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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604079
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:20:13 PM


Document Has Been Signed on 05/29/2024 04:20 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: 92DATE:
05/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Sabrina Priesman Executive DirectorTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Sabrina Priesman Executive Director.  During today's visit, LPA observed residents in care, conducted a health and safety check, reviewed records, and interviewed staff and residents.

The purpose of today's visit was to conduct follow up regarding a self reported incident. On May 18, 2024, the Department received an incident report from the facility describing an incident that occurred on May 16, 2024, where staff discovered that Resident 1's (R1's) medication was not being administered as ordered. [Please refer to the LIC811 Confidential Names List to identify individuals]. Interviews with S2 revealed that the resident is not a self-administrator of medications.  The health and service plan reflects that R1 is not a self-administrator of medications and R1's medications were ordered from P1. S2 stated that S1 noticed that R1's medication was running low and S1 ordered the medication from P1. R2 directed S1 to call P2 to have the medication delivered to the facility. P2 delivered the incorrect medication, the correct medication was delivered on May 19, 2024 and R1 starting taking the medication on May 19, 2024.

Interviews with S2 and review of R1's electronic medication administration record (E-MAR) revealed that the medication was not given to R1 from May 12, 2024 through May 18, 2024. The Physician was notified of the medication error and staff was directed to monitor R1 for no adverse side effects of the missed medication. Interview with S2 revealed that R1 had not been experiencing any adverse effects due to the medication not being administered not as ordered.

The following deficiency for medication administration is being cited and noted on the attached LIC809-D page. An exit interview was conducted with Executive Director Sabrina Priesman whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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Document Has Been Signed on 05/29/2024 04:20 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: WESTMONT OF LA MESA
FACILITY NUMBER: 374604079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2024
Section Cited
CCR
87645(c)(2)

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87465 Incident Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by:
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RSD conducted an in-service training for staff on proper medication administration and verification by 6/29/2024 after discovering the medication error.
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Based on interview and record review, the licensee did not ensure that R1's medication was administered as ordered by the physician. This poses a potential health risk to 1 of 92 residents in care.
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ILS

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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) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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