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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604079
Report Date: 02/29/2024
Date Signed: 02/29/2024 04:54:14 PM

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
08/11/2022 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20220811140908
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: 138DATE:
02/29/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Kimberly GarciaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Neglect resutling in serious injury from resident on resident altercation.
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 Execuive Director (ED) Kimberly Garcia.

The Department’s investigation included staff, resident, and outside source interviews, and facility and outside source records reviews.

It was alleged lack of supervision resulted in an altercation between two residents causing one (1) resident to sustain serious bodily injury. Staff, resident, and outside source interviews revealed on August 8, 2022, at approximately 10:00 P.M. Resident 1 (R1) was assaulted by Resident 2 (R2) in R1’s room. Staff and outside source interviews and an outside source records review revealed R1 sustained large lacerations and skin tears. Staff interviews and records reviews also revealed both residents resided in the memory care unit of the facility.

[CONTINUED ON 9099C]
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: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
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 6
Control Number 08-AS-20220811140908
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: 02/29/2024
NARRATIVE
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 A resident records review revealed R1 was admitted to the assisted living unit of the facility on October 19, 2019, with a diagnosis of Chronic Kidney Disease, Hypertension, AFIB, and Type II Diabetes. A review of resident records dated May 18, 2022, revealed R1 was showing symptoms of confusion, disorientation and wandering behaviors. On July 7, 2022, R1 was transferred from assisted living to the memory care unit of the facility. Staff interviews revealed R1 kept to themselves, and mainly stayed in their room. Staff interviews and a resident records review revealed R2 was admitted to the facility on August 17, 2020, with a primary diagnosis of Alzheimer’s disease, but no signs of aggressive behavior. An interview with Staff 1 (S1) revealed R2 was non-verbal and had a routine of walking in circles around the hall and a tendency to wander into other resident’s rooms. R2 would not show signs of agitation before they became aggressive and assault the caregivers and R2 had only physically assaulted staff, never a resident. The interview with S1 also revealed Outside Source 1 (OS1) hired a Private Caregiver (PC), however the PC opted to be reassigned due to R2’s aggression. An interview with Staff 2 (S2) revealed R2 was difficult to redirect because they would become angry and mean, and on occasion would spit on staff and other residents, although S2 was surprised by R2’s extreme violent behavior against R1 during the current incident. An interview conducted with Staff 3 (S3) revealed when R2 was first admitted they were pleasant but soon had a mental decline and was extremely emotionally unbalanced. S3 corroborated that R2 was a wanderer and had a tendency to wander into other resident’s rooms. A facility records review revealed, in contrast to staff statements, on November 20, 2020, R2 physically assaulted another resident in care and on December 20, 2020, a resident records review revealed R1 was assessed as in need of a Personal Care Attendant (the amount of time was not unspecified) due to their behaviors, and on May 5, 2022, approximately three (3) months prior to the incident under investigation, R2 was assessed as in need of a Personal Care Attendant every day for four (4) times a day. Interviews conducted with the Executive Director (ED) and S3 revealed R2’s Primary Care Physician (PCP) was adjusting their medications to address these behaviors prior to the incident.

[CONTINUED ON 9099C]
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20220811140908
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: 02/29/2024
NARRATIVE
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The interview with S3 also revealed on the day of the incident there were four (4) staff working in the memory care unit that housed approximately 28 to 30 residents, and R2 did not have a Personal Attendant or Private Caregiver. An interview with Staff 4 (S4) revealed, on the day of the incident, at approximately 7:00 p.m. they had checked on R1, and they were resting in bed conversing with a visitor. S4 also revealed checking on R2 at approximately 8:00 p.m. and could not locate R2 and asked a staff member regarding R2’s whereabouts and the caregiver pointed across the unit where R2 was observed walking down the hall towards R1’s room, S4 didn’t think anything of it because it was R2’s normal daily routine to walk the unit halls. Approximately 10 minutes later, Staff 5 (S5) came running down the hall towards S4 stating R2 had been injured and R1 was in their room. S4 and S3 ran to R1’s room and found R1 in their bed covered in blood and S4 immediately called 911 and began attending to R1’s injuries, while S5 escorted R2 out of the room. S4 revealed they asked R1 what happened, and they said they walked out of their bathroom and saw R2 was in their room sitting in their recliner. R1 asked R2 why they were in their room and told them to leave. R1 revealed after telling R2 to leave they began attacking them, and when R2 ceased the attack they sat back down in the recliner and R1 called the front desk receptionist for help from their phone, although memory care staff already knew by the time the receptionist tried to notify them

Staff interviews revealed both residents were transported to the hospital. An outside source records review revealed R1 had dark blue Ecchymosis (contusions) on the right side of their face, and Ecchymosis and skin tears to their left side of their face, upper chest, bilateral upper and lower arm, and right anterior thigh, requiring wound care. R1’s injuries were caused by scratching and hitting during the assault by R2. R1’s injuries were treated and bandaged and R1 was discharged back to the facility the following day. An interview conducted with the ED revealed R2 remained at the hospital in restraints due to their agitation and was diagnosed with a Urinary Tract Infection (UTI). Upon discharge R2 was relocated to another facility.
[See LIC 811 for confidential names]

Based on evidence obtained, the allegation is substantiated because the preponderance of the evidence standard has been met. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D.

An exit interview was conducted with ED Garcia and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) was provided. ED signature below confirms receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20220811140908
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: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2024
Section Cited
CCR
84761(A)
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The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1)tends to wander; (2) is confused or forgetful (5) has a documented history of behaviors which may result in harm to self or others.

This requirement was not met as evidenced by:
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Executive Director agreed to have all staff attend a CCL approved training on assessing changes in behavior/conditions to determine appropriate level of care.

Proof of training will be provided by POC due date.
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 Based on records reviews and interviews, the licensee did not ensure the amount of supervision determined necessary by assessments for one (1) Resident 1 [R1] in care which posed an immediate safety risk to 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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
08/11/2022 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20220811140908

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: 138DATE:
02/29/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director (ED) Kimberly GarciaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Illegal eviction
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 Execuive Director Kimberley Garcia

The Department’s investigation included a staff interview and outside source records review.

It was alleged the Licensee issued an unlawful eviction to a resident. An Outside Source 1 (OS1) interview and an outside source record review alleged the Executive Director (ED) would not allow Resident 2 (R2) to return to the facility after their hospital stay, or R2 would need a private care giver upon return. An interview conducted with the ED revealed R2 was never told they could not come back to the facility and that it was a miscommunication.

[CONTINUED ON 9099C]
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: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20220811140908
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: 02/29/2024
NARRATIVE
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The ED revealed being in communication with R2’s POA regarding what was best for R2. An Outside Source 1 (OS1) record review revealed OS1 had been misinformed and recanted that the ED ever said R2 could not return to the facility upon discharge. An additional outside source records review revealed a meeting with the facility staff and outside sources determined R2 needed a higher level of care.

Based on staff and outside source interviews, as well as an outside source records reviews, the above allegation was determined to be unsubstantiated. An unsubstantiated finding means although the allegation could be valid the preponderance of evidence standard was not met.

An exit interview was conducted with ED Garcia. A copy of this report and Licensee/Appeals Rights (9058 01/16) will be provided to ED Garcia at the conclusion of the visit. Signature below confirms receipt of the documents.

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

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6