435202744-10-3-2024-26-AS-KHOS-DA5JU5-20241017072059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 10/03/2024
Date Signed: 10/03/2024 10:32:04 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
05/17/2022 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20220517143434

FACILITY NAME:	WESTMONT OF MILPITAS		FACILITY NUMBER:	435202744
ADMINISTRATOR:	BRAVO, SHERYL		FACILITY TYPE:	740
ADDRESS:	80 CEDAR WAY		TELEPHONE:	(408) 770-9575
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	225	CENSUS:	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Gregory Becker		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

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Resident did not feel safe and comfortable in facility environment
Facility not providing transportation to medical appointments
Staff neglected resident’s hygiene

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegations. LPA met with Executive Director, Gregory Becker.

On 05/17/2022, the Department received the complaint. On 05/26/2022, the initial complaint investigation was conducted.

Documents were obtained throughout the investigation to include resident (R1)’s admission agreenement, incident reports, physician’s reports, medical records, advance health care directive, power of attorney (POA) documents, service plan, preplacement appraisal, personal rights form, and resident sign in / sign out sheets.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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 7

Control Number 26-AS-20220517143434

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WESTMONT OF MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 10/03/2024

NARRATIVE

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It was alleged that resident (R1) did not feel safe and comfortable in the facility’s environment because R1 did not have a telephone to receive calls. On 05/26/2022, R1 was interviewed. Based on interview, R1 stated to have felt isolated because R1 did not have a telephone to receive calls. R1 did not provide more details for the allegations besides feeling isolated and not having a telephone to receive calls.

On 05/26/2022, LPA Dolores interviewed 3 staff members. Based on staff interview, 3 out of 3 staff states the facility does have a telephone residents can use to make and receive calls. 3 out of 3 staff stated that R1 had never voiced that he/she did not feel safe or comfortable at the facility. S1 states that R1 would use the office phone to make sure R1 would be at his/her medical appointments as R1’s medical appointments were conducted via telephone.

On 04/18/2024, LPA Rai and LPA Monter interview 3 residents regarding the allegation. Based resident interview, 3 residents (R6, R7, R10) stated the facility has telephones for the residents to use.

Based on observation, the facility has operable telephones throughout the facility.

It was alleged that the facility is not providing transportation to R1’s medical appointments.

On 05/26/2022, R1 was interviewed. Based on interview, R1 stated he/she had not attended a single chiropractor appointment because the facility’s transportation will only pay for 15 miles. R1 stated his/her chiropractor appointment was 30 miles away.

On 05/26/2022, LPA Dolores interviewed 3 staff members. Based on staff interview, the facility’s transportation radius is within 15 miles and if the resident wants to go further than the 15 miles, then the residents will be billed. S1 stated that R1’s medical appointments were conducted via telephone.
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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 26-AS-20220517143434

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WESTMONT OF MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 10/03/2024

NARRATIVE

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S1 states that R1 did not have in-person appointments, that S1 knew of. S2 stated that R1 did not have any referrals to a chiropractor that they knew of. S1 and S2 states R1’s POA was really good at informing the facility staff of R1’s appointments.

On 04/18/2024, LPA Rai and LPA Monter interviewed 9 residents regarding the allegation. Based on resident interview, the facility has a transportation service. 1 out of 9 residents states there is an issue with the transportation service as there were times were his/her transportation was cancelled the day of the appointment, therefore is now using a transportation service provided by his/her insurance.

Based on review of the facility’s admission agreement, it’s indicated that the facility will make available scheduled transportation to medical and dental appointments, shopping areas and various social activities. It’s indicated that scheduled transportation within a twelve-mile radius of the community is provided and there may be an extra charge for services outside the service area.

It was alleged that staff neglected the resident’s hygiene as R1 was not showered for a week.

On 05/26/2022, R1 was interviewed. Based on interview, R1 stated the staff told him/her that he/she needed to shower as he/she started to smell bad. R1 stated that staff brought R1 bath towels and soap after requesting for the items. R1 stated that he/she did not shower for the first week of being admitted to the facility.

