Inspection Reports for Westmont of Chico
2750 Sierra Sunrise Terrace, Chico, CA 95928, United States, CA, 95928
Back to Facility ProfileInspection Report Summary
The facility’s most recent inspection on April 24, 2025, found no deficiencies, continuing a pattern of clean annual inspections in recent years. Earlier reports included a substantiated complaint in November 2022 related to allowing a symptomatic caregiver to work, which led to a COVID-19 outbreak and a $10,000 fine. Prior to that, in 2020, several serious deficiencies were cited involving inadequate supervision, unsafe medication administration, delayed medical care, and insufficient staffing, some of which contributed to resident harm and hospitalization. Many complaint investigations over time were unsubstantiated, indicating that most allegations were not supported by evidence. Overall, the facility appears to have improved since the more serious issues identified in 2020 and 2022, with recent inspections showing compliance and no new deficiencies.
Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 25
Capacity: 48
Deficiencies: 0
Apr 24, 2025
Visit Reason
The inspection was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care.
Findings
The facility was observed to be clean, in good repair, and odor-free with no immediate health, safety, or personal rights violations. Resident bedrooms had required furnishings, activities were provided, and food storage and medication security met requirements. Fire extinguishers were serviced recently and a fire drill was in progress. Resident and staff files contained all required documentation.
Report Facts
Residents' files reviewed: 6
Staff files reviewed: 5
Fire extinguisher service date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pomali Thitphaneth | Resident Service Director | Met with Licensing Program Analyst during inspection |
| Cliff Keene | Administrator | Joined inspection approximately 30 minutes after start |
| Kayla Adkison | Licensing Program Analyst | Conducted the inspection |
| Lauren Crocker | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 48
Deficiencies: 0
Apr 25, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations including a resident sustaining a fracture due to lack of care/supervision, staff mismanagement of medication, violation of resident personal rights, and facility cleanliness.
Findings
The investigation found all allegations unsubstantiated or unfounded based on interviews, record reviews, and observations. The resident's fracture was not linked to lack of care, medication was properly managed, no resident intimidation or harm was found, and the facility was safe and sanitary.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a resident sustaining a fracture due to lack of care/supervision, staff mismanagement of medication, violation of resident personal rights by failure to prevent resident-on-resident intimidation, harassment, and/or harm, and the facility being unclean. The investigation found no preponderance of evidence to support these allegations.
Report Facts
Capacity: 48
Census: 26
Complaint Control Number: 59-AS-20240205092652
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaynae Boyles | Licensing Program Analyst | Conducted the complaint investigation and made the unannounced visit |
| Lauren Crocker | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Pomali Thitphaneth | Administrator | Met with the Licensing Program Analyst during the investigation |
| Cliff Keene | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 24
Capacity: 48
Deficiencies: 0
Apr 2, 2024
Visit Reason
The visit was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care.
Findings
The facility was observed to be clean, in good repair, and odor-free with no immediate health, safety, or personal rights violations. All required furnishings, safety equipment, and documentation were in place, and no deficiencies were cited.
Report Facts
Resident files reviewed: 6
Staff files reviewed: 6
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaynae Boyles | Licensing Program Analyst | Conducted the inspection and authored the report |
| Cliff Keene | Administrator | Facility administrator met with the Licensing Program Analyst during the inspection |
Inspection Report
Census: 26
Capacity: 48
Deficiencies: 0
May 11, 2023
Visit Reason
This was an unannounced case management visit focused on legal and non-compliance issues.
Findings
The Licensing Program Analyst toured the facility, reviewed staff training, and discussed a couple of topics. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cliff Keene | Administrator | Met with during the visit. |
| Mel Rabauliman | Resident Service Coordinator | Toured the facility with the Licensing Program Analyst. |
Inspection Report
Annual Inspection
Capacity: 48
Deficiencies: 0
Feb 16, 2023
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure health and safety compliance.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed, and no deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pomali Thitphanethand | Resident Services Director | Met with Licensing Program Analyst during inspection and toured facility. |
| Cliff Keene | Administrator | Named as facility administrator and recipient of exit interview report. |
| Rebecca Knight | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Lauren Crocker | Licensing Program Manager | Named in report header. |
Inspection Report
Follow-Up
Capacity: 48
Deficiencies: 1
Nov 29, 2022
Visit Reason
The visit was a Case Management follow-up on a substantiated allegation of failure to meet personnel requirements and conduct inimical related to COVID-19 exposure risks.
