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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005908
Report Date: 12/08/2025
Date Signed: 12/08/2025 05:08:14 PM

Document Has Been Signed on 12/08/2025 05:08 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:		NANCY RODRIGUEZFACILITY TYPE:
740
ADDRESS:4889 & 4775 KATELLA AVE.TELEPHONE:
(858) 729-6720
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY: 152CENSUS: 140DATE:
12/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Nancy RodriguezTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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On December 8, 2025, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Executive Director Nancy Rodriguez were available to assist with the facility inspection.

The facility is licensed for one hundred fifty two (152) non-ambulatory residents with approved hospice waiver for twenty five (25) residents. Currently, there are nine (9) Hospice residents present during today’s visit.

Facility has two buildings, the first is a three story with one hundred (100) apartments housing Assisted Living residents. The second building is a two story with a Memory Care located on first floor with twenty (20) apartments and second floor with fourteen apartments housing Assisted living residents. Every apartment has a private restroom.

At around 8:45 AM, LPA conducted a tour of the physical plant accompanied by Executive Director Nancy Rodriguez, and the following was observed: Facility has a swimming pool located on first floor outside of main dinig room area. Pool has a secured gate which meets licensing requirements. Facility has a kitchen and bistro area located on first floor. Facility also has a activities room, movie theater, salon and common area living room all located on first floor. During inspection, resident rooms were visited and rooms had beds and bedding supplies which were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were operational with water temperature measured between 117.8 to 119.6 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility.



CONTINUED ON 809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jenifer Tirre
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 12/08/2025
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LPA observed the facility to be furnished at the time of the visit. Sharps objects were stored and not accessible to residents in care. The kitchen was inspected, and sufficient perishables and non-perishable food was maintained adequately. Facility has a storage area for emergency food and water which had adequate supply of food.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of the Medication Records Administration (MAR) was conducted, LPA reviewed ten (10) Medication records and LPA observed the records are in compliance.


LPA observed First Aid Kit was maintained. The last fire drill was conducted on June 25, 2025. LPA observed records from Trasom Fire and Security dated February 10, 2025 which showed equipment testing for fire alarm system and extinguishers as operational and passed inspection.

A review of thirteen residents (R1-R13) service files and eight staff (S1-S8) personnel files revealed to be complete. The facility has the current administrator's certification on file for Nancy Rodriguez # 7010206740 - Expiration 05/6/2027.

No deficiencies during this inspection visit.

An exit interview was conducted with Executive Director Nancy Rodriguez, and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jenifer Tirre
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC809 (FAS) - (06/04)
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