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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 02/23/2023
Date Signed: 04/06/2023 02:48:27 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
06/30/2022 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20220630152422
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:
02/23/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Benjie Doctolero, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Resident's rates were raised without proper notification.
Resident's Representative was not provided with a notice setting forth the reason(s) for a rate increase.
Resident's Representative was not provided with a general description of costs pertaining to a rate increase.
INVESTIGATION FINDINGS:
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*This is an amendment to an original 9099 dated 2/21/2023*
*This is an amendment to the original 9099 of 2/23/2023. A new final 9099 with 9099-D form was generated on 3/24/2023.

On 02/23/2023 at 2:45PM, Licensing Program Analyst (LPA), C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPA met with Benjie Doctolero, Administrator and Jerrick Hall RSD and explained the reason for the visit.

During the course of the investigation the Department interviewed 3 staff (S1, S2 and S3) and Reporting Party (RP); and obtained & reviewed the following documents: facility and staff roster, Resident Face Sheet, Resident Status Change Form, Residency Agreement, Move in Worksheet, Move out Notice, Bill Delivery Request Form, Shower Schedule AM/PM Shift, Physician's Report, Fairmount Podiatry Group (person responsible for payment form), Physician Communication, Narrative Charting, CA MC Health and Service Evaluation Results and Service Plan.
CONTINUE ON LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
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 6
Control Number 15-AS-20220630152422
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: 02/23/2023
NARRATIVE
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Continue from LIC9099

Resident's rates were raised without proper notification.

RP stated that R1 rates were raised without proper notification. LPA interviewed S1 and S2 and requesting the facility provide correspondence showing that the facility provided the RP with proper notification of rent increase. The Department obtained a record indicating an annual adjustment to the rent which would have increased approximately 14.9%. Facility failed to provide any documentation showing rent increase due to R1 status change. During an interview with S2 once the doctor declared a resident with dementia, they are automatically moved to memory care unit which is a part of the admission agreement.

Based on interviews and record review the facility failed to provide the Department with proof of correspondence for the increase in rate change, therefore this allegation is SUBSTANTIATED.

Resident's Representative was not provided with a notice setting forth the reason(s) for a rate increase.

RP stated that she was not provided with the reason for the rate increase. During record review the department reviewed the Physician communication which states family needs to be informed of change in condition and need for higher level of care-Memory Unit. The Department requested proof of contact between RP and the facility via letter or email. The facility failed to provide the Department with proof of contact.

Based on interviews and record review the facility failed to provide the Department with proof of correspondence for the reason (status change) for the rate change, therefore this allegation is SUBSTANTIATED.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 15-AS-20220630152422
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: 02/23/2023
NARRATIVE
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Continue from LIC9099

Resident's Representative was not provided with a general description of costs pertaining to a rate increase.

RP stated that the facility did not provide a description of costs pertaining to the rate increase. The Department requested description of cost pertaining to the rate increase, the Department received a copy of R1’s Resident Status Change Form which shows the effective date, new apartment style, apartment number and new rent amount and transfer reason (change in condition) however the RP stated that she did not received any information.

Based on interviews and record review the facility failed to provide the Department with proof of correspondence for the general description of cost pertaining to the rate change, therefore this allegation is SUBSTANTIATED.

Exit interview conducted and a copy of this report and appeal rights provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
06/30/2022 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20220630152422

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:
02/23/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Benjie Doctolero, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Resident's hygiene needs not being met while in care.
Resident's Representative's requests for communication with staff were not responded to in a timely manner.
INVESTIGATION FINDINGS:
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On 02/23/2023 at 2:45PM, Licensing Program Analyst (LPA), C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPA met with Benjie Doctolero, Administrator and Jerrick Hall RSD and explained the reason for the visit

Resident's hygiene needs not being met while in care.

RP stated that R1’s hygiene needs were not met while R1 was in care. The Department conducted a record review which shows R1 was scheduled for showers on Wednesday’s PM shift. An interview with S3 that stated R1 would shower approximately once a week, R1 would refuse a shower on Wednesday evenings but would agree to shower on Thursdays. S3 stated R1 would complain about her toenails. S3 also stated that she would assist R1 with her laundry.

Based on interviews and record review the Department has investigated the above allegation and found they are Unsubstantiated

Continue on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20220630152422
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: 02/23/2023
NARRATIVE
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Continue on LIC9099A

Resident's Representative's requests for communication with staff were not responded to in a timely manner.
RP stated that her requests for communication with staff was not responded to in a timely manner. RP did not provide the Department with proof of any attempts to contact the facility. RP also stated that she wished to withdraw her complaint and refused to continue communication with the Department.

Based on interviews and record review the Department has investigated the above allegation therefore the allegation above is Unsubstantiated.

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

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20220630152422
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: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2023
Section Cited
HSC
1569.655(a)
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***This is an amended report from visit on 2/24/2023***
Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase; application of section
(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or... rate structures for services...the residents' representatives setting forth... the reason for the increase...
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***This is an amended report from visit on 2/24/2023***
Administrator will review admissions agreement California Code of Regulations 87507 as well as Health and Safety Code 1569.655. Administrator will self certify that regulations were read and understood by POC date.
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This requirement was not met as evidenced by;
Based on LPA observations and interview conducted licensee failed to provide written notice to resident/ responsible party establishing level of care change and/or rate increase which poses a potential health and safety risk to residents in care.
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Type B
04/18/2023
Section Cited
CCR
87507(g)(3)(B)(4)(5)
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***This is an amended report from visit on 2/24/2023***00
(g) Admission agreements... following:
(3) Payment provisions,... following:
(B) Rate for additional items...
4. If the licensee offers additional ... agreement was signed, a list of these ...representative. 5.A statement acknowledging ... services that were not available at the time the admission ... resident’s representative, if any... admission agreement.
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***This is an amended report from visit on 2/24/2023***
Administrator will review admissions agreement California Code of Regulations 87507(g)(3)(B)(4)(5), and re-train staff and submit staff sign in sheet & training materials to CCLD by POC date.
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This requirement was not met as evidenced by: Based on LPA observations, record review and interviews conducted licensee failed to provide written notice to resident/ responsible party establishing a rate increase which poses a potential health and safety risk to residents 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: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6