<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601300
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:12:16 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240216154646
FACILITY NAME:WESTMONT OF BRENTWOODFACILITY NUMBER:
075601300
ADMINISTRATOR:AGUSTIN SAMANIEGOFACILITY TYPE:
740
ADDRESS:450 JOHN MUIR PKWYTELEPHONE:
(925) 516-8006
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:200CENSUS: 103DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Scott Shahade, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff pushed resident resulting to resident sustaining injuries
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/19/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with Executive Director/administrator (ED/ADM) to deliver the finding of above allegation. LPA explained the purpose of the visit with ED.

During investigation, the department obtained the following documents from administrator – Personnel record, Residents roster, R1’s admission agreement, physician's report, Needs/Services plan, Hospice care plan, incident report, hospital discharge report. Health & safety check conducted see LIC 809 dated 02/22/24.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
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 15-AS-20240216154646
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WESTMONT OF BRENTWOOD
FACILITY NUMBER: 075601300
VISIT DATE: 02/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff pushed resident resulting in resident sustaining injuries.
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff (ED, S1, S2, S3, S4), residents (R1, R2, R3, R4), R1’s responsible party (POA), third party witnesses (W1, W2) and reviewed resident (R1) documents. Review of R1’s records showed she was first admitted at the facility on 03/03/22 and resided in the memory care unit due to dementia. On 02/16/24 around 0600 hours, R1 exhibited exit-seeking behaviors by attempting to leave the facility through one of the back doors of the memory care unit. S1 attempted to stop R1 from leaving which started an argument. R1 acted aggressively against S1 by yelling racial slurs and by pushing/shoving her walker into S1. S1 reacted by pushing R1’s walker back into the resident causing her to fall resulting in R1 sustaining a close compression fracture of the L-4 vertebra and forehead contusion. Another staff (S2) stated she witnessed the entire incident. S2 stated that S1 pushed R1 in an aggressive manner, that it was not an accident. Other staff (S3, S4) stated that when they arrived at the incident, S1 told them that R1 pushed her walker at her so she pushed R1’s walker back at her. S1 admitted she pushed R1 but did not intend for her to fall. In addition, S2 stated S1 used both hands aimed at R1’s collar bone to aggressively push R1 down. Afterwards, S1 gathered her belongings and left the building without helping R1. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff pushed resident resulting in resident sustaining injuries was found to be substantiated.

Immediate civil penalty of $500 assessed during visit for staff physical abuse of resident while in care.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240216154646
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WESTMONT OF BRENTWOOD
FACILITY NUMBER: 075601300
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2025
Section Cited
CCR
87468.1(a)(3)
1
2
3
4
5
6
7
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

1
2
3
4
5
6
7
Immediate civil penalty of $500 assessed during visit due to resident injuries sustained from abusive staff.

Incident was investigated internally and S1 terminated on 02/20/24. Also, Memory Care Director was also terminated on 04/26/24.
8
9
10
11
12
13
14
This requirement was not met as evidenced by staff physically abusing a resident which posed a potential health & safety risk to residents in care.
8
9
10
11
12
13
14
Deficiency corrected during visit.
In-service staff retrainings on how to properly redirect dementia residents with behaviors completed on 02/21/24. ED gave LPA copy of completed staff re-trainings.
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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3