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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005908
Report Date: 03/10/2025
Date Signed: 03/10/2025 05:07:40 PM

Document Has Been Signed on 03/10/2025 05:07 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WESTMONT OF CYPRESSFACILITY NUMBER:
306005908
ADMINISTRATOR/
DIRECTOR:		PATRICK FRAZIERFACILITY TYPE:
740
ADDRESS:4889 & 4775 KATELLA AVE.TELEPHONE:
(858) 729-6720
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY: 152CENSUS: 134DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Nancy RodriguezTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 152 non-ambulatory residents. Facility has an approved hospice waiver for 25 residents. Facility has 114 residents in care including 20 in the Memory Care Unit. Facility consists of two separate buildings for both Assisted Living and Memory Care. Executive Director (ED) Nancy Rodriguez arrived shortly to conduct facility tour. ED has a valid certificate that expires on 5/7/2025. ED provided updated liability insurance that expires on 9/15/2025.

LPA along with ED toured the facility at 8:45 AM. LPA toured the physical plant, checked food service, and facility documentation. LPA observed a cafe area, kitchen, dining room, library, fitness room, activities room, salon and movie room in the main building. Resident units had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and showers was free of mold/mildew. Water temperature measured between 105 degrees F and 120.5 degrees F in all bathrooms tested. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Egress exit alarms were operational during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Fire/Smoke alarm system was serviced by a third party company on 2/10/2025. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts monthly emergency drills with the last drill conducted on 2/26/2025. The activity program is displayed in multiple locations throughout the facility and tailored to the needs of independent and memory care residents respectively. LPA observed residents relaxing in the facility's common areas, partipating in activities or in their respective bedrooms. Outside grounds were toured. Walkways around the pool were adequately fenced and clear of hazards.There is shaded outdoor seating for residents. LPA observed the emergency food and water supply. LPA reviewed ten resident files and five staff files.
CONTINUED ON LIC809C DATED 3/10/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WESTMONT OF CYPRESS
FACILITY NUMBER: 306005908
VISIT DATE: 03/10/2025
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All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders. Four out of five staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in two medications rooms, one in each building.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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