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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604079
Report Date: 04/04/2024
Date Signed: 05/01/2024 01:51:22 PM


Document Has Been Signed on 05/01/2024 01:51 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
SAN DIEGO RO, 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: 89DATE:
04/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sheryl McCaskill Operation SpecialistTIME COMPLETED:
11:00 AM
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On April 4, 2024, Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced case management visit at the facility. LPA was greeted by Sheryl McCaskill Operation Specialist and granted entry after identifying herself. LPA met with Sheryl McCaskill Operation Specialist and explained the purpose of the visit.

The facility self-reported an incident to Community Care Licensing on March 21, 2024 regarding an incident that occurred on March 19, 2024. Reporting indicated that Resident 1 (LIC811 Confidential Names list provided to Administrator to identify R1) had an unwitnessed fall which resulted in a change in condition. R1 refused to go to the hospital the day of the fall on March 19, 2024. On March 20, 2024 at 1:15 pm R1 was sent by ambulance to the hospital for further evaluation and treatment.

During today’s visit, LPA conducted a Health and Safety check of R1 and requested facility records. No deficiencies were cited at this time.

An exit interview was conducted with Sheryl McCaskill Operation Specialist and a copy of this report and Licensee/Appeal Rights (LIC 9058 03/22) was provided.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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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