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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200801
Report Date: 02/18/2022
Date Signed: 02/18/2022 01:06:04 PM

Document Has Been Signed on 02/18/2022 01:06 PM - 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: 48DATE:
02/18/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Donna Bautista-Colmenares, Executive DirectorTIME COMPLETED:
01:15 PM
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On 2/18/2022 at 12:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an proof of correction (POC) visit for the deficiency cited on Complaint Investigation conducted on 2/9/2022. LPA met with Executive Director (ED), Donna Bautista-Colmenares.

LPA received POC (picture proof & in-service training) for CCR 87468.1(a)(2) on 2/11/2022 via e-mail.

On this date LPA observed "yellow zone" signs were posted on resident's doors, PPEs stations located on each floor, memory care unit had specific PPE supply rooms. Staff was wearing N95 mask and face shields. During visit, LPA obtained a copy of the new mitigation plan (LIC808). LPA cleared deficiency as of 2/18/2022.

No deficiencies are being cited on this date.

POC letter for CCR 87468.1(a)(2) was printed and given to ED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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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