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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202006
Report Date: 08/07/2024
Date Signed: 08/07/2024 02:52:11 PM

Document Has Been Signed on 08/07/2024 02:52 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
CCLD Regional Office, 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:
08/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:16 AM
MET WITH:Grace MenorTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Deficiencies visit and met with Administrator (ADM) Grace Menor.

On 06/19/2024, the Department of Developmental Services conducted a semi-annual inspection at the facility. The facility was not compliance with Title 22 Regulations.

During the inspection, it was observed that staff S1 conducted tracheal suction on resident R1. S1 put on non-sterile gloves and used an unsheathed suction catheter for suction of R1. S1 cleared the catheter with saline irrigation and placed a gauze over the remaining solution in the container, then replaced the suction catheter back into the package. Suction catheter packaging and saline solution are designated for single use only. These single use items were observed reused in the facility.

The deficiency was noted during the inspection. Citation is issued today. See LIC809-D.

Exit interview was conducted with ADM. The reports were provided to ADM for signature. A copy of the reports was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 08/07/2024 02:52 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 07/31/2024 at 08:58 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CA NATIONAL MENTOR - WESTMONT HOME
FACILITY NUMBER: 435202006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2024
Section Cited
CCR
80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement was not met as evidenced by:
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Administrator stated to send a plan of correction and staff training log to ensure staff follow the compliance protocol for the procedures for tracheal suction and the usage of saline solution for residents by the POC due date.
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Based on the observation, the facility did not ensure staff's procedures for tracheal suction follow the compliance protocol. it was observed that S1 used an unsheathed suction catheter for suction of R1, and cleared the catheter with saline irrigation and placed a gauze over the remaining solution in the container, then replaced the suction catheter back into the package. Suction catheter packaging and saline solution are designated for single use only. These single use items were observed reused in the facility.This poses/posed a immediately health, safety risk to persons 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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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