Findings
The investigation confirmed that a supervisor allowed a caregiver with COVID-19 symptoms to work multiple shifts, exposing residents and staff to unnecessary risk. The facility was cited for violations of personnel requirements and conduct inimical, and a $10,000 civil penalty was issued.
Complaint Details
The complaint was substantiated. It involved a supervisor (S1) who allowed a caregiver (S2) with COVID-19 symptoms to work multiple days while not fit for duty, leading to a COVID-19 outbreak among residents and staff.
Deficiencies (1)
| Description |
|---|
| Failure to meet personnel requirements resulting in conduct inimical by allowing a symptomatic caregiver to work. |
Report Facts
Civil Penalty Amount: 10000
Facility Capacity: 48
COVID-19 Positive Residents: 4
COVID-19 Positive Staff: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cliff Keene | Administrator | Named in relation to the findings and receipt of penalty and report |
| Donna Gurriere | Licensing Program Analyst | Conducted the inspection and investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the case |
Inspection Report
Census: 28
Capacity: 48
Deficiencies: 0
Jul 6, 2022
Visit Reason
The visit was a case management visit to ensure compliance with the terms and conditions set forth in the Stipulation and Waiver; and Order effective June 29th, 2020.
Findings
The Licensing Program Analyst toured the facility, reviewed staff schedules, training documents, and client check logs, and found the facility was meeting minimum staffing requirements and providing required training. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cliff Keene | Administrator | Met with Licensing Program Analyst during the case management visit. |
| Pomali Thitphaneth | Resident Services Director | Met with Licensing Program Analyst during the case management visit. |
| Jaclyn Avila | Licensing Program Analyst | Conducted the case management visit. |
| Laura Munoz | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 48
Deficiencies: 0
Jul 6, 2022
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that the facility was overcharging a resident, financially abusing a resident, and failing to meet a resident's needs.
Findings
The investigation included interviews, observations, and document reviews, none of which supported the allegations. The complaint was found to be unfounded, with no evidence of overcharging, financial abuse, or failure to meet resident needs.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, and/or were without a reasonable basis.
Report Facts
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaclyn Avila | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cliff Keene | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 29
Capacity: 48
Deficiencies: 0
Apr 13, 2022
Visit Reason
Unannounced case management visit conducted due to unusual incident reports involving two residents who had falls resulting in injuries.
Findings
Two self-reported incident reports were reviewed involving falls that resulted in injuries to two residents. Both incidents were isolated, and the facility ensured residents' medical needs were met. No citations were issued.
Report Facts
Number of residents involved in incidents: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cliff Keene | Administrator | Met with Licensing Program Analysts during the visit. |
| Pomoli Thitphaneth | RSD | Met with Licensing Program Analysts during the visit. |
| Jaclyn Avila | Licensing Program Analyst | Conducted the unannounced case management visit. |
| David Loperena | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Annual Inspection
Census: 24
Capacity: 48
Deficiencies: 0
Mar 9, 2022
Visit Reason
The inspection was an unannounced Required-1 Year annual inspection to assess infection control compliance at the facility.
Findings
The facility was found to be in substantial compliance with infection control requirements. No immediate health, safety, or personal rights violations were observed, and no deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cliff Keene | Administrator | Met with Licensing Program Analyst and Manager during inspection and involved in infection control domain completion. |
| Jaclyn Avila | Licensing Program Analyst | Conducted the inspection and infection control domain evaluation. |
| Laura Munoz | Licensing Program Manager | Conducted the inspection and infection control domain evaluation. |
Inspection Report
Census: 24
Capacity: 48
Deficiencies: 0
Mar 9, 2022
Visit Reason
The visit was a case management visit to ensure compliance with the terms and conditions set forth in the Stipulation and Waiver; and Order effective June 29th, 2020.
