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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604079
Report Date: 02/28/2023
Date Signed: 02/28/2023 05:12:41 PM


Document Has Been Signed on 02/28/2023 05:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MESAFACILITY NUMBER:
374604079
ADMINISTRATOR:ARMOUR, DAVIDFACILITY TYPE:
740
ADDRESS:9000 MURRAY DRTELEPHONE:
(619) 369-9700
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:164CENSUS: 121DATE:
02/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Business Office Director Mayra Rodriguez and Compass Rose (Memory Care) Director Eva AmorimTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Concierge Dareen Mattie. LPA then met and explained the purpose of the visit with Business Office Director Mayra Rodriguez and Compass Rose (Memory Care) Director Eva Amorim.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the San Diego Regional Office on 02/10/2023. According to the report, management recently learned about two incidents from their caregivers: a) there was a night Staff #1 (S1) yelled at Resident #1 (R1) to go to bed and turned off the television (which R1 was watching), causing R1 to become “visibly upset,” and b) there was a day S1 yelled at R1, “berated” R1 for having a moment of incontinence, and physically checked R1’s briefs in a common area in front of other residents. [See LIC 811 Confidential Names List for a description of person identifiers used in this report.]

During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed R1 and staff. CCLD verified that R1 was physically unharmed/uninjured. Due to their baseline disorientation and memory loss, R1 was not able to participate as a reliable historian in this investigation. According to their latest LIC602 Physician’s Report, R1 was diagnosed with dementia.

According to staff interviews and personnel records: upon learning of the allegations, facility managers put S1 on administrative leave pending internal investigation. Per licensee’s internal investigation: S1 denied the allegations. However, there were at least three co-workers who corroborated each of events described in the above SOC341 report. Witnesses revealed that S1's actions made R1 cry. According to interviews and personnel records: Licensee terminated S1’s employment on 02-09-2023 as result of their investigation.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023
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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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 OF LA MESA
FACILITY NUMBER: 374604079
VISIT DATE: 02/28/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Rodriguez, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/28/2023 05:12 PM - 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 OF LA MESA
FACILITY NUMBER: 374604079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2023
Section Cited

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87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff…”
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Per personnel records and staff interviews: Licensee terminated S1’s employment at the facility effective 02-09-2023. Licensee agreed to use a third-party source to retrain remaining staff on Residents’ Personal Rights (as described in regulations 87468.1 and 87468.2). Licensee agreed to send a copy of the training sign-in sheet (which will include the instructor’s full name, signature, and agency) and any handouts used to LPA by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff (S1) did not accord dignity to 1 of 121 residents (R1), which posed a potential personal rights risk to persons in care.
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Type B
03/30/2023
Section Cited

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87468.1(a)(3) Personal Rights of Residents in All Facilities: “(a) Residents in all residential facilities for the elderly shall have all of the following personal rights: (3) To be free from…abuse…” This requirement was not met, as evidenced by:
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Per personnel records and staff interviews: Licensee terminated S1’s employment at the facility effective 02-09-2023. Licensee agreed to use a third-party source to retrain remaining staff on Elder Abuse Prevention and Mandated Reporter Requirements. Licensee agreed to send a copy of the training sign-in sheet (which will include the instructor’s full name, signature, and agency) and any handouts used to LPA by the POC due date.
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Based on records and interviews, licensee staff (S1) did not ensure 1 of 121 residents (R1) was free from abuse, which posed a potential personal rights risk to persons 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023
LIC809 (FAS) - (06/04)
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