435202744-4-25-2024-26-AS-RMAO-D55UVC-20240510155455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 04/25/2024
Date Signed: 04/25/2024 05:14:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2024 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20240322090615

FACILITY NAME:	WESTMONT OF MILPITAS		FACILITY NUMBER:	435202744
ADMINISTRATOR:	BECKER, GREGORY		FACILITY TYPE:	740
ADDRESS:	80 CEDAR WAY		TELEPHONE:	(408) 770-9575
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	225	CENSUS: 171	DATE:	04/25/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator, Gregory Becker		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff forcefully pushed resident to a wheelchair.
Facility staff was rough when assiting resident with postural support.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator (ADM) Greg Becker and stated the purpose of today’s visit.

On March 22, 2024, the Department received a complaint alleging facility staff was rough when assisting a resident with a postural support. It has also been alleged facility staff forcefully pushed a resident to a wheelchair.

Continuation in LIC 9099-C, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20240322090615

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WESTMONT OF MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 04/25/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 2 of 3.

On March 21, 2024, Local Law Enforcement (LLE) interviewed resident, R1. R1 stated S1 entered his/her room and told R1 his/her dinner was here. S1 told R1 to that he/she needed to get up. R1 stated as he/she was walking towards the living room, R1 placed his/her hand on R1’s upper back and slightly pushed R1 forward. R1 stated the pushing didn’t increase his/her existing pain. R1 stated S1 tried to put on R1’s back brace, but S1 didn’t know how to properly secure it. R1 stated, he/she pressed her call button to summon help. R1 stated S1 had shaken the brace aggressively.
R1 stated during this incident, staff S2 came for five minutes, but then left. R1 stated he/she did no tell S2 what had happened because R1 was scared. R1 stated S2 later returned and helped R1 back to the bed. R1 stated S1 has assisted her in the past.

On March 21 and 27, 2024, LLE interviewed Staff S2 and Staff S3. S3 stated he/she received a call on his/her radio to help R1 with his/her back brace. S3 stated S1 looked upset. S3 stated he/she assisted R1 remove his/her back brace. R1 told S3 that S1 was aggressive with him/her but didn’t mention how. S3 stated he/she did not hear an argument or yelling prior to entering R1’s room. S3 stated he/she never saw S1 shake R1.

LLE interviewed Staff S2. S2 stated he/she received a page that R1 pressed his/her alert pendant. S2 opened the door to R1’s apartment and saw R1 sitting in the couch chair in the living room. S2 saw S1 standing by the counter in the kitchen. S2 asked R1 why he/she pressed her pendant. R1 stated she needed help with his/her back brace. S2 stated he/she did not see S1 attempting to put the brace on R1. S2 stated he/she contacted another caregiver to help with the back brace. S2 stated R1 didn’t look scared or upset.

On March 28, 2024, Licensing Program Analyst, Manuel Monter interviewed resident R1. R1 stated, S1 put the walker in front of him/her and then moved him/her by pushing him/her on the walker. R1 stated S1 pushed him/her until he/she got to the living room. R1 stated then when he/she arrived to his/her chair, S1 pushed him/her, to his/her chair. R1 stated he/she has a wheelchair, but he/she didn't use it that day.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240322090615

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WESTMONT OF MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 04/25/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 3 of 3.

On April 18, 2024, Licensing Program Analysts Manuel Monter and Simi Rai interviewed Resident Services Director, RSD. RSD stated the resident was assessed for bruises and/or marks. RSD stated R1 was observed to not have any bruises or marks.

Based on a review of R1’s Progress notes dated March 23, 2024, a head-to-toe assessment was done on R1. No signs of bruising was observed. R1’s skin is intact and no reports from care staff of any skin issues.

Based on a review of S1’s training records obtained during today’s visit, S1 received in-service training on 3/12/2024 for approximately 1 hour on “Donning/Doffing Brace” which was provided by Home Health Physical Therapist.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies were cited at this time as per California Code of Regulations Title 22.This report was reviewed with Administrator, Gregory Becker and a copy of this report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 3