435202744-8-22-2023-26-AS-RMAO-CVUMQA-20230920094824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 08/22/2023
Date Signed: 08/22/2023 05:18:22 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
10/14/2021 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20211014163838

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: 144	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Executive Director, Lauren Powell		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident wandered away from facility due to lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced complaint visit to deliver investigation finding. LPA met with Executive Director (ED) Lauren Powell.

On 10/14/2021, the Department received a complaint of the above allegation. An initial complaint investigation visit was conducted on 10/21/2021 by LPA Steve Chang and interviewed staff (S1-S2).

Based on interview with facility staff, Staff (S1) stated resident (R1) has a 24-hour dedicated 1:1 caregiver. S2 stated R1 was not allowed to leave the facility unattended but R1 had the right to leave the facility with dedicated 24-hour 1:1 caregiver. On the day of the elopement incident, 10/8/2021, ED stated the 1:1 caregiver was not 24-hours but worked a shift from 2pm through 10pm. On 10/8/2021 at approximately 11:30pm, R1 exited the facility from the front door without the supervision of 1:1 caregiver or facility staff.

Continuation on LIC 9099-C, Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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-20211014163838

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: 08/22/2023

NARRATIVE

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Page 2 of 2.

On 10/15/2021, LPA Steve interviewed R1’s family members FM1-FM2. FM1 stated the law enforcement officer called FM1 and stated they have R1 in their custody and R1 was seen walking on Main Street, street near the facility. FM1 stated FM1 picked up R1 from the police officers and brought R1 to FM1’s home and not back to the facility. FM1 stated the resident was alone with the police officers and did not observe the facility staff nor the 1:1 caregiver with R1. FM2 stated R1 had a 24-hour 1:1 dedicated caregiver with R1 in the facility and R1 could leave the facility without the 1:1 caregiver.

On 08/04/2022, the Department continued investigation and LPA Chang interviewed Executive Director Lauren Powell (ED). ED stated R1 cannot leave the facility unattended but had the right to leave the facility with 1:1 caregiver. ED stated the facility staff called law enforcement immediately when R1 exited from the facility on night of 10/8/2021.

On 11/9/2022, the Department continued to investigate the allegations and LPA Simi Rai conducted a phone interview with Executive Director Lauren Powell (ED) and Tina, Business Office Director (BOD) and Conrado Duarte, Sales Director (SD). The facility’s front doors close at 8pm from the outside but anyone from the inside can leave through the doors without unlocking the doors. R1’s 1:1 caregiver’s shift ended at 10:00pm on 10/8/2021. At 11:30pm, S2 called law enforcement when R1 left the facility unassisted.

Based on review of R1’s Physician Report dated 9/30/2021, R1 has a dementia diagnosis and R1 is not able to leave the facility unassisted. R1 requires supervision and safety due to dementia diagnosis with sundowning behavior.

The Department has conducted an investigation of the above allegation. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed by Executive Director (ED) Lauren Powell and a copy of the report was provided. Appeal Rights was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20211014163838

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: 08/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/23/2023 Section Cited CCR 87468(a)(2)	1 2 3 4 5 6 7	Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodatins, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Executive Director submit a written plan on understanding regulations and schedule in-service and training to staff by POC date. Executive Director agreed and understood.
	8 9 10 11 12 13 14	On 10/8/2021, R1 who is demented left the facility through the front doors unassisted and was found by law enforcement unattended which poses an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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