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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:36:22 AM

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
12/09/2022 and conducted by Evaluator Carol Fowler
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221209135142
FACILITY NAME:WESTMONT OF PINOLEFACILITY NUMBER:
079200801
ADMINISTRATOR:DOCTOLERO, BENJIE FFACILITY TYPE:
740
ADDRESS:2850 ESTATES AVETELEPHONE:
(510) 758-1122
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:100CENSUS: 51DATE:
12/15/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Jerrick Hall, RSDTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Insufficient staffing to meet residents' needs
INVESTIGATION FINDINGS:
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On 12/15/2022 at 9:40PM, Licensing Program Analysts (LPAs) C. Fowler an L. Hall arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings for the allegations above. LPA met with Residents Service Director, Jerrick Hall and explained the reason for visit.

During the investigation, LPAs interviewed Staff 1 (S1) and obtained the following documents, staff roster, facility roster, and November staffing schedule. S1 stated during interview the facility was short staffed in the month of November. During record review LPAs observed that on11/24/2022 there were three (3) staff scheuled for the day but only 2 were working at the same time Staff 2 (S2) and Staff 3 (S3).

Based on LPAs interviews 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
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
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 2
Control Number 15-AS-20221209135142
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: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2022
Section Cited
CCR
87705(4)
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87705 Care of Persons with Dementia
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
This requirement is not met as evidenced by:
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Licensee agreed to submit a written plan on how the facility will cover shifts in case of an emergency and submit an updated LIC500 by POC date.
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Based on LPAs observation licensee did not comply with the section cited above by facility not having an adequate number of staff for residents which poses a potential health and safety risk.
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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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2