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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202006
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:57:10 PM

Document Has Been Signed on 12/16/2024 12:57 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CA NATIONAL MENTOR - WESTMONT HOMEFACILITY NUMBER:
435202006
ADMINISTRATOR/
DIRECTOR:		GRACE MENORFACILITY TYPE:
734
ADDRESS:1750 WESTMONT AVE.TELEPHONE:
(408) 364-1499
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 5CENSUS: 5DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Grace Menor, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Marcella Tarin and Kenneth Madrigal conducted an unannounced annual inspection and met with Administrator (ADM) Grace Menor. ADM states the facility has 5 clients and 5 staff. This facility is licensed to serve 5 developmentally disabled adults ages 18 and over with special health needs. LPAs toured the exterior and interior of the facility with ADM to include the kitchen, office, client rooms, dining room, bathrooms, and backyard. All exit and passageways were free and clear of obstruction.

LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPAs observed the medication storage area, knives storage area, and cleaning product storage areas in the kitchen were locked and inaccessible to clients in care. The facility thermostat temperature display was observed at 68 degrees F. LPAs measured hot water temperature with a range of 105.2 to 106.3 degrees F.

The facility was equipped with smoke and carbon monoxide detectors. Facility's fire system was last inspected in 04/10/2024. Fire extinguishers were last serviced on 11/09/2024. LPAs observed the facility's first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed. The facility's last drill was on 11/16/2024 and drills are being conducted monthly.

LPAs toured 5 client bedrooms. 5 out of 5 client bedrooms had a bed, functioning lights, a chair, dresser and storage room for personal belongings.

LPAs reviewed 5 staff records. 5 out of 5 staff records were observed to be complete and included but not limited to fingerprint background clearance, health screening with TB results, personnel records and current CPR/First Aid certification.

See LIC809-C

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CA NATIONAL MENTOR - WESTMONT HOME
FACILITY NUMBER: 435202006
VISIT DATE: 12/16/2024
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LPAs reviewed 5 client records. 5 out of 5 client records were observed as complete to include but not limited to current medical assessments, admission agreements, needs/services plans, emergency contact information, and consent forms.

LPAs reviewed 5 client's Centrally Stored Medication and Destruction Records (CSMDRs). 5 out of 5 clients CSMDRs were observed to be complete, with all medication documented.

LPAs reviewed 5 clients P&I records with the ADM. LPAs observed 5 out of 5 client's P&I records to have all money documented accurately.

No deficiencies were cited today per California Code of Regulations, Title 22. An exit interview was conducted with ADM Grace Menor and a signed copy of this report was provided.

SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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