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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 10/01/2024
Date Signed: 10/01/2024 10:56:17 AM

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
05/20/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20240520082858
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: DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:RICHARD REMIGIO, EXECUTIVE DIRECTORTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care.
INVESTIGATION FINDINGS:
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On 10/01/2024 at 9:50AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPA met with Richare Remigio, Executive Director and explained the reason for the visit.

During the course of the investigation LPAs interviewed reporting party (RP) 1 resident (R1) and witness (W1). LPAs obtained documents (staff roster and residents’ roster, ID and emergency information, residency agreement, Physician's report, Appraisal Needs and Services Plan, list of medications).

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

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 15-AS-20240520082858
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: 10/01/2024
NARRATIVE
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CONTINUE FROM LIC 9099

Allegation: Resident sustained unexplained injuries while in care.

Investigation Finding: unsubstantiated.

RP reported that RP witnessed small wounds when RP would visit R1 at the facility. RP stated that RP had no evidence of anyone hurting R1. RP stated that R1 told RP when care staff would help R1 out of bed R1 would sometimes bump R1s leg, RP also stated that R1 was forgetful and sometimes R1 would not know what happened and how R1 got the small wounds. RP stated that RP has visited R1 4 to 5 times and noticed the small wounds and wanted to report what RP saw.

W1 reported that W1 is not sure how the small wounds got on R1, W1 stated that R1 informed W1 that R1 leg was bumped when R1 was being helped out of bed by care staff.

R1 stated that R1 was not sure how the small wounds got on R1 leg. R1 stated that it just happens to R1 skin.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that Resident sustained unexplained injuries while in care is unsubstantiated.



No deficiencies observed during visit.

Exit interview conducted and a copy of this report provided.

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

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
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