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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603509
Report Date: 03/28/2023
Date Signed: 03/28/2023 09:46:40 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/03/2023 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20230303100738
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: 67DATE:
03/28/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Operations Specialist, Patrick FrazierTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Lack of supervision resulted in resident elopement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA gained access to the facility, identified herself and met with Operations Specialist, Patrick Frazier. LPA explained the purpose of the visit which was to deliver findings for the above allegation.

The Department’s investigation consisted of record reviews, interviews with staff and outside sources.

On March 03, 2023, it was alleged that staff lacked supervision of resident 1 (R1 – See LIC 811- Confidential Names List) which resulted in elopement. On January 25, 2023, the facility self-reported an absence without leave (AWOL) incident report to the Department. The report indicated that on January 23, 2023, at approximately 6:20 pm, staff 1 (S1) heard the alarm go off on an exterior door in memory care.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
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-20230303100738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/28/2023
NARRATIVE
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S1 assumed an unrelated resident set the alarm off. S1 then proceeded and disarmed the alarm. S1 looked out the window to ensure there was no resident outside; however, did not open the door and check the perimeter. Approximately five minutes later, R1 was observed outside of the front of the building by staff 2 (S2). S2 then brought R1 back inside the building and R1 was assisted back to the memory care unit. Interviews with staff corroborated the incident. Records reviewed confirmed R1 was unable to leave the facility unassisted and R1’s responsible party was notified.

The Department has investigated the allegation of lack of supervision resulted in resident elopement. Based on evidence obtained, the allegation is substantiated. A substantiated finding means that the allegation is valid because the preponderance of the evidence standard has been met. 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 Frazier and a copy of this report, LIC 811, LIC 9099 D and Licensee/Appeals Rights (LIC 9058 01/16) was provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230303100738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2023
Section Cited
HSC
1569.317
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1569.317 Absentee notification plan for missing residents Every residential care facility for the elderly, as defined in Section 1569.2, shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan… this requirement was not met as evidenced by:
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Operations Specialist provided verification of Elopement Drill training provided to all memory care staff by a contracted Nurse on March 16, 2023. POC cleared.
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Based on interviews and records reviewed Licensee did not ensure staff complied with the facility’s absentee notification plan. Staff 1 (S1) did not complete an immediate systematic search of the property after an exit door alarm went off. This posed a potential safety risk to 1 out of 68 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) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/03/2023 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20230303100738

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: 67DATE:
03/28/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Operations Specialist, Patrick FrazierTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Licensee did not keep personal hygiene products inaccessible to at risk resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA gained access to the facility, identified herself and met with Operations Specialist, Patrick Frazier. LPA explained the purpose of the visit which was to deliver findings for the above allegation.

On March 03, 2023, it was alleged that during an unspecified timeframe, licensee did not keep personal hygiene products inaccessible to an at-risk resident. More specifically, it was alleged that resident 1’s (R1’s) breath smelled like a floral shampoo and R1 consumed their hygiene product.

Records reviewed revealed that R1 was able to groom themselves and was not at risk if allowed direct access to personal grooming and hygiene items. Interviews with staff revealed that there was no concern with R1 consuming hygiene items. There was insufficient evidence to support this allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230303100738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/28/2023
NARRATIVE
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The Department has investigated the allegation listed above. Based on evidence obtained, including interviews and records reviewed, the above allegation is determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard.

An exit interview was conducted with Frazier and a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) was provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5