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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603509
Report Date: 09/30/2024
Date Signed: 09/30/2024 11:18:15 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2020 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20200625151823
FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:NEWTON, RANDALFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:105CENSUS: 89DATE:
09/30/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director Jessica ZepedaTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Neglect/ Lack of supervision resulted in resident sustaining injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced visit to deliver complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Jessica Zepeda. Throughout the investigation the Department requested records, and conducted interviews with external and internal sources, including staff and residents.

It was alleged staff neglect resulted in a resident sustaining injury while in care. A source alleged Resident # 1 (R1) suffered multiple falls, including one on June 4th, 2018, and a second fall on January 31st, 2019, that resulted in hospitalization, and lacerations requiring stitches.
R1, a Seventy-Nine (79) year old memory care resident, was diagnosed with Dementia and assessed as a high fall risk during admission to the facility. A medical assessment revealed R1 could be confused and agitated at times. A service plan dated February 19th, 2019, revealed the facility assisted the resident with incontinence care, escorting, dressing, medication management, a puree diet, and hygiene, including two-person assistance with baths and showers. (See LIC 9099C form for continuation of report.)
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
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 6
Control Number 08-AS-20200625151823
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 09/30/2024
NARRATIVE
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Throughout R1 residing at the facility, interviews with staff and R1’s family revealed R1’s health declined from being ambulatory with the use of a walker, to eventually wheelchair bound.

Assessments conducted by the facility for R1 on 1/4/18, 2/6/18, 8/1/18, 1/31/19, 8/16/19, 2/15/20, and 6/24/20, consistently revealed R1 was at high risk for falls. Narrative charting records documented on June 3rd, 2018, R1 sustained a witnessed fall, R1 hit a wall, and staff summoned medical attention due to R1 sustaining a skin tear to the head. On January 31st, 2019, during the overnight shift, staff found R1 on the floor next to R1’s bed with a laceration to the head, and staff summoned medical attention. R1 was transported to the hospital on both occasions, with the fall on 1/31/2019 requiring stitches. Review of photographs obtained from R1’s medical provider, confirmed R1 suffered lacerations on both occasions.

From approximately March 24th, 2018, to October 11th, 2019, R1 sustained approximately twelve (12) witnessed and unwitnessed falls. On at least seven of the twelve noted falls, R1’s falls were unwitnessed. A Service Plan for R1 dated January 31st,2019, did not reveal any measures addressing R1's falls. On subsequent visits the Department requested records, but the facility was not able to produce such records, including service plans addressing R1’s falls.

Although staff reported checking in on R1 every two hours, the facility did not implement any fall prevention measures for R1 until after the fall on January 31st, 2019, which resulted in a hospital visit and R1 sustaining a laceration requiring stitches. By January 31st, 2019, review of records revealed R1 had sustained approximately ten (10) falls with no severe injuries. Interviews with multiple staff and R1’s family corroborated the facility implemented fall prevention measures after January 31st, 2019. The measures included placing bed rails and lowering of the bed. An Outside Agency Form dated January 31st, 2019, revealed fall prevention measures were discussed with staff on that date. The measures discussed with the external agency included lowering R1’s bed, conducting frequent checks and cleaning R1’s room to minimize trip hazards. During the investigation the facility produced assessments and service plans for R1, but these did not indicate what fall mitigating measures were implemented, nor what staff actions were implemented to mitigate R1’s falls.

(See additional LIC 9099C form for continuation of report.)
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20200625151823
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2024
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement was not met as evidenced by:
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Executive Director agreed to provide in service training to all care staff/ Med techs regarding the following topics; proper record keeping, change of condition, service planning, and internvention implementation, by 10/11/2024.
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Based on review of records, and interviews, the licensee did not ensure R1 was free of neglect, which resulted in R1 sustaining injuries, this posed an immediate health, safety, and personal rights risk to 1 of 89 residents in care.
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The ED agreed to provide the LPA a log of who attended the trainings, by 10/11/24.
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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: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2020 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20200625151823

FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:NEWTON, RANDALFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:105CENSUS: 89DATE:
09/30/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director Jessica ZepedaTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Neglect resulted in resident suffering from dehydration
Neglect resulted in pneumonia
Staff are not administering medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced visit to deliver complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Jessica Zepeda.Throughout the investigation the Department requested records, and conducted interviews with external and internal sources, including staff and residents.

