435294345-8-10-2021-26-AS-KHOS-C88HEQ-20211028060818

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294345
Report Date: 08/10/2021
Date Signed: 08/10/2021 04:26:02 PM

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
07/08/2021 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20210708115804

FACILITY NAME:	WESTMONT OF MORGAN HILL		FACILITY NUMBER:	435294345
ADMINISTRATOR:	BILLY MITCHELL		FACILITY TYPE:	740
ADDRESS:	1160 COCHRANE RD		TELEPHONE:	(408) 779-8490
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	112	CENSUS: 74	DATE:	08/10/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Billy Mitchell		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Resident needs are not being meet by the facility
Facility staff do not prevent resident to resident altercations
Facility staff do not allow residents to have visitors
Facility staff do not assist resident with medical and dental appointments.
Facility does not serve food of good quality
Facility does not safeguard resident's personal property

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Executive Director Billy Mitchell.

On 07/08/2021, the Department received a complaint with the above allegations. On 07/09/2021, LPA Marrufo conducted an initial complaint investigation visit. LPA Marrufo conducted a facility tour and made observations of resident rooms, kitchen areas, and meals being served to residents. Throughout the investigation, LPA Marrufo interviewed 7 residents, 10 staff, and 4 witnesses. LPA Marrufo also obtained the following documents for residents R1-R5 throughout the investigation: Physician's Report, Admissions Agreements, Needs and Services Plan, Emergency Contact Form, and Daily Logs. See LIC9099-C for more information. Page 1 of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

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 4

Control Number 26-AS-20210708115804

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 MORGAN HILL	FACILITY NUMBER: 435294345
	VISIT DATE: 08/10/2021

NARRATIVE

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LPA Marrufo obtained copies of staff training logs related to resident care and abuse for staff S1-S8. LPA Marrufo also obtained a memory care activities calendar and Physician and Medical Visits Policy.

5 out of 7 interviewed residents stated the facility is meeting resident needs. 2 out of 7 declined to give a response. 10 out of 10 interviewed staff stated the facility is meeting resident needs. 4 out of 4 witnesses stated the facility is meeting resident needs.

LPA Marrufo toured the living units of residents R1-R5. During interviews, facility staff and family members stated that resident R1 has a habit of hiding and losing R1’s dentures. LPA reviewed Daily Logs for R1 and observed there to be entries on 03/19/2021 and 07/06/2021 in which facility staff communicated to R1’s medical Power-of-Attorney (POA) stating that R1’s dentures had been lost. LPA Marrufo toured R1’s living unit and observed R1’s emergency call button to be located on top of R1’s dresser. LPA Marrufo observed the emergency call button did not have a lanyard attached to it. During visit, LPA Marrufo requested facility staff to attach the lanyard to the emergency call button and hang it over R1’s neck.

During interviews, a facility staff and a witness stated that R1 has a habit of keeping R1’s walker brake’s locked, which wears down the brakes on the walker. Both staff and R1’s POA stated that R1’s POA is responsible for providing a replacement walker.

4 out of 7 interviewed residents stated facility staff prevent resident to resident altercations. 3 out of 7 interviewed residents declined to answer. 10 out of 10 interviewed staff stated facility staff prevent resident to resident altercations. 4 out of 4 interviewed witnesses stated facility staff prevent resident to resident altercations.

See LIC9099-C for more information. Page 2 of 4.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20210708115804

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 MORGAN HILL	FACILITY NUMBER: 435294345
	VISIT DATE: 08/10/2021

NARRATIVE

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3 out of 7 interviewed residents stated facility staff do allow residents to have visitors. 1 out of 7 interviewed residents stated facility staff do not allow residents to have visitors. 2 out of 7 residents declined to answer. 10 out of 10 interviewed staff stated facility staff do allow residents to have visitors. 4 out of 4 interviewed witnesses stated facility staff do allow residents to have visitors.

3 out of 7 interviewed residents stated facility staff assist residents with medical and dental appointments. 1 out of 7 interviewed residents stated facility staff do not assist residents with medical and dental appointments. 2 out of 7 residents stated they did not know if staff assist residents with medical and dental appointments. 2 out of 7 residents declined to answer. 10 out of 10 interviewed staff stated facility staff assist residents with medical and dental appointments. 4 out of 4 interviewed witnesses stated facility staff assist residents with medical and dental appointments.

LPA Marrufo reviewed a copy of the Physician or Medical Visits policy, dated 10/19/2019. The policy states that if a resident is unsafe to be left without an escort to a physician or medical visit, the facility will arrange for a staff member to accompany the resident. During interviews with 3 out of 3 facility drivers, the drivers stated that it is the procedure of the facility to either meet a resident’s family member at a physician or doctor’s visit or escort the resident to the doctor’s visit and check the resident in to the appointment.

4 out of 7 interviewed residents stated the facility serves food of good quality. 1 out of 7 interviewed residents stated to not be sure if the facility offers food of good quality. 2 out of 7 residents declined to respond. 10 out of 10 interviewed staff stated the facility serves food of good quality. 4 out of 4 interviewed witnesses stated the facility serves food of good quality.

See LIC9099-C for more information. Page 3 of 4.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 26-AS-20210708115804

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 MORGAN HILL	FACILITY NUMBER: 435294345
	VISIT DATE: 08/10/2021

NARRATIVE

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LPA Marrufo observed the facility kitchen as meals were being prepared, the food cart that takes meal trays to the facility memory care unit, and the kitchen and dining area in the facility memory care unit. LPA observed food to be warm and stored in ovens. During meal service, LPA interviewed 4 residents while they were being served lunch and all 4 residents stated they thought the lunch was of good quality. LPA attempted to interview a 5th resident during meal service, but the resident declined to be interviewed.

LPA observed the food storage areas in the assisted living and memory care areas. LPA checked canned foods in the pantry and perishable foods in facility refrigerators and did not observe any expired foods or any unsealed foods.

4 out of 7 interviewed residents stated the facility safeguard’s resident’s personal property. 1 out of 7 interviewed residents stated to not know if the facility does not safeguard resident’s personal property. 2 out of 2 residents declined to respond. 10 out of 10 interviewed staff stated the facility safeguard’s resident’s personal property. 4 out of 4 interviewed witnesses stated the facility safeguard’s resident’s personal property.

Based on information from interviews conducted with staff, residents, and witnesses, review of records, and observations, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

An Advisory Note was issued. See LIC9102 for more information.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Executive Director Billy Mitchell and a copy of the report was provided.

Page 4 of 4.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4