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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604692
Report Date: 05/24/2024
Date Signed: 05/28/2024 02:35:35 PM

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
05/16/2024 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240516135258
FACILITY NAME:WESTMONT OF CARMEL VALLEYFACILITY NUMBER:
374604692
ADMINISTRATOR:ROSSI, MARIAFACILITY TYPE:
740
ADDRESS:5720 OLD CARMEL ROADTELEPHONE:
(858) 465-7356
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:138CENSUS: 70DATE:
05/24/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director Chad BoeddekerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff did not issue medication as prescribed
Staff did not maintain medication records
INVESTIGATION FINDINGS:
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13
-Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegations. LPA met with Executive Director Chad Boeddeker and discussed the purpose of the visit.
On May 16, 2024, Community Care Licensing (CCL) received a complaint staff did not issue medication as prescribed by medical professional and staff are not documenting medication issued accurately.
-During investigation, LPA Strong collected pertinent facility documentation and conducted interviews. According to allegation, staff at the facility have issued incorrect dosage of medication to residents in care and some doses are missed due to lack of refills. Records collected revealed that Resident 1 (R1) was issued a larger dose than prescribed of medication 1 (M1) on March 27, 2024, and March 28, 2024. Observations of M1 corroborated that facility had incorrect dosage available to R1. Medication administration record for R1 also revealed R1 was not issued multiple other medications between March 30, 2024, and March 31, 2024 as the medication was pending delivery. Interview with another resident corroborated that some medication doses have been missed on at least one occasion.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
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 4
Control Number 08-AS-20240516135258
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 OF CARMEL VALLEY
FACILITY NUMBER: 374604692
VISIT DATE: 05/24/2024
NARRATIVE
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 Interview with outside source corroborated that such resident had missed a dose.

It was also alleged that staff did not maintain medication administration records (MAR) accurately. Interview with staff revealed that some staff have been instructed by previous Memory Care Director to sign MAR even though medication was not issued. Records collected revealed R1’s MAR was not signed on March 29, 2024, and there was no documentation of reason medication was not issued. Interview with outside sources corroborated that MAR was not filled out accurately in March of 2024.

-Based on records reviewed and interviews, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Chad Boeddeker to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
05/16/2024 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240516135258

FACILITY NAME:WESTMONT OF CARMEL VALLEYFACILITY NUMBER:
374604692
ADMINISTRATOR:ROSSI, MARIAFACILITY TYPE:
740
ADDRESS:5720 OLD CARMEL ROADTELEPHONE:
(858) 465-7356
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:138CENSUS: 69DATE:
05/24/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director Chad BoeddekerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not ensure staff were trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Executive Director Chad Boeddeker.
-On May 16, 2024, Community Care Licensing (CCL) received a complaint licensee did not ensure staff were trained. During the investigation, LPA Strong conducted interviews, and reviewed facility records. According to allegations, staff were not fully trained prior to issuing medication to residents in care. Interview with staff revealed staff are hired as dual caregivers/medication technicians and trained as such throughout their initial month. Records collected revealed that all staff actively issuing medication without direct oversite have completed trainings. Interview with outside source did not reveal any information to corroborate allegations.
-Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation are unsubstantiated. An exit interview was conducted with Executive Director Chad Boeddeker, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20240516135258
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 OF CARMEL VALLEY
FACILITY NUMBER: 374604692
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2024
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care (c)facility staff designated by the licensee shall be permitted to assist the resident with self-administration as, providing the following is met (2) Once ordered...the medication is given according to the physician's directions.
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Licensee agrees to provide staff with an in-service training regarding medications.
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This requirement was not met as evidence in; Based on records and interviews the licensee did not issue medications as prescribed in 2 of 70 persons in care [R1/R2] which posed a potential health risk to persons in care.
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Type B
06/07/2024
Section Cited
CCR
87465(c)(3)
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Incidental Medical and Dental Care (c)facility staff designated by the licensee shall be permitted to assist the resident with self-administration as, providing the following is met (3)A record of each dose is maintained in the resident's record.
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Licensee agrees to provide staff with an in-service medication administration record.
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This requirement was not met as evidence in; Based on records and interviews the licensee did not maintain record of medication dose in 1 of 70 residents in care [R1] which posed a potential health risk to persons in care.
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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: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4