435202744-12-12-2022-26-AS-KHOS-CMKQUM-20221229112859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 12/12/2022
Date Signed: 12/12/2022 04:34:42 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/15/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220715145551

FACILITY NAME:	WESTMONT OF MILPITAS		FACILITY NUMBER:	435202744
ADMINISTRATOR:	BRAVO, SHERYL		FACILITY TYPE:	740
ADDRESS:	80 CEDAR WAY		TELEPHONE:	(408) 770-9575
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	225	CENSUS: 97	DATE:	12/12/2022
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Lauren Powell, ED		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Resident was physically abused while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver the investigation finding, and met with Executive Director (ED) Lauren Powell.

On 7/15/2022, the Department received a complaint that resident was physically abused while in care.

On 7/22/0222, An initial investigation visit was conducted. LPA interviewed ED, 1 staff (S1), and 2 residents (R1, R2). Resident's physician report and Appraisal Needs and Service plan were obtained.

Continued, see LIC 9099-C. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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 2

Control Number 26-AS-20220715145551

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WESTMONT OF MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 12/12/2022

NARRATIVE

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Resident was physically abused while in care:

On 7/22/2022 and 08/04/2022, LPA interviewed Executive Director (ED) Lauren Powell and Memory Care Director, Natalie Jones (S1). ED and S1 stated R1 has dementia and had similar incident experience at previous skilled nursing home facility where R1 had accused being abused while in care. ED stated R1's family member (FM) was aware of R1's dementia and they want R1 to remain residing in the facility.

ED and S1 both stated that R1 might have confused the facility from the previous facility. ED and S1 both stated that the facility could not identify who is the alleged staff in the facility due to lack of details as to who, when and where the abuse occurred. ED and S1 assessed R1 immediately after they were notified of the alleged abuse, there were no bruising or sign of injures observed or found on R1's body on 7/15/2022.

On 7/22/2022, LPA interviewed R1. R1 stated a facility staff threatened to physically harm her/him. R1 could not remember when and where the alleged abuse occurred. R1 stated that he/she never seen the abuser, it was only that time.

On 8/8/2022, LPA interviewed R1's family member (FM). FM stated that he/she could not confirm if the incident really did occur or not because R1 had similar allegations at the previous facility. FM stated R1 was assessed, no bruises or signs of abuse on his/her body.

Based on the documents reviewed and interviews conducted, there was not enough evidence to indicate that the resident was physically abused or threatened. R1 confirmed he /she was threatened but not physically harmed by staff. R1 had similar allegations at another facility.

The Department has investigated the above allegation. Based on investigation, 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.

Exit interview was conducted with ED. This report was provided to ED for signature. A copy of this report was provided to ED.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

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