374603509-4-26-2024-08-AS-IESA-D5U42J-20240601184313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603509
Report Date: 04/26/2024
Date Signed: 04/26/2024 03:27:26 PM

Substantiated

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
07/26/2021 and conducted by Evaluator Becky Kennedy

COMPLAINT CONTROL NUMBER: 08-AS-20210726092242

FACILITY NAME:	WESTMONT AT SAN MIGUEL RANCH		FACILITY NUMBER:	374603509
ADMINISTRATOR:	NEWTON, RANDAL		FACILITY TYPE:	740
ADDRESS:	2325 PROCTOR VALLEY RD		TELEPHONE:	(619) 271-4385
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91914
CAPACITY:	105	CENSUS: 63	DATE:	04/26/2024
		UNANNOUNCED	TIME BEGAN:	02:48 PM
MET WITH:	Jessica Zepeda		TIME COMPLETED:	04:19 PM

ALLEGATION(S):

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Staff did not meet resident's incontinence care needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Becky Kennedy concluded the investigation which began on 7/29/21. LPA Kennedy made an unannounced visit to the above facility today and met with Jessica Zepeda, Executive Director.

LPA advised Ms.Zepeda that the reason for today's visit is to deliver the investigation findings on the above allegation.

The investigation consisted of interviews with internal sources, a review of reports and records, and a tour of the facility.

It was alleged that Resident 1 (R1) (see LIC 811 for confidential names) requested incontinence care from facility staff and the care was not provided for approximately six hours when R1 called again to request care.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky Kennedy	TELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210726092242

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: 04/26/2024

NARRATIVE

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The investigation revealed that R1 activated their call button at 9:17 PM to request care as they had defecated and needed to be cleaned. Staff 1 (S1) responded to the resident and informed them that they could not provide the care at that time as S1 was the only caregiver on duty at that time. S1 was near the end of their shift. S1 reported that they informed the relieving caregiver about R1’s need for care. The care need was not transferred to the next shift in writing violating facility policy. The relieving caregiver did not provide care to R1.

R1 fell asleep without receiving care. R1 woke up about and called for care at 3:26 AM and the care staff provided the required care. R1 received care over six hours after their first request for assistance. R1 was left in soiled clothing for an excessive period of time.

The preponderance of evidence standard has been met and this allegation is substantiated.

A deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6 Chapter 8, and is listed on the 9099D.

An exit interview was conducted with Jessica Zepeda, Executive Director and a copy of this report, LIC 811, LIC 9099 D and Licensee/Appeals Rights (LIC 9058 01/16) was provided.

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky Kennedy	TELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210726092242

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: 04/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/26/2024 Section Cited CCR 87464(4)	1 2 3 4 5 6 7	87464 Basic Services(to include) (4) Personal assistance and care as needed by the resident …with those activities of daily living ...	1 2 3 4 5 6 7	Facility will coach S1 regarding edorsing care needs to other staff if unable to provide care, endorse in writing from shift to shift, and to elivate issues with specific residents to supervisor.
	8 9 10 11 12 13 14	Based on interviews and record review 1 of 63 residents did not receive basic services when care was not delivered to R1 for six hours which posed a potential risk to the health of 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: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky Kennedy	TELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC9099 (FAS) - (06/04)

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