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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 06/12/2024
Date Signed: 06/12/2024 04:26:34 PM

Unsubstantiated


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
06/03/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20240603153742
FACILITY NAME:WESTMONT OF PINOLEFACILITY NUMBER:
079200801
ADMINISTRATOR:REMIGIO, RICHARDFACILITY TYPE:
740
ADDRESS:2850 ESTATES AVETELEPHONE:
(510) 758-1122
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:100CENSUS: 69DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
03:48 PM
MET WITH:SHANECE TUPUOLA (MC) COORDINATORTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal items.
Staff did not provide resident medication as prescribed.
Staff does not provide daily activities for resident.
INVESTIGATION FINDINGS:
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On 06/12/2024 at 3:48PM, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to conduct an initial 10-day complaint investigation and deliver complaint findings for the allegation above. LPA met with Shanece Tupuola, Memory Care Coordinator and explained the reason for the visit

During the course of the investigation LPA interview staff, toured facility and obtained and reviewed records.

Allegations: Staff did not safeguard resident's personal items.
Staff did not provide resident medication as prescribed.
Staff does not provide daily activities for resident.

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

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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-20240603153742
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: 06/12/2024
NARRATIVE
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Continue from LIC9099

Reporting party stated Staff did not safeguard resident's personal items, Staff did not provide resident medication as prescribed, Staff does not provide daily activities for resident. Interview with S1 revealed that family is asked to write residents name and room number on clothing items and facility also request that family not bring valuable items to residents in memory care. However if an item is missing the facility reports to staff to search for the missing item and it's charted and reported to the Executive Director and Business Office Director. Interview with S2 revealed that residents are given medication as prescribed by the Physician, S1 also stated that when a resident moves into the facility they will bring all medications they have and the facility will request an authorization from the Physician and any refills needed. R1 missed medication due to a prescription not covered by the residents medical coverage. LPA reviewed residents medical records which revealed the medications are given as prescribed. LPA toured facility and witnessed residents including R1 participating in arts and crafts, snacking, watching TV, watching TV, listening to music and getting hair cuts.

Based on interviews, tour and record review the Department has investigated the above allegation and found it to be Unsubstantiated.

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

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
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