Findings
The Licensing Program Analyst and Manager toured the facility, reviewed staff schedules, training documents, and client check logs, and found the facility was meeting minimum staffing requirements and providing required training. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cliff Keene | Administrator | Met with during the case management visit |
| Jaclyn Avila | Licensing Program Analyst | Conducted the case management visit and inspection |
| Laura Munoz | Licensing Program Manager | Conducted the case management visit and inspection |
Inspection Report
Census: 22
Capacity: 48
Deficiencies: 0
Jan 5, 2022
Visit Reason
The visit was an unannounced case management visit to discuss a Holiday Party where staff appeared to be unmasked.
Findings
The Licensing Program Analyst observed residents socially distanced and staff wearing masks during the visit. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cliff Keene | Administrator | Met with Licensing Program Analyst during the case management visit and explained the purpose of the visit. |
| Jaclyn Avila | Licensing Program Analyst | Conducted the case management visit and observed compliance with COVID-19 protocols. |
| Rayna L Bryson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 45
Capacity: 48
Deficiencies: 0
May 25, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on infection control to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited and technical assistance was provided.
Report Facts
Capacity: 48
Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cliff Keene | Administrator | Met with Licensing Program Analyst during inspection |
| Pomali Thitphanethand | Resident Services Director | Met with Licensing Program Analyst during inspection |
| Rebecca Knight | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 1
Apr 22, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on December 3, 2020, regarding neglect and lack of supervision and care at the facility.
Findings
The investigation found one allegation of neglect/lack of supervision unsubstantiated due to insufficient evidence, and one allegation of neglect/lack of care substantiated related to failure to ensure a resident received prescribed medication after hospital discharge. No deficiencies were found for the unsubstantiated allegation, but a deficiency was cited for the substantiated allegation.
Complaint Details
The complaint investigation involved allegations of neglect/lack of supervision resulting in serious injuries to Resident 1, which was unsubstantiated, and neglect/lack of care for failure to ensure Resident 1 received prescribed medication immediately upon hospital return, which was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, specifically staff did not fill Resident 1's new prescription for pain medication upon hospital discharge. | Type A |
Report Facts
Capacity: 48
Census: 48
Deficiencies cited: 1
Plan of Correction due date: Apr 29, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Knight | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cliff Keene | Administrator | Facility administrator met during the investigation and named in the report |
| Rayna L Bryson | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Census: 19
Capacity: 48
Deficiencies: 2
Nov 5, 2020
Visit Reason
The visit was an announced case management inspection to address deficiencies related to a staff member working while symptomatic and management's failure to assess the risk to residents.
Findings
The facility failed to prevent a symptomatic staff member from working and did not assess the potential health risk to residents, resulting in cited deficiencies under California Code of Regulations, Title 22.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement was not met as staff with evidence of physical illness tended to residents, posing an immediate health and safety risk. | Type A |
| Conduct inimical to the health, morals, welfare, or safety of individuals in or receiving services from the facility. The licensee failed to assess staff with an illness, subjecting residents to an immediate health and safety risk. | Type A |
Report Facts
Capacity: 48
Census: 19
Plan of Correction Due Date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cliff Keene | Administrator | Met with Licensing Program Analyst during the visit |
| Jaclyn Avila | Licensing Program Analyst | Conducted the inspection visit |
| Rayna L Bryson | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 48
Deficiencies: 0
Nov 5, 2020
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint alleging that staff were not accurately recording on the medication logs.
Findings
The investigation found no evidence to substantiate the complaint; interviews and record reviews did not reveal inaccuracies in medication logs. The allegations were determined to be unsubstantiated and no citations were issued.
