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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:28:59 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230508123315
FACILITY NAME:WESTMONT OF MILPITASFACILITY NUMBER:
435202744
ADMINISTRATOR:BRAVO, SHERYLFACILITY TYPE:
740
ADDRESS:80 CEDAR WAYTELEPHONE:
(408) 770-9575
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:225CENSUS: 167DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Gregory BeckerTIME COMPLETED:
04:26 PM
ALLEGATION(S):
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Staff mishandling resident’s medication.
Facility had an outbreak of norovirus.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Executive Director (ED) Gregory Becker.

On 05/08/2023, the Department received a complaint with the above allegations.

On 05/18/2023, the Department conducted an initial investigation visit.

LPA interviewed the previous Executive Director and one staff. LPA requested Resident .Physician report, Appraisal Needs and Services Plan, Admission Agreement and Medical records.


Continue on LIC9099-C. Page 1 of 3.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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 26-AS-20230508123315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTMONT OF MILPITAS
FACILITY NUMBER: 435202744
VISIT DATE: 09/17/2024
NARRATIVE
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Staff mishandling resident’s medication:
On 5/8/2023, the Department received a complaint alleging staff mishandling resident's medications. It has been alleged resident R1's Medication #1 was not on the doctor prescribed medication list, and it has also alleged Medication #2 was not being administered.

On 05/18/2023, LPA interviewed Director of Memory Care (DMC). DMC stated the facility staff administer medications to resident R1 based on the doctor's prescriptions orders. DMC stated R1's family member requested to stop Medication #1 for R1, but the facility staff explained to R1's family member that a medication cannot be stopped without R1's physician order. DMC was unable to provide the exact date that R1's family member requested to stop R1's Medication #1.

Based on document review, Medication #1 was prescribed to R1 by R1's PCP to start on from 3/9/2023 to 3/30/2023, and the Medication #1 was stopped by the doctor on 3/31/2023 and the medication was not administered to R1 after 3/31/2023..

A review of R1's doctor prescriptions, there was no prescription given to R1 for Medication #2 and the Medication #2 was not found in R1's medication list.

Based on the interview and review of R1's medical document, no evidence to indicate the facility staff mishandling R1's medications.

Facility had an outbreak of norovirus:

On 5/8/2023, the Department received a complaint alleging the facility having an outbreak of Norovirus. It has been alleged that the facility had an outbreak of Norovirus in April 2023.

On 5/18/2023, LPA interviewed Previous Executive Director Lauren Powell (PED). PED stated in April 2023, the facility only has one Norovirus case of resident. PED stated the facility sent the incident report to Community Care Licensing (CCL) office.

Continue on LIC9099-C. page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20230508123315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTMONT OF MILPITAS
FACILITY NUMBER: 435202744
VISIT DATE: 09/17/2024
NARRATIVE
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LPA interviewed Director of Memory Care (DMC). DMC stated there was no outbreak of Norovirus in the facility. An incident was sent to CCL office on 4/13/2023. DMC stated, the facility only had a case of Norovirus. DMC stated the resident was sent to hospital due to weak and was diagnosed Norovirus in the hospital.

The Department reviewed facility incident reports sent to CCL office in April 2023, there is only one case of Norovirus case.

Based on the interview and record reviewed, although the facility had a Norovirus case of resident, the facility only had one Novovirus case. The resident who had Norovirus was remained in the hospital to receive treatment, and the facility reported the Norovirus case to CCL office. There is no evidence to indicate the facility had a outbreak of Norovirus in April 2023..

The Department has investigated the above allegations. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citation noted today. Exit interview was conducted with ED. The report was provided to ED for signature. A copy of the report was provided to ED.

Continue on LIC9099-C. Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230508123315

FACILITY NAME:WESTMONT OF MILPITASFACILITY NUMBER:
435202744
ADMINISTRATOR:BRAVO, SHERYLFACILITY TYPE:
740
ADDRESS:80 CEDAR WAYTELEPHONE:
(408) 770-9575
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:225CENSUS: 171DATE:
09/17/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Gregory BeckerTIME COMPLETED:
04:26 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff refusing to allow resident to have visitor(s).
Resident feels uncomfortable with a male caregiver.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Executive DIrector (ED) Gregory Becker.

