Inspection Reports for Westmont of Brentwood

The visit was an unannounced complaint investigation to address allegations that staff did not respond to a resident's call button in a timely manner and left a resident in a soiled diaper for a long period of time.

The investigation found the allegations to be unfounded based on documentation and record review, determining that the facility ensured the resident received an appropriate level of care. No deficiencies were issued.

The complaint alleged that staff did not respond timely to a resident's call button and left the resident in a soiled diaper for a long period. The complaint was found to be unfounded and dismissed.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including insufficient staffing, lack of an Activities Director, unsanitary resident bathrooms, resident assault, delayed medical services, and neglect resulting in injury.

The investigation found all allegations to be unsubstantiated or unfounded based on record review, interviews, and facility tour. No deficiencies were issued and the allegations were dismissed.

The complaint investigation was triggered by allegations that the facility did not have enough staff, lacked an Activities Director, had unsanitary resident bathrooms, a resident assaulted another resident, the facility did not seek medical services timely, and neglect/lack of supervision resulted in injury. All allegations were found unsubstantiated or unfounded.

The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing requirements for the facility.

The facility was found to be clean, in good repair, and free of fire hazards. Food storage and temperatures were adequate, resident rooms were properly furnished and safe, medications and chemicals were securely stored, and staff and resident files were up to date. No immediate hazards or deficiencies were noted in the narrative.

The visit was an unannounced Case Management inspection conducted by the Licensing Program Analyst to serve a Decision and Order excluding a staff member from the facility and to ensure compliance with personnel reporting requirements.

No deficiencies were observed or cited during the visit. The Licensing Program Analyst served a Decision and Order excluding Staff 1 from the facility and instructed the Executive Director to update personnel records accordingly.

The visit was an unannounced Case Management visit conducted to follow up on an incident report submitted on 12/17/2024 regarding a client being out of medication for 6 days.

The facility took immediate and appropriate action by disciplining and retraining the medication technician involved, notifying the client's physician, and placing the client under observation with no issues observed. No deficiencies were cited.

The complaint involved Client #1 being out of medication for 6 days. The incident was substantiated and addressed with corrective actions including staff retraining and monitoring.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-10-29 alleging that staff do not ensure privacy while providing personal care to residents.

The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur, resulting in the allegations being unsubstantiated.

The complaint alleged that staff do not ensure privacy while providing personal care to residents. The investigation included interviews with three staff members, two of whom stated the allegations did not occur. The allegations were determined to be unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-07-05 regarding multiple allegations against facility staff practices.

The investigation found one allegation substantiated regarding failure to safeguard resident property, specifically a lost hearing aid not reimbursed to the resident. All other allegations, including medication dispensing, supervision, communication, hygiene, and cleanliness, were found unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unannounced and addressed multiple allegations including medication errors, supervision of children, communication with authorized representatives, hygiene issues, and safeguarding resident property. Only the allegation regarding safeguarding resident property was substantiated; others were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 2024-06-05 regarding infection control, facility odor, and resident laundry cleanliness.

The investigation found one substantiated allegation that staff failed to ensure the R1 room was sanitized after a resident left for the hospital, posing potential health and safety risks. Two other allegations regarding infection control and laundry cleanliness were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unannounced and conducted due to allegations that staff did not meet infection control requirements, the facility was malodorous, and staff did not ensure residents had clean laundry. The infection control and laundry allegations were unsubstantiated, while the failure to sanitize the resident room was substantiated.

The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations.

The facility was found to be clean, in good repair, and compliant with safety and health standards. No deficiencies were issued during this inspection.

The visit was an unannounced complaint investigation triggered by a complaint received on 2024-03-21 regarding allegations that staff did not follow infection control practices and reporting requirements.

The investigation included a review of facility files, staff interviews, and observations. No evidence was found to substantiate the allegations, and the complaint was determined to be unsubstantiated.

Allegations of staff not following infection control practices and reporting requirements were investigated and found unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced complaint investigation triggered by a complaint received on 2024-01-26 regarding multiple allegations about staff performance and facility monitoring.

The investigation found no preponderance of evidence to substantiate any of the allegations, including failure to provide contracted services, medication dispensing errors, timely assistance with care needs, and monitoring of facility entrance doors. No deficiencies were cited during the visit.

The complaint included allegations that staff did not ensure residents received contracted services, did not dispense medication as prescribed, did not assist residents timely with care needs, and did not adequately monitor facility entrance doors. All allegations were found to be unsubstantiated.

The visit was an unannounced complaint investigation triggered by an allegation that facility staff did not prevent the spread of scabies among residents and staff.

The investigation found no evidence that staff or residents contracted scabies. Based on interviews and records review, the allegation was unsubstantiated and no deficiencies were cited during the visit.

