374604079-6-19-2024-08-AS-SJAB-D6EM48-20240620091620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604079
Report Date: 06/19/2024
Date Signed: 06/19/2024 04:02:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
06/09/2023 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20230609102359

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: 126	DATE:	06/19/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Sabrina Priesman Executive Director		TIME COMPLETED:	11:36 AM

ALLEGATION(S):

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Staff pushed resident causing a bruise.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced complaint investigation visit to conduct follow-up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Sabrina Priesman Executive Director.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, records review, and a tour of the facility.

It was alleged that a staff grabbed resident’s shoulder causing a bruise. Review of resident 1 (R1) (Please refer to LIC811 with confidential names), medical records revealed that R1 has a memory impairment and a diagnosis of dementia, R1 was not able to recall the events that occurred.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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 3

Control Number 08-AS-20230609102359

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/19/2024

NARRATIVE

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Continued from LIC9099

Review of R1’s facility records revealed that R1 had a history of agitation and did not like staff to redirect her by getting close to her. Interviews revealed that on June 6, 2023 during activities Staff 1 (S1) observed Staff 2 (S2) walking R1 backwards and sat R1 down on a chair roughly. Staff 3 (S3) also observed S2 treating R1 roughly because R1 was not listening to redirection from S2. Staff 4 (S4) also observed S2 walking R1 backwards aggressively. S1, S3 and S4 reported the incident to S5.

On June 8, 2023 S5 requested Staff 6 (S6) to complete a body check on R1 and S6 discovered a quarter size bruise on R1's upper right arm. S5 concluded that S2 did not apply any of the elder abuse training that was received during S2's hiring period and monthly training. S5 discovered two previous counseling within S2's four months of working at the facility. S5 was terminated on June 8, 2023.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, the allegation is deemed substantiated. The following deficiencies are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Executive Director XX, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20230609102359

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/28/2024 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) residents... shall have all of the following personal rights (3) to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Immediate risk has been removed, LPA verified with the Licensee that S2 is no longer working at the facility as of 06/08/2023. Licensee will conduct an in-service training on reporting requirements, personal rights, and abuse training for staff and provide sign in sheet.
	8 9 10 11 12 13 14	Based on interviews and records review, the Licensee did not ensure R1 was free from abuse resulting in bruising. This poses an immediate personal rights risk to 1 of 126 residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

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