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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208908
Report Date: 10/03/2022
Date Signed: 10/03/2022 02:39:20 PM

Document Has Been Signed on 10/03/2022 02:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:WESTMONT OF FRESNOFACILITY NUMBER:
107208908
ADMINISTRATOR:HAMILTON, PAMELAFACILITY TYPE:
740
ADDRESS:7442 & 7468 N MILLBROOK AVETELEPHONE:
(858) 729-6720
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 155CENSUS: 91DATE:
10/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Administrator, Erik SchukTIME COMPLETED:
02:55 PM
NARRATIVE
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On 10/3/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Erick Schuk.

The purpose of this visit is to follow up on an incident report that was submitted to the Fresno CCL office. It was reported that on 08/03/2022, a medication error occurred resulting staff administering the same medication to R1 twice.

During the course of investigation #24-AS-20220729113420, it was found that R2 had multiple falls in the facility and the facility did not report the incidents to the Fresno CCL office.

Deficiencies are being issued in accordance to California Code of Regulations, Title 22, Division 6, on the attached 809D.

Exit interview conducted and a Plan of Correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Erik Schuk whose signature on this form confirms receipt of these documents

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/03/2022 02:39 PM - It Cannot Be Edited


Created By: Alexandria Walton On 10/03/2022 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: WESTMONT OF FRESNO
FACILITY NUMBER: 107208908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2022
Section Cited
CCR
87465(a)(4)

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87465(a)(4): (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed, this requirement was not met as evidenced by
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for this section are met to the Fresno CCL office by the POC due date.
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Based on record review, the license did not ensure the requirements for this section were met when staff administered two of the same medication to R1, which poses an immediate health and safety risk to residents/clients in care.
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Type B
10/31/2022
Section Cited
CCR87211(a)(1)

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87211(a)(1): Each licensee shall furnish...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence, this requirement was not met as evidenced by:
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Licensee agrees to train all staff on the requirements of section 87211 and submit proof of attendance and training topics to the Fresno CCL office by the POC due date.
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Based on record review, the licensee did not ensure the requirements for this section were met when LPA observed that R1 had multiple falls in the facility which were not reported to the Fresno CCL Office.
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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.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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