On 05/26/2022, LPA Dolores interviewed 2 staff members regarding the allegation. Based on staff interview, S2 stated that during the first week of R1’s admission they were providing R1 reminders to shower. During the first week, they noticed R1 was not showering and during the initial assessment showering was something R1 would do. S2 stated they did have to remind R1 to take showers. S1 states to have never observed R1 had a foul odor but R1 was forgetting to do things and needed reminders.
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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 26-AS-20220517143434

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WESTMONT OF MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 10/03/2024

NARRATIVE

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On 04/18/2024, LPA Rai and LPA Monter interviewed 4 residents regarding the allegation. Based on resident interview, it was stated that staff do help with showers. 4 out of 4 residents randomly interviewed stated to not need reminders to take showers.

The review of R1’s records indicates that R1 is diagnosed with a neurocognitive impairment and is able to bathe self. R1’s initial service plan and preplacement appraisal did not include the need for showers.

The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegation is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Executive Director, Gregory Becker and a copy of the report was provided.
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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
05/17/2022 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20220517143434

FACILITY NAME:	WESTMONT OF MILPITAS		FACILITY NUMBER:	435202744
ADMINISTRATOR:	BRAVO, SHERYL		FACILITY TYPE:	740
ADDRESS:	80 CEDAR WAY		TELEPHONE:	(408) 770-9575
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	225	CENSUS:	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Gregory Becker		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

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Facility holding resident against their will
Facility violating resident’s personal rights

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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 7

Control Number 26-AS-20220517143434

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WESTMONT OF MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 10/03/2024

NARRATIVE

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It was alleged that the facility was holding resident (R1) against their will.

Based on record review, R1 was admitted to the facility on 04/18/2022.

On 05/26/2022, LPA Dolores interviewed 2 staff members regarding the allegation. Based on staff interview, R1 moved into the facility under respite care. R1’s POA wanted to see how R1 would do at the facility and try it out. S2 states that R1’s family was trying to find resources and was guided to an assisted living environment since R1 was unable to take care of themselves. S1 and S2 stated that R1 visited the facility 4 times before moving in and this was to ensure that R1 liked the facility.

S1 stated that R1 voiced that he/she wanted to leave and S1 told R1 it was okay, and they can provide transportation. S1 stated that R1’s POA was saying that R1 could not leave because R1 has a neurocognitive impairment, and per R1’s POA’s instructions. S1 stated that R1 began saying that R1’s POA was holding him/her against his/her will, in which, S1 and S2 provided R1 with his/her POA documents.

S1 and S2 denied holding R1 against his/her will.

The review of R1’s records indicates that R1 is diagnosed with neurocognitive impairment and is unable to leave the facility unassisted. The review of records shows that R1’s POA for all powers including health care is the same person.

It was alleged that the facility violated the resident’s rights by denying R1 on a group outing to the mall.

On 05/26/2022, LPA Dolores interviewed 3 staff members regarding the allegation. Based on staff interview, 3 out of 3 staff stated R1 was allowed to go on group outings as their outings are supervised by staff. S3 oversees the outings and stated that R1 did not communicate with the staff that he/she wanted to join their outing to the mall.
PAGE 2 OF 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20220517143434

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WESTMONT OF MILPITAS	FACILITY NUMBER: 435202744
	VISIT DATE: 10/03/2024

NARRATIVE

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It was stated that R1 spoke with another resident at the facility and that resident did not inform the staff until they returned from the outing. S3 stated R1 was never denied outings. S3 advised R1 to communicate with the staff for next time.

Based on record review, R1 signed in and out for outings on 04/21/2022 and 05/05/2022.

The Department has investigated the above allegations. Based on interview and record review the above allegations are unfounded meaning the allegations are false, could not have happened, and/or is without a reasonable basis.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Executive Director, Gregory Becker and a copy of the report was provided.
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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 7