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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 07/30/2024
Date Signed: 07/30/2024 04:52:24 PM


Document Has Been Signed on 07/30/2024 04:52 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: DATE:
07/30/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH: Resident Service Coordinator, Fely ArqueroTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Resident Service Coordinator, Fely Arquero. Administrator was not present at the facility and busy at the time of the visit.

The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an informal meeting held on 04/26/2024.

LPA Rai reviewed staff in-service training summaries conducted from 04/23/2024 - 07/30/2024 on topics included but not limited to: "Elopement", "Skin Breakdown Monitoring", "Reporting Change of Condition", "When and Why to Call 911", "Fall Reduction Program", "Preventing Heat Related Illness", and "Fire and Safety". Each in-service training included facility's policies and procedures on training topics.

No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Resident Service Coordinator, Fely Arquero and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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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