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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202744
Report Date: 01/07/2025
Date Signed: 01/08/2025 08:26:21 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
06/10/2024 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20240610145129
FACILITY NAME:WESTMONT OF MILPITASFACILITY NUMBER:
435202744
ADMINISTRATOR:BECKER, GREGORYFACILITY TYPE:
740
ADDRESS:80 CEDAR WAYTELEPHONE:
(408) 770-9575
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:225CENSUS: 167DATE:
01/07/2025
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Mimi CoTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff do not provide adequate supervision resulting in residents sustaining falls
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Business Office Director (BOD) Mimi Co.

On 6/10/2024, the Department received a complaint with the allegation that staff do not provide adequate supervision resulting in residents sustaining falls.

On 6/20/2024, the Department conducted an initial investigation visit.

LPA interviewed 3 staff and requested resident's physician report, appraisal needs and service plan.

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: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
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
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
06/10/2024 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20240610145129

FACILITY NAME:WESTMONT OF MILPITASFACILITY NUMBER:
435202744
ADMINISTRATOR:BECKER, GREGORYFACILITY TYPE:
740
ADDRESS:80 CEDAR WAYTELEPHONE:
(408) 770-9575
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:225CENSUS: 167DATE:
01/07/2025
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Mimi CoTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure facility is cleaned and sanitized.
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Business Office DIrector (BCD) Mimi Co.

On 6/10/2024, the Department received a complaint with the allegation that Staff do not ensure facility is cleaned and sanitized.

On 6/20/2024, the Department conducted an initial investigation visit.

LPA interviewed 3 staff and requested resident's physician report, appraisal needs and service plan.

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: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20240610145129
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: 01/07/2025
NARRATIVE
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Staff do not ensure facility is cleaned and sanitized:
The allegation is that resident R1's bedroom was observed on the floor, and caregivers were unable to access the cleaning supplies room to obtain the cleaning supplies.

On 6/16/2024, LPA interviewed R1's family member (FM). FM stated on 5/24/2024, he/she visited R1. A home care nurse was checking R1 blood sugar. The home care nurse told FM that he/she saw feces on the floor in R1's room when he/she entered R1's room. FM stated he/she saw a staff was cleaning R1's room and changed R1's clothes. FM stated he/she did not see feces on the floor.

On 6/20/2024, LPA interviewed a Med Tech S1. S1 stated caregivers do the room cleaning more often than housekeepers, caregivers do the basic cleaning every shift. S1 stated staff have access to the cleaning supplies room and the facility has sufficient cleaning supplies.

LPA interviewed caregiver S2. S2 stated housekeepers do room deep cleaning and the caregivers do the basic cleaning. S2 stated the chemical cleaning supplies are locked in the cleaning supplies room and housekeepers have the access to the cleaning room. S2 stated caregivers are given disinfectant wipes S2 stated resident R1 was found with Bowel Movement (BM) in pants several times. R1 was given briefs, but R1 does not like it because it is uncomfortable. S2 stated R1 has laundry twice a day and showers as needed.

On 7/12/2024, LPA interviewed S4. S4 stated the facility cleans resident rooms twice per week. S4 stated if caregivers find BM, they will clean first and notify housekeepers to do deep cleaning.
LPA interviewed staff S3. S3 stated resident rooms are cleaned every other day. S3 stated if caregivers find BM on the floor of resident room, they will clean it up and housekeepers will give additional deep clean.

LPA interviewed Med Tech S1. S1 stated caregivers clean resident rooms every day. S1 stated if BM was found in resident room, caregivers will clean it up.

LPA interviewed caregiver S5. S5 stated if caregivers find BM on the floor in resident room, they will clean it up and notify housekeepers to do deep clean. S5 stated one day, R1 had BM in the pants when home care nurse came. S5 stated he/she cleaned it up, gave shower to R1 and changed R1's clothes.
Continue on LIC9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20240610145129
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: 01/07/2025
NARRATIVE
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LPA toured and checked 16 resident rooms, LPA did not see any BM or trash on the floor of the resident rooms.

Based on the review of R1's service plan dated 3/16/2024, R1 was at the beginning stage of incontinence.

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

No citations noted at today’s complaint investigation visit. Exit interview conducted with Business Office Director (BOD) Mimi Co. This report was provided to review and for signature. A copy of this report was provided to BOD.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20240610145129
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: 01/07/2025
NARRATIVE
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Staff do not provide adequate supervision resulting in residents sustaining falls:
The allegation is that resident R1 had multiple falls and was sent to Emergency room frequently.

On 6/16/2024, LPA interviewed resident R1's family member (FM). FM stated on 6/1/2024, he/she received a phone call from a Med Tech that R1 had a fall when he/she was driving to the facility to visit R1. FM stated R1 was not sent to hospital emergency room for R1's fall on 6/1/2024. FM stated R1 had two falls and was sent to emergency room in 2023. FM stated he/she cannot remember the dates of R1's fall in 2023. FM stated maybe around in July 2023 and October 2023.

On 6/20/2024, LPA interviewed Med Tech S1. S1 stated residents were hourly checked by staff. S1 stated caregivers report to Med Tech if they found residents were unusual. S1 stated resident R1 is usually in the activity room or TV room during waking hours. S1 stated R1 had fall before but R1 does not have frequent falls.

LPA interviewed caregiver S2. S2 stated resident R1 should use walker but sometimes R1 did not use walker. S2 stated staff picked up R1 with R1's walker when staff to place R1 in activity room or TV room. S2 stated R1 likes to get up by self and walk to the places faster. S2 stated R1 seldom told caregivers what he/she needs, such as need to go to restroom.

On 7/12/2024, LPA interviewed caregiver S3. S3 stated there are 3 caregivers for memory care unit for AM shift and for PM shift. S3 stated caregivers need to keep eyes on fall risk residents and closely monitoring them. S3 stated he/she does not know any resident fell and was sent to hospital recent 3 months.

LPA interviewed caregiver S4. S4 stated caregivers need to take care of the residents who are fall risk. S4 stated caregivers need to assistance those who are fall risk to/from their rooms to prevent falls.

LPA interviewed caregiver S5. S5 stated residents are checked every hour, caregivers follow residents who are fall risk when they are ambulating. S5 stated R1 had a fall several months ago and a Med Tech helped R1 up. The Med Tech notified R1's family member immediately. S5 was unsure if R1 was sent to hospital or not.

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

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20240610145129
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: 01/07/2025
NARRATIVE
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Based on review of R1's incident reports, there was no incident report that R1 was sent to hospital emergency room due to fall in July 2023 or in October 2023.

Based on the review of R1's physician report dated 4/28/2024, R1 uses walker/Cane, and should be escorted by staff due to physical impairment.

Based on the review of R1's Service plan dated 3/16/2024, R1 needs to use walker or cane, R1 not always use walker/cane, and R1 walks fast. R1 needs reminders to not get up abruptly.

Based on the review of R1's progress notes, on 6/1/2024, R1 has a fall on 6/1/2024, R1 was not sent hospital. At the same day, R1 was picked up by Family Member and went out for lunch.

Based on the interview and records reviewed, no evidence to indicate that staff do not provide adequate supervision resulting in R1 sustaining multiple falls and was sent to emergency room frequently.

Based on documents 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 allegation did or did not occur.

No citations noted for today’s visit. Exit interview was conducted with BOD. A copy of this report was provided to BOD.

Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6