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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200801
Report Date: 09/10/2025
Date Signed: 09/10/2025 02:48:04 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
08/11/2025 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20250811142148
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: 85DATE:
09/10/2025
UNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Resident Service Director Nhi NguyenTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee does not sure facility is adequately staffed to properly supervise residents
INVESTIGATION FINDINGS:
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On 09/10/2025 at 02:10 PM, Licensing Program Analysts (LPAs), Carol Fowler and David Doidge arrived unannounced to deliver findings regarding a complaint investigation for the allegation above. LPAs met with Nhi Nguyen, RSD, and explained the purpose for the visit

During the investigation, LPAs toured the facility, interviewed three (3) staff, obtained and reviewed records including but not limited to residents' roster, staff roster and schedule, physcian report, face sheet, resident assessment, service plan and email a copy of the LIC 624.

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

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
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 2
Control Number 15-AS-20250811142148
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: 09/10/2025
NARRATIVE
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Continued from LIC9099

Interview with S1 revealed that R1's room had been moved and R1 was confused and attempting to enter R1's old room. S1 witnessed R1 on the floor outside of the old room. S1 stated that R1 had a hangnail that was dried and bleeding. S1 called for another staff to help S1 get R1 up from floor. R1 was confused and did not want to leave the room. S1 and S2 stayed with R1. R1 was saying R1 didn't know the staff that were trying to move R1.

Interview with S2 revealed that R1 was on the floor, and S2 was called to help S1 get R1 up from floor, and R1 was a little combative and did not want to get up to leave the what R1 thought was R1's room. S2 observed that R1's fingure was bleeding from a drying hangnail.

S3 stated that R1 was on the floor, and fell attempting to get into R1's old room. S1 and S2 were trying to assist R1 in getting up from floor. S3 stated R1 has a walked used for walking and was trying to get into room and fell. R1 calmed down and allowed staff to direct R1 to correct room.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED.

No deficiencies cited 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: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
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