435202744-2-23-2024-26-AS-RMAO-D3LLG7-20240322084416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 02/23/2024
Date Signed: 02/23/2024 05:48:45 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
08/21/2023 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230821105004

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: 179	DATE:	02/23/2024
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Executive Director, Greg Becker		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff neglected a resident resulting in multiple fractures.
Licensee does not adequately staff facility to meet residents’ high level of care and needs.
Staff did not submit incident reports to Licensing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Executive Director, Greg Becker and stated the purpose of today’s visit.

On 8/21/2023, the Department received a complaint with the above allegations. On 8/22/2023, the Department conducted an initial investigation at the facility.

Based on the department’s investigation, resident (referred as R1) had motor impairment/paralysis and neurocognitive disorder and was considered fall risk. R1 required assistance with majority of his/her Activities of Daily Living (ADLs), which included standby assistance.

Continuation on LIC 9099-C, Page 1 of 4.

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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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 10

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
08/21/2023 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230821105004

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: 179	DATE:	02/23/2024
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Executive Director, Greg Becker		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff left resident(s) in wet and soiled diapers for an extended period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Executive Director, Greg Becker and stated the purpose of today’s visit.

On 8/21/2023, the Department received a complaint with the above allegation. On 8/22/2023, the Department conducted an initial investigation at the facility. On 2/23/2024, LPA Rai interviewed 1 staff.

Based on the Department’s investigation, resident (referred as R1) had motor impairment/paralysis and neurocognitive disorder and was considered fall risk. R1 required assistance with majority of his/her Activities of Daily Living (ADLs), which included standby assistance.

Continuation on LIC 9099-C, Page 1 of 3.

Unsubstantiated

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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 10

Control Number 26-AS-20230821105004

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: 02/23/2024

NARRATIVE

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Page 3 of 3.

On 11/30/2023, the Department interviewed Staff (S1) who stated R1 preferred female caregivers and staff including Med-Tech would check on R1’s wet undergarments. On 12/19/2023, the Department interviewed staff (S2) who stated residents are checked every 2 hours and every 30-60 minutes if the residents prefer to stay in their room. S2 stated that during the day, there are 6-7 facility staff monitoring residents in the common area, which include 3-4 caregivers. Based on staff schedule from 8/13/2023 – 8/26/2023, there were 4 caregivers on schedule for AM shift (6am-2pm), 3 caregivers for PM shift (2pm-10pm) and 2 caregivers in NOC shift (10pm-6am).

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Executive Director, Greg Becker and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 10

Control Number 26-AS-20230821105004

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: 02/23/2024

NARRATIVE

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Page 2 of 3.

Based on record review of R1’s Needs and Services Plan dates 2/22/2023, R1 needs total assistance for toileting, uses undergarments and R1 requires physical assistance with part of toileting tasks as well as daily skin checks due to skin condition to the groin/peri area. Based on Resident’s Care Summary, R1 was being assisted with frequent or unscheduled incontinence care, assistance with toileting for more than 3 times per day, which included bladder and bowel care.

On 11/15/2023, the Department interviewed with Assisted and Independent Living Resident Services Director (AL/IL RSD), who stated most resident normally spend time in the living room, but if residents are in their bedrooms, then staff check on the residents hourly to assist with incontinence care. AL/IL RSD stated R1 required full assistance with incontinence care.

Based on interviews conducted with staff (S1-S4), staff stated R1 would use the bathroom toilet and would rarely soil the undergarment. Staff would check on R1’s undergarments at minimum 5 times during AM shift (6am-2pm), at minimum 5 times during PM shift (2pm-10pm) and as needed during NOC shift (10pm-6am). Staff stated R1 would ask to be assisted to go to the bathroom and staff would provide stand-by assistance. S4 stated R1 had one episode of rash in the peri area, but it was resolved after using ointment in the affected area for a day. Staff stated R1 would verbalize if undergarments needed to be changed. S4 stated the facility does not document every time R1’s undergarments were changed, but it was a standard practice for staff to change the undergarments when soiled and during every shift change. S4 stated R1 would not remain in wet and soiled diapers for an extended period of time, since R1 would verbalize when to go to the bathroom, or the staff were regularly checking on R1’s undergarments. S4 stated the R1’s responsible party will provide incontinence products every 2 weeks. S4 stated they are changing the resident every shift and every day to ensure R1 has dry undergarments and would go through R1’s supply of incontinence products regularly.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 10

Control Number 26-AS-20230821105004

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: 02/23/2024

NARRATIVE

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Page 2 of 4.

