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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 04/25/2024
Date Signed: 04/25/2024 05:17:26 PM


Document Has Been Signed on 04/25/2024 05:17 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:WESTMONT OF MILPITASFACILITY NUMBER:
435202744
ADMINISTRATOR:BECKER, GREGORYFACILITY TYPE:
740
ADDRESS:80 CEDAR WAYTELEPHONE:
(408) 770-9575
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:225CENSUS: 171DATE:
04/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Gregory BeckerTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a Case Management visit and met with Administrator, Gregory Becker. The purpose of the visit is to follow-up on an incident report the Department received regarding medication error at the facility which occurred on 04/9/2024.

On 4/10/2024, the Department received an incident report regarding a medication error for resident (R1) which resulted in R1 taking additional dosage of medication which exceeded physician's order.

Based on interview with ADM and Resident Service Director (RSD), the facility manages R1's medication and R1's family brought and left medication in R1's room without the knowledge of facility staff. The facility's medication technician (Med-Tech) administered the medication as per doctor's orders. R1 administered two doses of medication on her own with the medication bottle available in the room.

During visit, LPA Rai reviewed R1's Physician's Report dated 3/22/2024, which states R1 has Dementia and is not able to administer own prescription and PRN medications and is not able to store own medication.

LPA Rai requests that Administrator, Gregory Becker submit a Plan of Action to address the ongoing staff training and mitigations that will be put in place to prevent future medication errors.

No deficiencies were cited at this time as per California Code of Regulations Title 22. An Advisory Note was issued, please see LIC 9102. This report was reviewed with Administrator, Gregory Becker and a copy of this report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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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