Allegation: Facility staff did not prevent spread of scabies amongst residents and staff. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced complaint investigation triggered by a complaint received on 2024-02-21 regarding facility door locks.

The investigation found that the facility door locks were in good repair based on observations and interviews with staff, the administrator, and residents. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff did not ensure facility door locks were in good repair. The allegation was unsubstantiated after investigation.

The visit was an unannounced complaint investigation triggered by a complaint received on 2023-12-12 alleging that staff did not dispense medication to a resident in a timely manner.

The investigation included a review of facility records and interviews with staff and the Administrator. Medication administration to the resident was found to be as prescribed, and there was insufficient evidence to prove the alleged violation. Therefore, the complaint was unsubstantiated.

The complaint alleged that staff did not dispense medication to a resident in a timely manner. The allegation was unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced complaint investigation triggered by a complaint received on 2023-11-30 alleging that staff did not seek medical attention for residents with scabies.

The investigation included a facility tour, record review, and staff interviews. The facility addressed scabies by notifying medical personnel and administering medication to affected residents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff did not seek medical attention for residents with scabies. The investigation found the allegation unsubstantiated.

A scheduled informal meeting was conducted via teleconference to discuss recently identified issues associated with the operation of the facility and to provide support on the subject matter.

The meeting addressed deficiencies related to facility staffing, care and supervision, medications, and reporting requirements. The Executive Director agreed to develop a written plan of action to ensure compliance by 02/26/2024, with potential increased monitoring or administrative action if not completed.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including sharing of hygiene products and clothes, disclosure of personal information, inadequate supervision, mishandling of medications, and failure to properly report incidents involving residents.

The investigation found some allegations unsubstantiated due to lack of preponderance of evidence, while the allegations regarding mishandling of medications and failure to properly report incidents were substantiated. Deficiencies were cited related to failure to administer medications as prescribed and failure to submit timely reports to the licensing agency.

The complaint investigation was initiated based on allegations received on 11/03/2023. Some allegations such as sharing hygiene products, sharing clothes, disclosure of personal information, and inadequate supervision were found unsubstantiated. The allegations of mishandling medications and failure to properly report incidents were substantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-11-06 regarding staff not responding to resident assistance and making inappropriate comments in the presence of residents.

The investigation included a facility tour, record review, and interviews with staff and the administrator. The allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove the violations occurred.

The complaint involved allegations that staff did not respond to resident assistance and made inappropriate comments in the presence of residents. The investigation concluded the allegations were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-15 alleging that the facility does not have an administrator.

The investigation found the complaint to be unfounded after reviewing the facility file, interviewing the administrator and staff, and touring the facility. The allegation that the facility does not have an administrator was determined to be false and without reasonable basis.

Complaint was found to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis. The complaint was dismissed.

Unannounced visit/investigation of a complaint received on 2023-07-05 regarding facility disrepair and room temperature maintenance.

The investigation found the allegations unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.

Allegations included facility disrepair and staff not ensuring a resident's room was maintained at a comfortable temperature. Both allegations were found unsubstantiated.

An unannounced Case Management visit was conducted following a report to Licensing on 7/24/23.

No deficiencies were cited during this Case Management visit. The Licensing Program Analyst toured the facility, reviewed resident files, interviewed staff and administrator, and attempted to interview residents.

The visit was a case management incident investigation regarding an incident involving resident R1 that occurred on 2023-06-14 and was not reported until 2023-06-26.

The Licensing Program Analyst found that the facility failed to report the incident involving resident R1 within the required timeframe, posing potential health, safety, and personal rights risks to residents in care.

The visit was complaint-related, investigating an incident involving resident R1. The incident was substantiated as the licensee did not report the incident timely, posing potential risks to residents.

The inspection visit was conducted as a complaint investigation following a complaint received on 04/04/2023 alleging that facility staff did not dispense medication as prescribed.

The investigation found that facility staff failed to give medication as prescribed to a resident, which was substantiated based on interviews, observations, and record reviews. This posed an immediate health and safety risk to the resident.

The complaint alleging that facility staff did not dispense medication as prescribed was substantiated based on the preponderance of evidence standard.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-04-04 alleging that facility staff did not assist a resident in a timely manner.

The investigation, including observation, records review, and interviews, found the allegation unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.

The allegation that facility staff did not assist a resident in a timely manner was investigated and found unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by complaints alleging inadequate staffing and improper handling of residents' medications at the facility.

The investigation found both allegations unsubstantiated based on observations, interviews, record reviews, and facility tours. There was no preponderance of evidence to prove the alleged violations occurred.

The complaint investigation was unsubstantiated for both allegations: 1) Facility does not have adequate staff to meet the needs of the residents, and 2) Facility staff are not properly handling resident's medications.

