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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:33:53 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 Daisy Panlilio
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: 66DATE:
08/22/2023
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Richard Remigio, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident's Representative was not provided with a general description of costs pertaining to a rate increase.
INVESTIGATION FINDINGS:
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On 08/22/23 at 2:20PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with executive director (ED) to deliver a plan of correction for above allegation that was not delivered by LPA C Fowler on 02/23/23. LPA explained the purpose of the visit with ED.

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 receive 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
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 2
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: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2023
Section Cited
CCR
87507(H)
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***This is an amended report from visit on 2/24/2023***
A provision indicating that an itemized monthly statement that lists all separate charges incurred by the resident that are collected by the facility shall be provided to the resident or the resident’s representative, if any.
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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(H), 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: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2