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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 02/09/2022
Date Signed: 02/09/2022 01:20:52 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
02/01/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220201101723
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: 49DATE:
02/09/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Syritta Rogers, Resident Service Director
Lydia Hertzler, Regional Director of Operations		TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not following infection control guidelines
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/9/2022 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and delivered findings for the allegation above. LPA met with Resident Service Director, Syritta Rogers and informed her the reason for visit. Also present was Contra Costa County's Infection Prevention Control Program Manager, Christina Ponce.

During the course of investigation, LPA interviewed 2 staff and reviewed facility's mitigation plan. LPA toured facility including memory care unit, assisted living areas, dining room, and other common areas.

Interviews with staff indicated there was no dedicated staff that was only working with positive residents. Staff stated that they were assigned to the positive resident, but also working with negative residents too. Per facility's mitigation plan dated 12/30/2020, dedicated staff would be assign to work with positive residents only. LPA observed that staff was in the common area during visit with other negative residents. (Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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-20220201101723
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 PINOLE
FACILITY NUMBER: 079200801
VISIT DATE: 02/09/2022
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
LPA observed staff in the yellow zone was only wearing a KN95 mask and visitor in the yellow zone was only a surgical mask. Per CCLD and Contra Costa County guidelines, staff and visitors should be wearing an N95 mask and face shield. Also, gowns and gloves should be warn when staff/visitors go into the resident's room.

LPA was informed that facility had 3 new resident admissions in the past 3-4 weeks. Per Contra Costa County guidelines, outbreak facilities cannot admit new residents unless cleared by the COST (Community Outbreak Support Team). Facility still have active positive cases and did not have clearance from COST to admit new residents.

LPA observed staff working with positive residents are co-mingling with staff that are working with negative residents. LPA was informed that there is not a separate break area or bathroom for staff working with positive residents. Facility did not have clean PPEs located outside of isolation room or in the yellow zone.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220201101723
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 PINOLE
FACILITY NUMBER: 079200801
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2022
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:
1
2
3
4
5
6
7
Facility has agreed to comply with CCLD and county guidelines by making changes recommended by COST. Facility will submit a new infection control plan and picture prooof to CCLD by POC date.
8
9
10
11
12
13
14
Based on investigation, licensee did not comply with the section cited above by not following infection control guidelines which poses a potential health and safety risk to the persons in care.
8
9
10
11
12
13
14
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: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3