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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601300
Report Date: 06/16/2025
Date Signed: 06/16/2025 03:08:21 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
02/19/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250219100005
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: 100DATE:
06/16/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Scott Shahade, Executive DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Illegal eviction
Facility staff did not ensure resident took medications as prescribed
Facility staff did not ensure resident's call pendant was working
Facility staff did not ensure resident's bedroom light was working
Facility staff did not ensure resident's bathroom had toilet paper
Facility staff did not safeguard resident's belongings
Facility staff did not prevent residents from engaging in inappropriate behaviors towards each other
INVESTIGATION FINDINGS:
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On 06/16/2025 at 12:30PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to deliver findings for the above allegations. LPA met with Scott Shahade, Executive Director and explained the purpose of the visit.

During the course of the investigation, LPA T. Syess-Gibson interviewed staff, LPA was unable to interview resident (R1) due to diagnosis on physician report (LIC602). LPA attempted to interview complainant but was unsuccessful. R1’s admission agreement, physician’s report, and incident reports dated November 11, 2024, and January 19, 2025 were reviewed and obtained.

Continue on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
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-20250219100005
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WESTMONT OF BRENTWOOD
FACILITY NUMBER: 075601300
VISIT DATE: 06/16/2025
NARRATIVE
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Continued from LIC9099

staff roster with contact telephone numbers, resident’s roster with apartment numbers, device activity report (call button), maintenance log (work orders), housekeeping cleaning checklist were obtained and reviewed.

Illegal eviction

During the investigation, LPA reviewed an eviction notice issued by the licensee on 03/18/2025. After reviewing eviction notice, the 30-day notice does meet requirements in regulation 87224.

Facility staff did not ensure resident took medications as prescribed

During investigation, LPA reviewed Medication Administration Record (MAR) and observed R1’s medication was administered as prescribed.

Facility staff did not ensure resident's call pendant was working

During investigation, LPA reviewed work orders and toured R1 room and observed call button on the wall near bed and in the restroom was in operating condition. LPA also reviewed the work order report and did not see any reported issues with the call button for room #2.

Facility staff did not ensure resident's bedroom light was working

During interviews, it was revealed the facility changed the light bulb at the entrance of residents’ room the same day the light bulb went out.

Continue on LIC9099C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250219100005
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WESTMONT OF BRENTWOOD
FACILITY NUMBER: 075601300
VISIT DATE: 06/16/2025
NARRATIVE
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Continued from LIC9099C

Facility staff did not ensure resident's bathroom had toilet paper

During interviews and document review, it was revealed that housekeeping clean residents’ room weekly, replaces toilet tissue during the time of cleaning, if a resident needs toilet tissue in between the cleaning schedule it is replaced or if housekeeping sees toilet tissue running it will be replaced with a new roll.

Facility staff did not safeguard resident's belongings

During interviews, it was stated that R1 walks around with his box and leaves the box in random places such as dining room, activity room and television room in memory care. It was also stated that staff has found the box many times and returned it to the resident.

Facility staff did not prevent residents from engaging in inappropriate behaviors towards each other

During the investigation and review of documents, staff did take the proper steps in separating both residents during the time of the altercation and monitoring both residents after inappropriate behavior acts. The facility notified CCL , resident’s responsible person and has reached out to R1’s physician for a possible medication adjustment for new aggressive behaviors.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.



Exit interview conducted and a copy of report was given.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3