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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202744
Report Date: 10/04/2024
Date Signed: 10/04/2024 03:54:46 PM

Document Has Been Signed on 10/04/2024 03:54 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:WESTMONT OF MILPITASFACILITY NUMBER:
435202744
ADMINISTRATOR/
DIRECTOR:		BECKER, GREGORYFACILITY TYPE:
740
ADDRESS:80 CEDAR WAYTELEPHONE:
(408) 770-9575
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 225CENSUS: 169DATE:
10/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Administrator Gregory BeckerTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs Manuel Monter & Marcella Tarin conducted an unannounced case management visit continuation in regards an incident report, which stated a resident had eloped from the facility. LPAs met with Administrator Gregory Becker. LPAs explained the purpose of the visit.

On August 26, 2024, the Department received an incident report (LIC624) regarding a resident (referred as R1) who eloped from the facility. According to the report, on August 20, 2024, at 12:10am, during rounds staff (referred as S12) noted that resident R1 was not in his/her bedroom in the memory unit. Staff S11 and S12 conducted a census of all memory care residents to account for the whereabouts of R1. During the rounds, the local law enforcement (LLE) arrived with resident R1, who was found outside the facility.

On August 19, 2024, at about 10:16pm Local Law Enforcement (LLE) responded to resident R1 being found nearby the Apartments complex (Apex). (Based on a google maps review of the location R1 was found, R1 was .5 miles away from the facility). At around 12:30am, R1 was brought back to the facility by LLE wherein staff stated they were unsure how he/she had left the facility.

Based on a review of R1’s Elopement Risk Assessment, dated July 2, 2024, R1 has a history of elopement and has wandering behaviors. Based on a review of R1’s Physicians Report, dated July 2nd, 2024, R1 has a diagnosis of neurocognitive disorder. R1 also has wandering behaviors and cannot leave the facility unassisted.


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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2024
NARRATIVE
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On August 28, 2024, and September 16, 2024, the Department interviewed 13 staff (referred as S1-S13) and Memory Care Director (MCD). 11 Out of 13 staff interviewed stated R1 has had wandering and exit seeking behaviors since he/she moved into the facility.

S1 stated R1 was in his/her group, for the PM shift, the day of the elopement. S1 stated the last time he/she saw R1 was at 8:15pm on August 19, 2024. S1 stated he/she did not perform a head count of all residents assigned to him/her because he/she was busy helping other residents.

Staff S12 confirmed R1 was in his/her group of residents, for the night shift on August 19, 2024. S12 stated the PM shift had informed the shift, that all the residents were in bed, but did not conduct a head count at 10:00pm.

On October 4, 2024, LPA Monter and Tarin, interviewed MCD. MCD confirmed that staff need to conduct a head count of residents in the memory care unit at the beginning of their shift and end of their shift.

Based on interviews, R1 was last seen by S1 at 8:15pm, on August 19, 2024. R1 was not found during head count, at 12:10am, on August 20, 2024.

Based on interview, the facility staff did not preform their duties and responsibilities by not conducting a head count/welfare check for all residents in memory care between the changes in shift, PM and NOC, at 10pm to meet the care & supervision needs of the residents in memory care unit.

As a result, the department issued an immediate civil penalty of $1,000 for a repeat violation the absence of supervision, which resulted in R1 eloping from the facility.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
This report was reviewed with Administrator Gregory Becker and a copy of the report was provided. Appeal Rights was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/04/2024 03:54 PM - It Cannot Be Edited


Created By: Manuel Monter On 10/04/2024 at 10:19 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2024
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Administrator stated he will submit our plan of action regarding elopements. ADM stated he will update R1's apprisal. ADM stated he will send a letter of understanding regarding the regulation.
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Based on interview and record review, on August 19, 2024, R1 with a neurocognitive disorder left the memory care unit unassisted and was found by law enforcement 0.5 miles away from the facility. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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ADM stated he will send the Plan of Action by POC date October 7, 2024
Type A
10/07/2024
Section Cited
CCR87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision... delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Administrator stated he/she will submit a plan of corrections regarding staffing in the memory care unit.
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Based on interview, the staff perform their duties & responsibilities by not conducting a head count/welfare check for all residents in memory care between the changes in shift, PM & NOC, at 10pm to meet the care & supervision needs of the residents. This posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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ADM stated he will send the Plan of Action by POC date October 7, 2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024


LIC809 (FAS) - (06/04)
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