Based on investigation, it was not clear on which caregiver was assigned to R1 on the days he/she sustained falls and injuries, which were 6/3/2023, 6/9/2023 and 8/13/2023. Staff recalled R1 wearing a foam splint on his/her pinky finger for a while. Staff were unaware that R1 fractured his/her ribs until the Department confirmed R1’s injuries based on medical records. Staff did not recall on how R1 sustained a dislocated left pinky finger and fractured ribs on 6/3/2023. Staff believed R1’s finger injury was from R1 scooting his/her chair forward and scrapping the fingers underneath a table.

On 10/2/2023, the Department interviewed R1’s responsible party (RP). RP stated the first incident occurred on 6/3/2023. R1 sustained a hand injury when he/she was trying to sit down, and another resident (R2) pushed R1 out of the way. R1 was not seen by a medical doctor until 6/5/2023. An X-Ray was done on R1’s hand and ribcage since R1 complained of pain on the left ribcage. The results showed R1’s finger dislocated and R1 sustained injuries to the ribs.

On 6/9/2023, the second incident occurred where R1 had another fall at the facility. R1 was pushed by another resident to the ground. The third incident occurred on 8/13/2023 when R1 was punched in the face by another resident in the living room. R1 began hyperventilating and was nauseous.

On 12/14/2023, the Department interviewed the former Resident Services Director (RSD). RSD explained standby assistance is when staff will walk with the resident, supervising residents during showers or toileting, but the staff do not assist when residents are sitting down. RSD stated R1 fell one or twice when he/she attempted to use the restroom by himself/herself. R2 was sent out to the hospital for an evaluation but does not remember the specific date of when R1 fell. RSD stated that in April/May 2023, during dinner service, a resident pushed R1 out of his/her chair. RSD was not aware of R1 sustaining any injuries on his/her ribs or anywhere else but was aware that R1 sustained bruising to his/her left hand.

On 11/30/2023, the Department interviewed staff (S1), S1 stated that he/she did not recall what happened when R1 sustained injuries to his/her left pinky finger, he/she did not recall when it happened. On 12/19/2023, the Department interviewed staff (S2), S2 stated that R1 is a fall risk who utilized a walker with standby assistance. S2 stated that R1 is not combative and does not have any self-injurious behaviors.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 10

Control Number 26-AS-20230821105004

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: 02/23/2024

NARRATIVE

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Page 3 of 4.

S2 did not know what happened or how R1 sustained the finger dislocation or the fractured ribs from 6/3/2023. S2 stated he/she not aware of R1 was brought to the hospital and had a brace on his/her finger and not aware of an altercation R1 had with another resident in 6/9/2023. On 12/14/2023, the Department interviewed Staff (S3) stated R1 lost her balance a lot and was a fall risk and needed a caregiver with her but did not have 1:1 supervision.

On 11/15/2023, the Department interviewed with Assisted and Independent Living Resident Services Director (AL/IL RSD) who stated that staff is assigned to sit and supervise the residents but was unable to provide the names of staff who were assigned to provide care and supervise for 6/3/2023, 6/9/2023 and 8/13/2023. AL/IL RSD was also unaware of the 6/3/2023 and 6/9/2023 incidents.

Based on available information gathered on the incident which occurred on 8/13/2023 in the living room where R1 and R2 had a physical altercation. 3 facility staff members heard both residents screaming and did not observe the residents' altercation. One staff member (S4) was in the kitchen/dining room when he/she heard R1 and R2 screaming and went to the living room and separated the residents after R2 hit R1 twice and R1 hit R2 back. R1 sustained a small cut and swollen upper lip and R2 had a small bruising marks on the hand. There was no documentation of a staff being present at the time of the altercation in the living room.

