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 01/16/2024. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Michael Sokolowski. According to the facility’s license, the facility has a maximum capacity of 105 residents, all which will be non-ambulatory and seven may be bedridden (and the bedridden residents may only reside on the ground floor). During today’s inspection, according to records, there were a total of 71 residents in care, of which 43 were non-ambulatory and none were bedridden. During today’s visit, LPAs, accompanied by licensee’s staff, toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. LPAs privately interviewed multiple staff and residents. LPAs also reviewed multiple staff and resident records/files. The files which were reviewed contained the required documents. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained required furniture. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Confidential records and centrally stored medications were kept in locked areas. The facility had at least two days of perishable food and seven days of non-perishable food present. The facility had cooking and dining utensils to facilitate resident meal service. The Walk-In Refrigerator’s temperature was compliant at 40 F, and the Walk-In Freezer’s temperature was complaint at 0 F. The facility’s ambient internal temperature was compliant at 74 F. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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: 01/19/2024

NARRATIVE

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[CONTINUED FROM LIC 809] Where tested, hot water temperature at taps (which were used by residents for personal care) were compliant: Bedroom #107 sink was 116.1 F, Bedroom #131 sink was 115.5 F, Bedroom #214 sink was 109.7 F, Bedroom #229 sink was 114.5 F, Bedroom #246 sink was 112.4 F.

There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents diagnosed with Dementia. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility.

Smoke and fire alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. A complete first aid kit was present and readily accessible. Licensee's staff also presented proof of current/active business liability insurance. Required licensing postings were observed in visible areas of the facility.

Based on LPAs’ observation and confirmed by manager interviews: The facility presently uses delayed-egress doors in its secured memory care area. However, Licensee did not ensure that the facility’s local fire authority granted approval in writing for use of delayed-egress doors, as was required before their use. Per the facility license which CCLD issued to Licensee, approval for use of delayed-egress doors was also not expressly approved.

One (1) 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 Licensee. LPAs also issued Technical Assistance (TA) regarding Infection Control (see the LIC 9172-TA).

An exit interview was conducted with Sokolowski, to whom a copy of this report, the LIC 809-D, the LIC9172-TA, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/19/2024 10:12 AM - 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: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(k)(2)

Care of Persons with Dementia

(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of delayed egress devices. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement was not met, as evidenced by: Based on observation and record review, in an area of the facility where 1 of 71 residents (R1 through R24) resided, licensee utilized delayed egress devices on exterior doors but did not ensure that its fire clearance included approval of delayed egress devices. This posed a potential safety risk to persons in care.
	POC Due Date: 02/18/2024
	Plan of Correction
1 2 3 4	By the POC due date, Licensee will E-mail to the CCLD San Diego Regional Office (RO) documents (i.e., Cover Letter, LIC200 Application, and LIC9054 Local Fire Inspection Authority Information), to begin the process for requesting another fire inspection, with the intent of securing approval for delayed-egress doors.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

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