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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604079
Report Date: 06/28/2023
Date Signed: 06/28/2023 10:48:04 AM


Document Has Been Signed on 06/28/2023 10:48 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:WESTMONT OF LA MESAFACILITY NUMBER:
374604079
ADMINISTRATOR:GARCIA, KIMBERLYFACILITY TYPE:
740
ADDRESS:9000 MURRAY DRTELEPHONE:
(619) 369-9700
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:164CENSUS: DATE:
06/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kimberly GarciaTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Kimberly Garcia.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 6/22/2023). According to the LIC624: on 6/18/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] R1 returned to the facility unharmed on 6/18/2023.

During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed staff. LPA was unable to interview R1 due to R1 being offsite on vacation with family.

According to R1’s latest LIC602 Physician’s Report (dated 3/22/2023), their doctor determined that R1 was not able to safely leave the facility unassisted. LIC602 states that R1 should be escorted by staff due to cognitive and physical impairment. Interviews and records showed that Licensee had a written Absentee Notification Plan as part of R1’s record of care, and that staff followed this plan.

No deficiencies were cited for this incident. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Garcia, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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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