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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 12/20/2024
Date Signed: 12/20/2024 03:01:36 PM

Substantiated


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
05/21/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20240521185706
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: DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gregory BeckerTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Facility did not notify POA that the resident will need higher level of care resulting in increase rate.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Executive Director, Gregory Becker.

On 05/21/2024, the Department received the complaint. On 05/29/2024, the initial complaint investigation was conducted. The following documents were obtained to include the compass rose resident roster, memory care schedule for May 2024, illness tracking form for GI Illness/Norovirus/Other illness, and resident (R1)’s physician’s report, service plan, admission agreement, account statement ledger, and other correspondences.

It was alleged that the facility did not notify resident (R1)’s power of attorney (POA) that resident (R1) will need higher level of care resulting in an increased rate. See LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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 7
Control Number 26-AS-20240521185706
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: 12/20/2024
NARRATIVE
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The review of R1’s account ledger shows that R1’s level of care cost increased from $1,325 to $2,450 in March 2024. This new level of care cost was carried through until May 2024. In June 2024, R1's care cost decreased to $1,950.

On 05/29/2024, 3 staff members were interviewed. Based on staff interview, it was stated that because R1’s assessment was at the 6 month time-frame, a re-assessment was completed due to that reason and not because R1 needed a different level of care or there was a change in condition. The review of R1’s service plan dated 05/14/2024, shows that R1’s level of care decreased from a care level 5 (05/20/2023) to a care level 3 (05/14/2024). The facility was unable to produce documentation to reflect an updated care plan showing the care increase between February 2024 – March 2024.

Based on interview with staff (S4), the level of care cost is reflected from the assessments which are discussed with the resident’s authorized representative and director in memory care. If a resident’s level of care is being increased, S4 would mail a letter to the resident’s POA regarding the notice of the increased level of care cost.

Based on the admission agreement between the facility and R1, it stated that upon a change in the care needs that will result in increase points the facility will provide a written notice to the resident or representative, if any, within two business days of providing service at the new level of care that results in a rate increase. It states that the notice will include a detailed explanation of the additional services provided and charges associated with such. Based on interview with the ED, record review and observation the facility was unable to produce any documentation that was provided to R1’s POA regarding the increase of level of care cost to include an updated care plan and written notice. Based on staff interview, the staff was unable to provide an explanation as to why R1’s care cost increased in March 2024.

The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with the Executive Director, Gregory Becker and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20240521185706
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2024
Section Cited
CCR
87507(f)
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(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:
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Licensee will have a discussion with the home office and accountants regarding R1's ledger from March - May 2024 for possible credits back into R1's account. Licensee will provide an update to the Department regarding this concern.
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Based on interview, record review and observation the licensee did not comply with this section wherein the licensee did not provide R1's authorized representative with a written notice regarding the level of care increase prior to charging R1 the new care cost which poses an immediate health, safety and personal rights risk to persons in care.
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Licensee will submit an outline of their procedures regarding notification of level of care increase. Licensee will submit this POC to LPA Dolores via email by POC due date of 12/21/2024.
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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.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
05/21/2024 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20240521185706

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: DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gregory BeckerTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Facility did not notify family and visitors of scabies outbreak
Facility did not allow resident to get his/her own electric wheelchair
Facility’s memory care unit is severely under staff resulting in neglect of resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Executive Director, Gregory Becker.

On 05/21/2024, the Department received the complaint. On 05/29/2024, the initial complaint investigation was conducted. The following documents were obtained to include the compass rose resident roster, memory care schedule for May 2024, illness tracking form for GI Illness/Norovirus/Other illness, and resident (R1)’s physician’s report, service plan, admission agreement, account statement ledger, and other correspondences.

