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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 09/16/2024
Date Signed: 09/16/2024 02:41:31 PM


Document Has Been Signed on 09/16/2024 02:41 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: 167DATE:
09/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Gregory BeckerTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards an incident report, which stated a resident had eloped from the facility. LPA's met with Administrator Gregory Becker. LPA's explained the purpose of the visit.

On August 26, 2024, the Department received an incident report, regarding resident R1. The incident report stated on August 20, 2024, at 12:10am, staff noted that resident R1 was not in his/her bedroom. Staff conducted immediately conducted a census of all memory care residents to account for the whereabouts of R1. During the census, local law enforcement arrived with resident R1, who was found outside the facility.

On September 16, 2024, LPA interviewed 1 staff, and facility Memory Care Director.

LPAs determined that the above incident requires further investigation. 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 the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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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