The visit was conducted as a follow-up to an incident reported to the department on 03/01/2023, specifically to verify details related to the incident and facility actions.

The Licensing Program Analyst visited the facility, followed infection prevention protocols, and attempted to interview a resident with dementia who was unable to confirm the return of a missing ring. The resident's family confirmed the ring was returned and kept in their possession. The facility terminated an employee (S1) related to the incident and disassociated them from the facility roster.

The visit was an unannounced Case Management follow-up to an incident report submitted regarding a hospice resident who received a discontinued medication.

A deficiency was cited for failure to assist residents with self-administered medications as required, specifically for administering a discontinued medication to a resident, posing an immediate health and safety risk. A civil penalty of $250 was assessed for a repeat violation.

The visit was triggered by a complaint regarding a hospice resident receiving a discontinued medication on 09/13/2022.

The visit was an unannounced case management follow-up to an incident report regarding a medication error where staff administered the same medication twice to a resident, and to investigate multiple falls of another resident that were not reported to the licensing agency.

Deficiencies were found related to failure to assist residents properly with self-administered medications and failure to report multiple falls of a resident to the licensing agency, posing immediate health and safety risks.

The visit was triggered by a complaint investigation following an incident report of a medication error and unreported multiple falls of a resident. The investigation number is #24-AS-20220729113420.

The inspection visit was an unannounced complaint investigation triggered by an allegation that staff did not respond timely to an egress alarm, resulting in a resident exiting memory care, falling, and sustaining an injury.

The investigation found that staff failed to respond to the egress alarm for approximately 34 minutes, leading to a resident leaving the facility undetected and sustaining a head injury. The allegation was substantiated and a deficiency was cited related to insufficient staff supervision and care.

The complaint was substantiated based on interviews and records review. Staff did not respond timely to the egress alarm, resulting in a resident exiting memory care, falling, and sustaining an injury.

Unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-05-13 regarding resident care and facility conditions.

Based on observation, record review, and interviews, all allegations including foul odors, unkempt bathrooms, unattended residents, transportation issues, medication management, and failure to seek medical care were found to be unsubstantiated. No deficiencies were issued during the inspection.

The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred.

An unannounced annual inspection was conducted by Licensing Program Analyst Walton to evaluate compliance with regulatory requirements at the facility.

The facility was generally compliant with safety and infection control measures, including clear pathways, use of facial coverings, and sanitation practices. However, deficiencies were cited for medications and knives being accessible to residents in room 134, posing immediate health and safety risks.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-04-08 regarding staff fraudulently signing medication administration records, mismanagement of resident medications, and delayed response to resident calls for assistance.

The allegation that staff fraudulently signed medication administration records was substantiated based on interviews and record reviews, revealing that medications were signed off as given prior to actual administration, posing an immediate health and safety risk. Other allegations regarding trash maintenance, meal service, and floor cleanliness were found to be unsubstantiated.

The complaint investigation was substantiated for the allegation that staff fraudulently signed medication administration records. The allegations of staff mismanaging medications and delayed response to resident calls were previously cited and addressed with a Plan of Correction. Other allegations related to trash, meal service, and cleanliness were unsubstantiated.

The inspection was conducted as a follow-up to an incident reported on 2022-04-18 regarding a medication administration error where medications prepared for a resident were not administered but documented as given.

The facility was found deficient for failing to ensure all residents were assisted with self-administered medications as needed, posing an immediate health and safety risk. A deficiency was issued under California Code Regulations, Title 22, Division 6.

The visit was an unannounced Case Management - Deficiencies Inspection to follow up on 6 incident reports that were not submitted to the Fresno CCL office within 7 days of occurrence.

A deficiency was cited for failure to submit written incident reports within seven days of occurrence, as evidenced by 6 incident reports submitted late. A Plan of Correction was reviewed and developed with the Administrator.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-11-30 regarding residents' showering needs not being met and other allegations.

The allegation that residents' showering needs were not being met was substantiated based on staff interviews and review of shower records showing incomplete shower schedules. Other allegations regarding ants, falls due to lack of supervision, and bruising were found unsubstantiated due to lack of sufficient evidence.

The complaint investigation was substantiated for the allegation that residents' showering needs were not being met. Other allegations about ants, falls, and bruising were unsubstantiated due to insufficient evidence.

Unannounced complaint investigation visit conducted in response to a complaint received on 2022-01-11 regarding multiple allegations about resident care and facility conditions.

The investigation found no preponderance of evidence to substantiate the allegations concerning safeguarding of personal belongings, cleanliness of resident's room, adequacy of bedding, hygiene needs, availability of hand soap, and condition of resident's TV. No deficiencies were issued during this inspection.

