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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 07/21/2021
Date Signed: 07/21/2021 11:41:05 AM

Unsubstantiated


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
05/18/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210518160827
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: 54DATE:
07/21/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Patrick Frazier, Operations Specialist/administratorTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
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5
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7
8
9
Resident sustained an unexplained, suspicious injury
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
8
9
10
11
12
13
On 07/22/21, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the findings of above allegation. LPA explained the reason for the visit with operations specialist/administrator.

During investigation, R1 had an unwitnessed fall while in the TV room on 05/17/21 which resulted in five stitches to her left cheek. Prior to 05/17/21 incident, R1 also had another unwitnessed mechanical fall on 05/13/21 that resulted in a bruise to her right eye. In both instances, R1 was taken to the hospital for treatment/evaluation and released back to the facility with increased staff monitoring to reduce the chance of a fall. Interviews with staff confirm R1 is a fall risk, has an unsteady gait and often forgets to use her wheelchair to walk around due to dementia. Facility staff has communicated with R1’s family to hire a one on one caregiver to help supervise R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

No deficiencies cited during this visit. Exit Interview conducted and a copy of this report provided to operations specialist/administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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