It was alleged that the facility did not notify family and visitors (of those who were not affected) of a scabies outbreak in the memory care unit. On 05/22/2024, the reporting party (RP) also alleged that the resident’s families were not notified after resident’s were experiencing intestinal distress. Page 1 of 4.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 26-AS-20240521185706
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: 12/20/2024
NARRATIVE
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The RP provided a photograph of a memo that was posted at the memory care unit dated 05/18/2024, which provided as a notification to the residents and families of a flu like bug that was going around causing residents to be sick. The memo advised to refrain from visiting at this time and to continue washing hands often and hand sanitize.

Based on interview with staff (S3), family members of those residents who were affected by scabies were contacted. A memo was also posted in the memory care unit as part of the notification. Residents who were itching were immediately treated and their family member were also notified. It was stated that they only notify family who were affected by the scabies. It was stated that they did not notify every family member, but they did post a memo in the memory care unit.

On 05/29/2024, the Executive Director (ED) was interviewed. Based on interview, the ED states that they notify the community of potential concerns verbally and through a memo they post. Mass notifications were done only for COVID-19, however, not with the stomach flu. It was stated that they only notify the resident’s family if the resident was affected.

Per the reporting party, a memo was posted in the memory care unit but no email was sent to the family members notifying family of the scabies outbreak.

The review of the facility’s infection control policy and procedures dated in 2023 includes a checklist to notify residents and responsible parties which could be done by posting a sign at the entrance. In the facilities infection control plan, there is no indication of a mass email required to be sent to all residents and/or their responsible parties.

It was alleged that R1’s physician prescribed R1 with an electric wheelchair, however the facility did not allow resident (R1) to use the electric wheelchair to help with R1’s mobility.
Page 2 of 4.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20240521185706
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: 12/20/2024
NARRATIVE
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Based on interview with staff (S2), it was stated that in the past, R1 would get angry and would wheel him/herself towards people in his/her manual wheelchair. S2 stated that there would be times when R1 would try to run over staff in his/her manual wheelchair.

On 05/29/2024, 8 staff members were interviewed. Based on staff interviews, the care staff denied observing R1 attempt to hurt staff or residents with his/her wheelchair. Staff stated that sometimes R1 would get upset, however, denied having aggressive or inappropriate behavior towards residents and staff with his/her wheelchair.

Based on record review of R1’s physician’s report it indicates that R1 is confused/disoriented and has aggressive, wandering, and sundowning behaviors. The review of R1’s service plan dated May 2024 and signed in June 18, 2024 shows that R1 needs occasional support due to disruptive, aggressive, or socially inappropriate behaviors. R1’s care plan notes that at time R1 will lost his/her temper.

Based on interview with staff (S2), R1 had been determined to be unsafe in an electric wheelchair in the memory care unit as there were concerns that R1 may hurt him/herself and others.

It was alleged that the facility’s memory care unit is severely understaffed as there is only 3 caregivers in memory care, in which the ratio is 1 caregiver to 10 residents. It was alleged that due to the shortage of staff, residents care needs are being neglected as staff are not able to respond quick enough. For example, a resident’s responsible party asked staff for help to change R1, but the staff replied stating he/she couldn’t help because other residents had a bowel movement and also needed help.

On 05/29/2024, 5 staff members in memory care were interviewed. Based on staff interview, it was stated that the facility’s memory care is understaffed and staff are overwhelmed. It was stated that the facility management reduced the staffing ratio from 4 caregivers to 3 caregivers, in which each caregiver is assigned about 10 residents to their group. Page 3 of 4.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20240521185706
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: 12/20/2024
NARRATIVE
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Staff stated that due to the reduction of staff, it’s affected the resident’s quality of care. Staff expressed the difficulty to attend to the residents when needed but because they work so hard they are able to take care of their needs where the residents are not neglected.

On 05/29/2024, 3 staff from the management team was interviewed. Based on interview, 3 out of 3 staff denied the facility’s memory care unit being understaffed. It was stated that they divide the residents in groups based on their care and services. It was stated that they are not looking for more staff and more staff will be added if they get more residents and hospice residents. Staff stated that with the current resident census of 29 residents, their staffing is sufficient.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Gregory Becker and a copy of the report was provided.

Page 4 of 4.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7