A review of R1’s Physician’s Report dated 2/14/2023, R1 had a diagnosis of neurocognitive disorder and motor impairment/paralysis on the left side weakness and is confused/disoriented but does not have aggressive behavior. Based on record review of R1’s Needs and Services Plan dated 2/22/2023, R1 does not have current history of disruptive, aggressive, verbal or socially inappropriate behaviors. R1 needs protection and supervision because resident makes unsafe or inappropriate decisions. R1’s mobility and gait are limited and balanced is decreased with left sided paralysis and is able to ambulate with walker and one-person assist.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 10

Control Number 26-AS-20230821105004

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: 02/23/2024

NARRATIVE

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Based on the investigation, R1 was not reappraised after being involved in multiple physical altercations resulting in injury during the month of June 2023 and August 2023. Based on review of R1’s Progress Notes from 5/10/2023 – 8/22/2023, facility staff did not document any changes in physical functions and the appropriate assistance provided when observation reveals unmet needs.

Based on the investigation and review of Incident Reports submitted by the facility, the Department did not receive an LIC 624 Unusual Incident / Injury Report from the facility for the incident which occurred on 6/3/2023. Based on review of email from Executive Director on 6/27/2023, R1 “bruised her finger. We do not have to report it to licensing” referring to the incident which occurred on 6/3/2023. The incident on 6/9/2023 and 8/13/2023 were reported to the Department wherein R1 sustained injury/fall after resident altercation. Due to the injuries sustained while the resident is under facility supervision, a written report shall be submitted to the Department within seven days of the occurrence of the event. As stated in California Code of Regulation 87211 Reporting Requirements, any incident which threatens the welfare, safety, or health of any resident need to be reported to the licensing agency.

Based on interviews and record review of the facility, the preponderance of evidence standard has been met therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.

An immediate civil penalty in the amount of $500 was assessed today. Additional civil penalties for the violation resulting in serious bodily injury is pending for further review.

This report was reviewed by the Executive Director, Greg Becker 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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 10

Control Number 26-AS-20230821105004

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: 02/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/01/2024 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety, or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Executive Director stated to submit a written plan of action understanding regulation by POC due date. Licensee/Executive Director agreed and understood.
	8 9 10 11 12 13 14	Based on interviews and record reviewed, of incident reports submitted to the Department, a report was not filed with the licensing agency addressed R1's injury in June 2023, which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 03/01/2024 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	87463 Reappraisals (a)...The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Executive Director stated to submit a plan of action understanding regulation by POC due date. Licensee/Executive Director agreed and understood.
	8 9 10 11 12 13 14	Based on record review, R1 did not have a reappraisal after multiple physical altercations in June 2023 and August 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 10

Control Number 26-AS-20230821105004

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: 02/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/02/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Executive Director stated to submit a written plan of action understanding regulation by POC due date. Licensee/Executive Director agreed and understood.
	8 9 10 11 12 13 14	Based on record review and interviews, R1's changes in physical, such as injuries sustained in resident to resident altercation, were not documented, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type A 02/24/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Executive Director stated to submit a written plan of action understanding regulation by POC due date. Licensee/Executive Director agreed and understood.
	8 9 10 11 12 13 14	Based on interviews and record review, the facility staff did not follow up on R1's injuries and R1's responsible party transported R1 to the doctor's clinic 2 days after the incident, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14

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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

Page: 9 of 10

Control Number 26-AS-20230821105004

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: 02/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/24/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 (a)(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Executive Director stated to submit a written plan of action understanding regulation and in-service training will ensure resident's rights are protected by POC due date. Licensee/Executive Director agreed and understood.
	8 9 10 11 12 13 14	Based on interview and record review, Licensee did not ensure that resident R1 received care, supervision and services to meet R1's care needs, which poses/posed 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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

Page: 10 of 10