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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604079
Report Date: 06/14/2021
Date Signed: 06/21/2021 11:40:49 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
01/30/2020 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20200130105004
FACILITY NAME:WESTMONT OF LA MESAFACILITY NUMBER:
374604079
ADMINISTRATOR:ARMOUR, DAVIDFACILITY TYPE:
740
ADDRESS:9000 MURRAY DRTELEPHONE:
(619) 303-0143
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:164CENSUS: 107DATE:
06/14/2021
UNANNOUNCEDTIME BEGAN:
12:51 AM
MET WITH:Executive Director, David ArmourTIME COMPLETED:
03:15 AM
ALLEGATION(S):
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Neglect resulted in unwitnessed fall and loss of consciousness.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Debbie Correia, conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit and the elements of the allegation with Executive Director (ED), David Armour.

The Department’s investigation consisted of facility staff and outside source interviews. The investigation also included facility record and medical record reviews.

It was alleged facility staff left Resident (R1) (See Confidential Names List LIC 811) unsupervised resulting in an unwitnessed fall. Resident records revealed on November 12, 2019 R1 was admitted to the level 4 memory care unit as a deemed a fall risk. On November 16, 2019, R1 was placed on Seaport Home Health, and subsequently placed on Seaport Hospice on January 1, 2020 for continued decline in health. R1 was wheelchair bound from sustaining a hip fracture from a fall prior to facility admission. Facility records revealed R1 had also has two prior falls while residing at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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-20200130105004
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 OF LA MESA
FACILITY NUMBER: 374604079
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/12/2021
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by:
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ED Armour will work with clinical team to provide training to staff regarding proper supervision to residents in care. Specifically, regarding high risk residents to prevent them from being left unattended. ED will provide documentation of training attendance and topics covered by POC due date.
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Based on evidence obtained from interviews and facility and medical records facility staff did not provide appropriate supervision to R1.Facility staff’s knowledge of R1’s falls prior to, and at the facility, demonstrates that R1 was at risk for falls, however staff neglected to implement fall safety and precaution plans to ensure their safety. This poses an immediate risk to resident’s in care safety.
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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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20200130105004
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 OF LA MESA
FACILITY NUMBER: 374604079
VISIT DATE: 06/14/2021
NARRATIVE
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An outside source revealed, out of concern of the care provided by the facility, R1’s Responsible Party (RP) hired a 24-hour Private Caregiver (PC), later the PC's hours were reduced to 16 hours due to financial constraints, and was only able to provide one-on-one care during the morning to early evening hours.

Interviews with facility staff revealed on January 16, 2020 between 19:00 and 20:00 hours R1 was watching TV in the common area of the memory care unit. There were two caregivers (S1 and S2) present to provide supervision, S2 had to repeatedly tell R1 to remain in the wheelchair after R1 had made several attempts to get up. S1 and S2 heard another resident yelling from their room. Both S1 and S2 left the common area to assist the yelling resident, leaving R1 unsupervised. When S2 returned R1 laying on the floor awake and alert, S1 and S2 assisted R1 back into their wheelchair and they all went to their room.

During the initial interview S1 claimed to be present in dining room but did not witness the fall, however during a follow up interview, it was revealed S1 was not present and expressed being apologetic and acknowledged one of the two caregivers should have remained in the common area to supervise R1. R1’s responsible party and Seaport Hospice were notified of the fall, and R1 was evaluated by the Hospice nurse who did not recommend sending R1 to the hospital, and proceeded to monitor R1 from January 17,2020 to January 20, 2020 while R1 remained in and out of consciousness. A review of medical records revealed that after the fall R1 experienced a significant change in condition and remained unresponsive to external stimuli for several days appearing to be transitioning.

Based on interviews and facility, resident, and medical record reviews the above allegation is determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. At this time, per Health and Safety Code Section 1569.49, a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.

An exit interview was conducted with ED Amour. A copy of this report and Licensee/Appeals Rights (9058 01/16) was emailed to ED Amour at the conclusion of the visit, LPA Correia requested an electronic message reply to confirm receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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
01/30/2020 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20200130105004

FACILITY NAME:WESTMONT OF LA MESAFACILITY NUMBER:
374604079
ADMINISTRATOR:ARMOUR, DAVIDFACILITY TYPE:
740
ADDRESS:9000 MURRAY DRTELEPHONE:
(619) 303-0143
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:164CENSUS: 107DATE:
06/14/2021
UNANNOUNCEDTIME BEGAN:
12:51 AM
MET WITH:Executive Director, David ArmourTIME COMPLETED:
03:15 AM
ALLEGATION(S):
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Resident was not checked on routinely for incontinence care.
Staff neglects residence personal hygiene.
Resident is kept in isolation.
Facility is not properly managing resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Debbie Correia, conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Executive Director (ED), David Armour.

The Department’s investigation consisted of facility staff and outside source interviews. The investigation also included a facility record and medical record reviews.

It was alleged that R1 was not checked on routinely for incontinence care and R1's personal hygiene was neglected. A review of resident records revealed R1 was admitted to the level 4 memory care unit of the facility on November 14, 2021, and two days later, on November 16, 2021, R1 began receiving Home Health Care that provided services with all ADL’s, personal hygiene and incontinence care. After R1 sustained an unwitnessed fall, in December 2019, R1's family hired a private caregiver to provide 24-hour care and supervision, subsequently, due to financial constraints the services from the private caregiver reduced to 16 hours due to finances.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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-20200130105004
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 OF LA MESA
FACILITY NUMBER: 374604079
VISIT DATE: 06/14/2021
NARRATIVE
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An interview with the Resident Services Coordinator (RSC) revealed the facility caregivers continued to provide normal services in addition the Home Health agency and a private caregiver. A review of R1’s facility and medical records revealed logs of bathing and toileting/incontinence care on a consistent basis while at the facility.

It was also alleged R1 was kept in isolation. Staff interviews revealed R1 would participate in facility activities on occasion, and after dinner would remain in the common area and watch TV with the other Residents. Interviews with outside sources and record reviews revealed R1 had consistent care from multiple agencies the entire length of stay at the facility, as well as visitations.

It was alleged facility staff did not properly manage R1’s medication. Medical records revealed during R1’s medication management was overseen by outside sources for the entire duration of R1’s stay at the facility. A medical record review that on February 2, 2020 R1’s physician discontinued all prescriptions except for comfort medication. An Interview with the Reporting Party alleged R1 was given a discontinued medication due to not facility staff using an old version of the physician’s medication order. A review of the facility records and outside records did not indicate any medication errors. Interviews with the facility med tech was unaware of any medication errors. LPA was unsuccessful interviewing outside sources regarding the allegation.

Due to lack of corroborating evidence, the finding regarding the above allegations were established to be unsubstantiated. This finding means although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted with ED Armour and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was emailed to ED Armour at the end of the visit. An electronic email read receipt confirms the documents were received.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5