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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 04/26/2024
Date Signed: 04/29/2024 09:37:43 AM


Document Has Been Signed on 04/29/2024 09:37 AM - 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:
04/26/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Vice President of Operations Steven Harms,
LVN Regional Resident Services Director Angelica Rothhaupt,
Executive Director/Administrator Gregory Becker 		TIME COMPLETED:
03:00 PM
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A Noncompliance meeting was conducted on April 26, 2024 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analysts Simi Rai and Mita Partoza, Vice President of Operations Steven Harms, LVN Regional Resident Services Director Angelica Rothhaupt, and Executive Director/Administrator Gregory Becker.

The purpose of the noncompliance meeting was to discuss the history of facility's serious violations cited under Title 22 California Code of Regulations to include Personal Rights, Incidental Medical and Dental Care, Observation of the Resident, Reappraisals and Reporting Requirements.

Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2 year monitoring plan by licensing which includes more frequent licensing inspections.

The San Bruno Adult and Senior Care - San Jose Unit will refer the facility for legal consultation which may result in administrative actions such as possible Administrator De-Certification, License Revocation, or Employee Exclusion.
The Licensee was informed during non-compliance meeting that additional civil penalties for serious bodily injury are pending review. RO will refer the facility to the Department’s technical support program (TSP) and provided a TSP brochure, Community Care Licensing Division (CCLD) website www.cdss.ca.gov.

Report was reviewed with Licensee representatives. A copy of this report, LIC 9111 was provided to Licensee representatives during today's office visit.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
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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