Complaint Details
Complaint alleging staff are not accurately recording on the medication logs. The complaint was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 48
Census: 19
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaclyn Avila | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cliff Keene | Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 48
Deficiencies: 1
Nov 5, 2020
Visit Reason
The visit was conducted to investigate a complaint alleging that staff did not administer medication as prescribed by the physician.
Findings
The investigation found that staff administered medication, including PRN medication, without first contacting the physician as required by the physician's order. The allegations were substantiated based on interviews and record reviews.
Complaint Details
The complaint alleging improper medication administration was substantiated. An additional related complaint about unsafe medication administration was also substantiated. Citations were issued on 11/05/2020.
Deficiencies (1)
| Description |
|---|
| Staff did not administer medication as prescribed by physician, specifically administering PRN medication without contacting the physician first. |
Report Facts
Capacity: 48
Census: 19
Estimated Days of Completion: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaclyn Avila | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rayna L Bryson | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Cliff Keene | Administrator | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 48
Deficiencies: 5
Nov 5, 2020
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2020-06-06 regarding lack of supervision, personal rights violations, and unsafe medication administration at Compass Rose facility.
Findings
The investigation substantiated the allegations that the facility failed to provide adequate care and supervision to resident R1, resulting in multiple falls and hospitalization. The facility also administered medication unsafely and failed to implement prescribed safety interventions such as seat and bed alarms. Several regulatory deficiencies were cited, and a civil penalty of $500 was assessed.
Complaint Details
The complaint alleged lack of supervision leading to resident R1's hospitalization due to falls, unsafe medication administration, and violation of personal rights. The allegations were substantiated based on interviews, medical records, and observations.
Severity Breakdown
Type A: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to update R1’s care plan despite changes in dementia care needs, resulting in lack of supervision. | Type A |
| Failed to provide an accessible signal system for R1 to summon help, despite documented falls and physician orders. | Type A |
| Failed to ensure sufficient staff to meet resident needs, resulting in unsupervised falls and hospitalization. | Type A |
| Failed to meet necessary medical needs by not providing seat and bed alarms as prescribed by physician. | Type A |
| Failed to contact resident’s physician prior to administering PRN medication as required, contributing to falls and hospitalization. | Type A |
Report Facts
Civil penalty: 500
Capacity: 48
Census: 19
Deficiency count: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaclyn Avila | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rayna L Bryson | Licensing Program Manager | Oversaw the complaint investigation |
| Cliff Keene | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 48
Deficiencies: 3
Nov 5, 2020
Visit Reason
The visit was conducted as a case management and complaint investigation related to an incident reported on 6/2/20 involving a resident's assisted fall on 5/29/20 and delayed medical care.
Findings
The investigation found that the facility staff failed to immediately report the resident's fall and delayed medical care for over 22 hours, resulting in hospitalization and subsequent death. Deficiencies were cited related to personnel competency and failure to provide timely medical intervention, posing immediate health and safety risks.
Complaint Details
The complaint investigation was triggered by a report of an assisted fall on 5/29/20 where medical aid was not rendered until 22.5 hours later, resulting in hospitalization and hospice admission. The resident subsequently died on 6/13/20. The incident is under review and may result in civil penalties.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility personnel failed to have competent staff to meet resident needs; resident's fall was not immediately reported and medical care was delayed for 22.5 hours resulting in hospitalization. | Type A |
| Failure to ensure staff sufficient in numbers, qualifications, and competency to meet resident needs, resulting in substantial risk of serious injury and severe pain. | Type A |
| Failure to immediately telephone 9-1-1 when an injury or circumstance posed an imminent threat to resident's health. | Type A |
Report Facts
Civil penalty amount: 500
Plan of Correction Due Date: Nov 6, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cliff Keene | Administrator | Met with Licensing Program Analyst during visit |
| Laura Seely | Residential Service Director (RSD), LVN | Reported the assisted fall incident to CCL |
| Jaclyn Avila | Licensing Program Analyst | Conducted the inspection and authored the report |
| Rayna L Bryson | Licensing Program Manager | Supervisor overseeing the inspection |
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