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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 07/21/2022
Date Signed: 07/21/2022 05:44:13 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
07/14/2022 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20220714114937
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:
07/21/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Kathy Boyd, Business Office DirectorTIME COMPLETED:
06:10 PM
ALLEGATION(S):
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Staff are not following COVID protocols
INVESTIGATION FINDINGS:
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On 7/21/2022 at 2:45PM, Licensing Program Analysts (LPAs), C. Fowler and L. Hall arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the above allegation. LPAs met with Kathy Boyd, Business Office Director, and explained the reason for the visit.

During the course of the investigation, LPAs interviewed Staff and obtained the following documents: staff schedule and COVID results for staff. During interviews with Staff all stated that COVID protocols are to call in sick, come to the facility to be tested ,and stay off for 5 days if asymptomatic and 10 days if symptomatic. Staff also stated that the med techs are the staff that works with any positive residents. During record review and interviews LPAs observed that the facility has not been reporting COVID positive staff or Residents to CCLD or Local Public Health. S1 stated that reporting of COVID positives stopped when a change of Executive Director occurred in May.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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-20220714114937
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: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2022
Section Cited
CCR
87211(a)(1)
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87211 (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including,... (1)A written report shall be submitted... and to... within seven ... of any of the... This report shall include the... of admission; date and nature of event;...; and disposition of the case. This requirement was not met as evidence by:
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Business Office Director agreed to submit a copy of the LIC624 for each staff that was COVID Positive to CCLD by POC date.
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Based on LPA's observation licensee did not comply with the section cited above by not reporting COVID positive staff/residents to CCLD, which poses a potential health and safety risk to clients in care.
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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: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220714114937
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: 07/21/2022
NARRATIVE
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continued from LIC 9099

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. a copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3