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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 07/25/2025
Date Signed: 07/25/2025 04:28:47 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
02/28/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220228155418
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: 84DATE:
07/25/2025
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Richard Remigio/Executive Director TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff mismanaged resident's medications.
INVESTIGATION FINDINGS:
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On this day, 7/25/25, at 3:05 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Executive Director (ED) Richard Remigio, and informed the reason for visit.

During the course on investigation, LPA obtained copies of staff schedule and resident roster. LPA reviewed residents records and obtained copies of the following residents' (R1, R2 and R3) documents: LIC601 Identification and Emergency Information; LIC602A Physician's Report; Appraisal; doctor's order of medications; discontinued order of medications; Medication Administration Records (MARs). The following were interviewed: residents (R1, R2) on 3/09/22; staff (S1, S2) on 7/11/25 and staff (S6) on 7/23/25.

.....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
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 3
Control Number 15-AS-20220228155418
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: 07/25/2025
NARRATIVE
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The reporting party stated resident was given more medications than what should be given and medications were given late.

Two out of 3 staff interviewed stated that it could happen that a resident is given a certain number of medications day prior and may be given different number of medications the succeeding days if there's a change in doctor's order. One of the residents interviewed stated this resident was given 11 medications in the morning of 02/19/2022 when this resident should be given only 9. This same resident was given 9 medications 02/27/2022. Review of doctor's order of medications dated 01/26/2022 and discontinued order of medications dated 01/26/2022 showed this resident has a total of 9 of the regular prescribed medications in tablet and capsule forms listed. Although notes in the MAR showed this resident was given medications on time, MAR for 02/2022 showed this resident was given one of the medications 1 1/2 tablets of the 10 mg tablet when prescription showed 10 mg only. MAR also showed only 6 medications in tablets and capsule forms listed of which 1 were administered at 5:00 pm on 02/2022. These findings were discussed with the ED.

Based on review of records and interviews, the preponderance of evidence standard has been met, therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220228155418
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: 07/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) .....(4) The licensee shall assist residents with self administered medications as needed.

-This requirement is not met as evidenced by:
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Executive Director agreed to in-service the staff and submit proof by 7/26/25.
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-Based in records review and interviews, the licensee did not comply with the section above in mismanaging resident's medications and administering incorrectly which posed an immediate health and personal rights risks to person 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: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3