374604079-1-30-2024-08-AS-DNGN-CZZ3M4-20240130172142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604079
Report Date: 01/30/2024
Date Signed: 01/30/2024 05:22:10 PM

Document Has Been Signed on 01/30/2024 05:22 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 MESA		FACILITY NUMBER:	374604079
ADMINISTRATOR:	GARCIA, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	9000 MURRAY DR		TELEPHONE:	(619) 369-9700
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	164	CENSUS: 143	DATE:	01/30/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Executive Director Kimberly Garcia		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dang Nguyen 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 01/29/2024). According to the LIC624: on 01/27/2024, Resident #1 (R1) eloped from the facility (meaning they left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] Staff responded to a door alarm, located R1 in the facility’s parking lot, and brought R1 back inside, unharmed. During today’s visit, LPA performed a brief facility tour and welfare check, verifying that R1 was indeed unharmed. LPA inspected the facility’s delayed-egress doors in its memory care section, finding them audible and operational. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 03/31/2023), R1 was diagnosed with Dementia and their doctor determined that they were not able to safely leave the facility unassisted. The LIC603 Preplacement Appraisal, Care Assessment, and Plan of Care which Licensee performed on R1 corroborated these same points. Due to their baseline memory-loss and language impairment, R1 was not able to participate as a reliable historian/interviewee in this case. Per LPA observation and corroborated by staff interviews: R1 lived in the facility’s secured “Compass Rose” memory care section. This section features four (4) delayed-egress doors, which unlock and open 30 seconds after the panic bar is pressed (assuming staff do not first enter a code to reset/rearm the door and its associated alarm). [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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: 01/30/2024

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[CONTINUED FROM LIC 809]

According to date and time stamped records, which were corroborated by staff interviews: On 01/27/2024 around 4:35 PM, staff heard one of the Compass Rose delayed-egress door alarms go off. When staff arrived at this specific door, no resident was near it. Staff, per their training, performed a team search of the interior and exterior of the facility building. Staff located R1 in the facility’s parking lot at 4:46 PM, unharmed.

Per manager interviews: The Compass Rose PM Shift is considered “fully staffed” with one (1) Medication Technician and four (4) Caregivers. According to the staff work schedule, and corroborated by staff interviews: During the incident, Compass Rose had two (2) Medication Technicians and four (4) Caregivers on duty.

No deficiencies were cited during today’s visit. However, LPA issued two (2) Technical Violations (TVs), regarding signage affixed to delayed-egress doors and reporting requirements (see the LIC 9102-TV pages). LPA also issued Technical Assistance (TA) regarding electronic equipment issued to care staff (see the LIC 9102-TA page).

An exit interview was conducted with Garcia, to whom a copy of this report, the LIC9102-TV, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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