The complaint was unsubstantiated. Allegations included staff not safeguarding resident's personal belongings, dirty resident's room, inadequate bedding, unmet hygiene needs, no hand soap in bathroom, and TV in disrepair. Interviews, observations, and record reviews did not support these allegations.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-02-03 regarding staff not responding timely to resident calls due to insufficient staffing and failure to provide appropriate transportation for residents.

The allegation that staff do not respond timely to resident calls due to insufficient staffing was substantiated based on observations and interviews, including an observed 27-minute delay in response to an emergency call. The allegation that the facility failed to provide appropriate transportation for residents was unsubstantiated due to lack of sufficient evidence.

The complaint was substantiated for the allegation that staff do not respond timely to resident calls due to insufficient staffing. The allegation regarding failure to provide appropriate transportation was unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including residents sustaining pressure injuries, staff leaving residents in soiled diapers for extended periods, inadequate food service, questionable death, and residents wandering away from the facility.

The investigation found all allegations to be unsubstantiated or unfounded due to lack of preponderance of evidence or reasonable basis. No deficiencies were issued during the inspection.

The complaint investigation was triggered by allegations of multiple residents sustaining pressure injuries, staff neglect in hygiene and food service, questionable death, and residents wandering away. The findings were unsubstantiated or unfounded, meaning the allegations were not proven or were false.

Unannounced visit/investigation of a complaint received on 2022-03-04 regarding allegations that staff failed to provide a comfortable environment for residents, the facility is in disrepair, and the facility is unkempt.

Based on observation, record review, and interviews with residents and staff, the allegations were found to be unsubstantiated. No deficiencies were issued during this inspection.

The complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations did or did not occur.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2021-11-29 regarding facility neglect, failure to observe changes in resident health, and unmet bathing needs.

Based on interviews and record reviews, the allegations were found to be unsubstantiated. No deficiencies were issued during this inspection.

The complaint involved allegations of facility neglect resulting in a resident developing an infection, failure of staff to observe changes in resident's health condition, and unmet bathing needs. The investigation concluded these allegations were unsubstantiated.

An informal meeting was held to discuss recently identified issues associated with the operation of the facility, including recent deficiencies and staffing concerns.

The meeting focused on recent deficiencies and staffing concerns at the facility. The Department offered to submit a referral to the Technical Support Program to assist the facility in returning to substantial compliance, which was accepted by facility leadership.

An unannounced complaint investigation was conducted following a complaint received on 08/20/2021 alleging that staff were not wearing masks.

The investigation found that 3 out of 4 dining room staff were observed not wearing facial coverings or wearing them improperly, violating official government orders and posing a potential health and safety risk to residents.

Complaint was substantiated. The complaint alleged staff were not wearing masks, which was confirmed during the investigation.

Unannounced complaint investigation visit conducted in response to an allegation that a resident sustained an unwitnessed fall resulting in fracture.

The allegation was found to be unsubstantiated based on record review and staff interviews. No deficiencies were cited during this inspection.

The complaint was unsubstantiated; although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur.

The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with regulatory requirements.

The facility was found to be in compliance with no deficiencies cited. Observations included proper infection control measures, secure medication storage, and no fire clearance issues.

The inspection was an unannounced Case Management Inspection conducted by Licensing Program Analyst A. Walton to assess compliance and conduct resident interviews.

No deficiencies were issued during the inspection. Resident interviews were conducted and an exit interview was held with the Executive Director.

The inspection was an unannounced complaint investigation conducted due to an allegation of illegal eviction received on 10/01/2020.

The investigation found that the facility failed to conduct a second needs and services appraisal for resident R1 and did not issue a 30-day eviction notice to R1 or the Responsible Party, substantiating the allegation of illegal eviction.

The complaint investigation was substantiated based on evidence that the facility did not follow proper eviction procedures for resident R1, including failure to conduct a second needs appraisal and failure to provide a 30-day eviction notice.

The inspection was an unannounced complaint investigation conducted due to allegations that staff were not responding timely to resident needs and that the facility did not report changes in condition to a resident's physician.

The allegation that staff were not responding timely to resident needs was substantiated based on interviews and record reviews indicating insufficient staffing. The allegation that the facility did not report changes in condition to a resident's physician was unsubstantiated with no deficiencies issued.

The complaint investigation was substantiated for the allegation that staff were not responding timely to resident needs due to insufficient staffing. The allegation that the facility did not report changes in condition to a resident's physician was unsubstantiated.

The inspection visit was an unannounced complaint investigation triggered by an allegation received on 01/22/2021 that the facility was not meeting resident needs due to insufficient staffing.

The investigation found, based on staff interviews and record reviews, that the facility did not have sufficient personnel to meet resident needs, substantiating the allegation of insufficient staffing.

The complaint was substantiated based on the preponderance of evidence standard after staff interviews and record review confirmed insufficient staffing to meet resident needs.

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