It was alleged neglect resulted in dehydration of a resident. A source reported visiting Resident # R1 (R1) on multiple occasions and witnessing staff not offering, nor providing water to R1. Interviews with staff revealed staff assisted R1 with feeding and drinking fluids. Multiple staff corroborated R1 was seated at 90 degrees, as there was a concern R1 could aspirate do to R1’s difficulty swallowing food. Staff interviews and an LIC 602 Physician’s Report for R1, dated February 6th, 2020, confirmed R1 had a special diet that included pureed food. Review Hospital’s discharge summary obtained by the Department, revealed R1 was hospitalized on June 20th, 2020, and transferred to a diffrerent hospital on June 22nd, 2020.
(See the LIC 9099C form for continuation of report.)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20200625151823
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 09/30/2024
NARRATIVE
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R1’s diagnoses included Hypernatremia (High Concentration of sodium in blood) due to Hypovolemia (decreased volume of circulating blood). There were no diagnoses related to, nor suspecting lack of fluid intake noted in the discharge summary. At the time of discharge form the hospital, R1’s diet had changed to nothing by mouth, until R1 was “more awake, and passes swallow eval”. The hospital's progress notes dated June 25th, 2020, noted R1 was hospitalized from June 22nd, 2020, to June 24th, 2020, with bilateral pneumonia and hypernatremia. Although Hypernatremia was noted as a admitting diagnoses, there were mentions of dehydration being a diagnosis. Additional interviews with multiple residents did not reveal there were concerns with lack of assistance with food, nor with lack of fluids available to residents.

It was alleged neglect resulted in pneumonia. A source reported R1 was hospitalized and diagnosed with Pneumonia. The reporting party questioned how R1 suddenly developed Pneumonia as it could not happen overnight. Records obtained from R1’s medical care providers, including a hospital discharge summary and progress notes dated June 25th, 2020, and a hospice agency revealed the Pneumonia was likely bacterial and the suspected cause was aspiration (inhalation of foreign object or substance into the airways). Interviews with staff revealed R1 was assisted and seated at 90 degrees, as there was concerns of aspiration due to R1’s difficulty swallowing. Interviews with staff also revealed R1 had developed a cough for approximately a week prior to being hospitalized on June 20th, 2020. Staff notified R1’s family and R1’s primary care physician. On June 205th,/20, emergency medical services were summoned as R1 presented low oxygen levels and was congestion.

It was alleged staff did not administer medication as prescribed. A source alleged the facility staff over medicated R1, as R1 seemed to sleep more and was less responsive. Interviews with residents, staff, resident’s responsible parties, and the Long-Term Care Ombudsman office did not reveal any concerns with staff over medicating residents. The LPA reviewed the Department’s Guardian system to locate the staff who was mentioned, but contact attempts were not successful. Additionally, the LPA requested additional records for review, but the facility was not able to produce such records.

Based on the investigation, there was not enough evidence to prove the alleged violations occurred, therefore, the allegations were Unsubstantiated.

An exit interview was conducted with Zepeda, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 08-AS-20200625151823
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH
FACILITY NUMBER: 374603509
VISIT DATE: 09/30/2024
NARRATIVE
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Based on evidence obtained, the allegation of staff neglect resulting in resident sustaining injury, was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D form.

An immediate $500 civil penalty was assessed, and a plan of correction was jointly formulated with Executive Director Jessica Zepeda. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division.

An exit interview was conducted with Zepeda, to whom a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6