435202744-6-7-2024-26-AS-KHOS-D6BLC7-20240617083751

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 06/07/2024
Date Signed: 06/07/2024 04:05:25 PM

Unfounded

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
05/02/2024 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20240502140812

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:	DATE:	06/07/2024
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Administrator Gregory Becker		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff physically abused resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Gregory Becker.

On May 2, 2024, the Department received a complaint alleging staff physically abused resident. It has been alleged that a resident stated staff were abusive to him/her on April 15, 2024.

On April 15, 2024, Local Law Enforcement (LLE) responded to a report that R1 was out of control and trying to hurt other residents and caregivers. Upon arrival, R1 kept saying staff hurt R1's hands and were abusive to him/her.

LLE interviewed Staff S2, who stated he/she was trying to calm down R1. S2 stated R1 grabbed his/her fingers and twisted them. S2 stated R1 was also trying to bite him/her. S2 stated staff did not hurt R1 and were not physically abusive towards him/her. Page 1 Out of 3.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

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-20240502140812

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: 06/07/2024

NARRATIVE

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LLE interviewed staff S4, who stated R1 was screaming and yelling in the common area. S4 stated R1 grabbed the collar of his/her scrubs and was pushing staff. S4 denied hurting R1.

LLE interviewed staff S5, who stated R1 was verbally aggressive staff and residents. S5 stated R1 tried to bite him/her and was pushing and hitting. S5 denied being physical towards R1.

LLE attempted to interview R1, but R1 would not speak to LLE. LLE examined R1 for any visible injuries. LLE observed a band aid on R1's fingers. LLE did not see any bruising.

On May 9, 2024, LPA Manuel Monter interviewed residents R1-R4. All residents interviewed stated the staff do not hurt residents and are very nice. All residents interviewed stated they do not remember the incident that occurred on April 15, 2024. All residents interviewed are located in the memory care unit.

On May 9, 2024, and June 4, 2024, LPA Monter interviewed Staff S1-S5. Staff S2-S5 stated R1 was agitated and trying to hit staff and other residents. Staff S2-S5 denied the allegation that staff hurt R1’s hand and were abusive to him/her. Staff S1 stated he/she assessed R1 on the April 17 and did not see any signs of bruising or injuries noted.

Based on a review of facility incident report, dated April 17, 2024, the incident report states on April 16, 2024, at 8:00pm, caregivers observed that R1 was agitated. R1 was walking down the hallway and trying to open the doors of the other residents and banging on the doors with his/her hands. Staff tried to de-escalate R1 to no avail. R1 tried to pick up chairs to throw them at the staff. R1 continued to be physically aggressive an attempted to bite the staff and spit at them. R1 was out of control and was showing signs of harm to other residents, staff and self. Medtech called 911 for further assistance. R1 was sent to Kaiser Santa Clara ER."

Based on a review of R1’s Physicians Report, dated March 27, 2024, states R1 has a neurocognitive disorder. R1 is also confused/disoriented and may sun-down.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240502140812

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: 06/07/2024

NARRATIVE

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Based on a review of R1’s Needs and Services Plan, dated April 17, 2024, states R1 gets very agitated and would use walker to ram door/walls, try to hit and yell at staff. R1 is uncooperative and resistant to care assistance.

The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited, an exit interview conducted with Administrator, Gregory Becker and a copy of the report was provided.

END OF REPORT

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC9099 (FAS) - (06/04)

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