On 05/08/2023, the Department received a complaint with the above allegations.

On 05/18/2023, the Department conducted an initial investigation visit.

LPA interviewed the previous Executive Director and one staff. LPA requested Resident .Physician report, Appraisal Needs and Services Plan, Admission Agreement and Medical records.


Continue on LIC9099-C. Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20230508123315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTMONT OF MILPITAS
FACILITY NUMBER: 435202744
VISIT DATE: 09/17/2024
NARRATIVE
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3
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5
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Staff refusing to allow resident to have visitor(s):
The allegation is that visitors are not allowed after 8:00PM and a family member was not allowed to visit right before 8:00PM.

On 05/18/2023, LPA interviewed previous Executive Director (PED). PED stated the facility's policy for visitor is from 8:00AM to 8;00PM. PED stated visitors can stay in the resident rooms after 8:00PM if visitors enter the facility before 8:00PM.

On 4/25/2024, the Department interviewed Resident Services Director (RSD). RSD stated if the visitor stay over 9:00PM, then facility staff will remind the visitors that it already 9:00PM, but the facility won't force visitors to leave the facility.

The Department interviewed a staff who stated the visiting policy was from 8:00AM to 8:00PM and is changed to from 7:00AM to 9:00PM and stated if the time is too late sometimes the residents refuse the visitors but not the staff refuse the visitors.

On 7/12/2024, LPA interviewed 4 staff. 4 out of 4 staff stated they did not force visitors to leave. 2 out of 4 staff stated staff remind visitors after 8:00PM, but staff did not force visitors to leave.

LPA reviewed the facility visitor log, entries showed family members including R1's family member (FM) entering the facility right before 8:00PM and right after 8:00PM.

On 7/12/2024, the Department interviewed FM. FM stated he/she was staying with R1 in R1's room but was unable to remember the exact date. FM stated he/she received a phone call from a staff that he/she needed to leave the facility because after 8:00PM. FM stated a staff also told him/her to leave because staff need to put residents in bed. FM stated staff did not physically force him/her to leave. FM provided 2 staff names (S1, S2) who notified FM to leave the facility. S1 and S2 already left the facility. LPA called S1 and left message. LPA called S2 and left message. LPA did not receive any response from S1 and S2.

Based on the interviews and records reviewed, no evidence indicates the facility staff refusing to allow resident to have visitor(s). Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20230508123315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: WESTMONT OF MILPITAS
FACILITY NUMBER: 435202744
VISIT DATE: 09/17/2024
NARRATIVE
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Resident feels uncomfortable with a male caregiver:
On 05/18/2023, LPA interview Director of Memory Care (DMC). DMC stated he/she grouped and scheduled groups of caregivers to serve groups of residents. DMC stated he/she tried the best to let female caregivers to take care of female residents and male caregivers to take care of male residents.

DMC stated the staff are given a group of residents to take care during the shift. A staff is not assigned to a particular resident but a groups of residents. DMC stated the availability of staff is based on biological gender and preference of the families or residents. DMC stated the family must submit a formal request to the facility if they are not comfortable being cared for by the opposite biological gender. DMC stated there was no request that R1 required caregivers with the same biological gender with R1 until the end of March 2023. DMC stated within a week of the request, after 3/31/2023, R1 only receives the same biological gender caregiver for R1's showering service.

R1's family member (FM) confirmed after 3/31/2023, R1 only receives the care from the same biological gender caregivers

On 7/12/2024, the Department interviewed FM. FM stated it was under impression to have preference to have same biological gender caregiver for R1, but not sure if that specified in document or care plan.

Based on document reviews of R1's Admission Agreement and pre appraisal information form, there is no statement of " receives the care from the same biological gender caregivers only".

Based on the interviews, the facility changed to have only the same biological gender caregiver to serve R1 for showering service.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citation noted today. This report was reviewed with ED, Gregory Becker and a copy of this report was provided. Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6