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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200801
Report Date: 05/20/2021
Date Signed: 05/20/2021 11:34:20 AM

Document Has Been Signed on 05/20/2021 11:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WESTMONT OF PINOLEFACILITY NUMBER:
079200801
ADMINISTRATOR:JOSEPHINE DAVISFACILITY TYPE:
740
ADDRESS:2850 ESTATES AVETELEPHONE:
(510) 758-1122
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 100CENSUS: 55DATE:
05/20/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Josephine Davis, AdministratorTIME COMPLETED:
11:55 AM
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On 05/20/21 at 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced Health and Safety check as a result of the department receiving a priority 2 complaint. LPA explained the reason for the visit with administrator. LPA observed all staff wearing face masks at the facility. LPA observed COVID-19 signs posted throughout the facility. The front entrance had a screening station for all staff, residents, visitors to be checked for COVID-19 symptoms upon entry with a plexi-plastic divider at the front desk for added safety.

During the health and safety check, LPA toured facility with administrator, including but not limited to bedrooms, kitchen, bathroom, and common areas. LPA observed 12 memory care residents watching TV and doing stretching exercises in the activities room with 4 staff wearing masks. LPA observed 3 assisted living residents wearing masks walking around the common areas with their pet dogs on leashes. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2021
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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