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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294345
Report Date: 07/28/2023
Date Signed: 07/28/2023 03:26:12 PM


Document Has Been Signed on 07/28/2023 03:26 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 MORGAN HILLFACILITY NUMBER:
435294345
ADMINISTRATOR:JOLIE HIGGINSFACILITY TYPE:
740
ADDRESS:1160 COCHRANE RDTELEPHONE:
(408) 779-8490
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:112CENSUS: 76DATE:
07/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jolie HigginsTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Executive Director (ED) Jolie Higgins and Resident Service Director (RSD) Ria Hernandez.

On 07/24/2023, the Department received an incident report for resident (R1) reporting R1 had eloped from the facility on 07/22/2023. On 07/22/2023 at 11:20am staff noticed resident was missing when residents were being called for lunch. R1 was last seen at 11:10am. Staff checked all rooms, did a head count, and immediately went out of the community to look for R1. Within 10 minutes, R1 was found in close proximity from the facility. R1 was brought back to the community and re-assessed. The Fire Department was contacted to evaluate resident and no change of condition was found. Family was notified. During the facility’s investigation, it was found that one of the egress doors did not reset after the facility was experiencing several power outages from 07/21/23 – 07/22/23. Based on interview with the ED, 4 out of 5 delayed egress doors were checked after the power outage on 07/21/23 - 07/22/23. 1 out of 5 doors was missed during the checks, which was the door R1 had exited from. Based on record review, R1 is not able to leave the facility unassisted. After the incident, the facility immediately updated R1’s care plan and placed R1 on alert charting. The facility completed an in-service training with staff on Egress doors and Elopement. Going forward the facility plans to designate a staff to ensure all egress doors are functioning properly after an outage.

During visit, LPA toured the memory care section with ED, RSD, and Maintenance Director (MD). 5 out of 5 egress doors were tested in Memory Care. 4 out of 5 egress doors observed working. 1 out of 5 egress doors not observed working and would not open. This is the same door R1 had exited from. Based on interview, the doors were checked on 07/22/23 – 07/24/23 and observed in working condition. LPA observed the facility's egress door after a couple hours. LPA observed the door was able to open after inputting a code. The facility is currently in contact with the vendor to fix the sound system for the egress door.

A deficiency was cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED) Jolie Higgins and Resident Service Director (RSD) Ria Hernandez and a copy of the report was emailed to ED and RSD due to technical difficulties.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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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Document Has Been Signed on 07/28/2023 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 MORGAN HILL
FACILITY NUMBER: 435294345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2023
Section Cited
CCR
87705(k)(6)

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(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: (6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement is not met as evidenced by:
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Licensee corrected the deficiency before visit. POC cleared.
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Based on interview, record review and observation resident (R1) was able to elope from the facility through a delayed egress door that was not checked to be functioning properly after several power outages which poses an immediate health, safety, and personal rights risk to persons in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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