Inspection Reports for Westmont of Riverside
17050 Arnold Dr, Riverside, CA 92518, United States, CA, 92518
Back to Facility ProfileInspection Report Summary
Most inspections over the past few years found no deficiencies, with the facility generally maintaining compliance and a safe environment. Several complaint investigations were unsubstantiated, including concerns about staffing, resident care, and facility maintenance. However, some deficiencies were substantiated, notably medication mismanagement found in the most recent report dated October 1, 2025, which posed an immediate risk to residents’ health. Earlier reports also cited issues such as inadequate hygiene supplies in February 2023 and improper staff training and resident restraint in January 2023, along with housekeeping and incontinence care problems in late 2022 that resulted in civil penalties totaling $1,000. The facility’s most recent annual inspection on September 30, 2025, was clean, indicating some improvement, but recent complaint investigations show that medication management remains a concern.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 201
Capacity: 225
Deficiencies: 1
Oct 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were mismanaging residents' medications, not responding to residents' calls for assistance in a timely manner, residents lacked access to telephones, and staff did not assist residents with required blood pressure checks.
Findings
The investigation substantiated the allegation of medication mismanagement, finding multiple residents missing medications or having medication errors. The allegations regarding delayed staff response to call buttons, lack of telephone access, and failure to assist with blood pressure checks were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were mismanaging residents' medications, with evidence of missing medications and medication errors for multiple residents. The allegations that staff did not respond timely to call buttons, residents lacked telephone access, and staff did not assist with blood pressure checks were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure medications were available for residents R3-R13, posing an immediate risk to residents' health, safety, or personal rights. | Type A |
Report Facts
Census: 201
Total Capacity: 225
Deficiencies cited: 1
Residents interviewed: 11
Staff interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Tony Vasallo | Licensing Program Manager | Named in relation to the investigation and plan of correction |
| Judith Pierfax | Executive Director | Met with Licensing Program Analyst during investigation |
| Keith Kasin | Administrator | Facility administrator named in report header |
| Moises Rivas | Resident Service Coordinator | Assisted with tour of resident rooms during investigation |
Inspection Report
Annual Inspection
Census: 201
Capacity: 225
Deficiencies: 0
Sep 30, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in compliance with all applicable regulations, with no deficiencies cited. The environment, employee records, resident records, and safety measures were all satisfactory.
Report Facts
Resident records reviewed: 20
Employee records reviewed: 10
Water temperature: 108.2
Fire extinguisher last tested: Dec 26, 2024
Emergency disaster drills frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Pierfax | Administrator | Met with during inspection and reviewed report findings |
| Yolanda Delgado | Licensing Program Analyst | Conducted the inspection |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Mary Valendez | Facility staff who granted entry to Licensing Program Analyst |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 225
Deficiencies: 0
Aug 23, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility does not have the ability to accommodate non-ambulatory residents with dementia in case of fire and that the facility does not conduct emergency drills as required.
Findings
The investigation found insufficient evidence to support the allegations. Interviews with the Resident Services Director, staff, and residents, as well as a facility tour and document review, indicated that the facility has multiple fire exits, conducts regular fire and safety drills, and staff are trained to assist residents during emergencies. No deficiencies were cited.
Complaint Details
The complaint alleged that the facility lacked the ability to accommodate non-ambulatory residents with dementia in case of fire and did not conduct required emergency drills. After interviews and document review, the allegations were found to be unsubstantiated.
Report Facts
Capacity: 225
Census: 205
Fire drill dates: Fire drills and training conducted on January 27, 2023; February 23, 2023; April 2, 2023; July 31, 2025; and Emergency Preparedness drill on September 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Vivian Villegas | Administrator | Facility administrator named in the report |
| Genesis Roman | Resident Services Director | Interviewed during the investigation regarding allegations |
| Giovanna Pazmino | Staff member to whom a copy of the report was provided during exit interview |
Inspection Report
Complaint Investigation
Census: 197
Capacity: 225
Deficiencies: 0
Jul 12, 2025
Visit Reason
The visit was conducted as an unannounced complaint investigation regarding an allegation that a resident had not received treatments ordered by her doctor.
Findings
The investigation found no evidence to support the allegation that the resident did not receive ordered treatments. Record reviews and staff and resident interviews indicated no neglect or failure to provide home health services. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that Resident #1 did not receive medication infusion treatments ordered by her doctor. The investigation included interviews, record reviews, and facility tours. The allegation was found unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 225
Census: 197
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Kasin | Administrator | Met with Licensing Program Analyst during investigation |
| Alicia Ballard | Memory Care Director | Met with Licensing Program Analyst and received exit interview |
| Regina Cloyd | Licensing Program Analyst | Conducted the complaint investigation visit |
| Yolanda Delgado | Licensing Program Analyst | Conducted initial unannounced investigation visit |
| Ulysses Coronel | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 225
Deficiencies: 0
Jun 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility is not maintained in good repair, specifically concerning malfunctioning automatic push button accessible doors.
Findings
The investigation found that the automatic push button accessible doors were functioning properly at the time of the visit. Interviews with staff, residents, and facility leadership, as well as a facility tour and review of maintenance records, did not substantiate the complaint. No deficiencies were cited.
Complaint Details
The complaint alleged that the automatic push button accessible door to the Trash/Recycle Room and the door outside the entrance/exit nearest the resident’s apartment were broken and unrepaired. The Executive Director denied the allegation. Staff and residents mostly reported the doors working properly, with some acknowledging past issues that were promptly fixed. One resident noted a former automatic door is now a regular door but can use other automatic doors safely. Maintenance records showed regular upkeep. The allegation was unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 225
Census: 174
Staff interviewed: 5
Residents interviewed: 7
Dates of investigation activities: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Lee | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Monya Henry | Administrator | Facility administrator named in the report |
| Judith Pierfax | Executive Director | Interviewed regarding the complaint allegation |
| Cynthia Cisneros | Community Wellness Director | Met with Department staff during the investigation and received the exit interview |
| Eva M Alvarez | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 225
Deficiencies: 0
Jun 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-12-05 regarding a resident being left in a soiled diaper and failure to safeguard a resident's property.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff, residents, and review of records indicated that residents were properly cared for and their property safeguarded. No deficiencies were cited and both allegations were deemed unsubstantiated.
Complaint Details
The complaint included two allegations: 1) Licensee left resident in soiled diaper, and 2) Licensee did not safeguard resident's property. Both allegations were investigated through interviews and record reviews and were found to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 225
Census: 174
Number of staff interviewed: 6
Number of residents interviewed: 7
Care checks frequency: 2
Care checks frequency: 4
Toileting frequency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Cynthia Cisneros | Community Relation Director | Met with the Licensing Program Analyst during the investigation and received the report |
| Alicia Ballard | Memory Care Director | Interviewed during the investigation regarding allegations |
| Keith Kasin | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 225
Deficiencies: 0
Jun 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 10/08/2021 regarding staffing sufficiency, timely assistance with toileting needs, and multiple resident falls.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Staff interviews, resident interviews, and document reviews indicated sufficient staffing and timely assistance. The facility had appropriate fall policies and took steps to address falls, but specific details on one resident were unavailable due to record retention limits.
Complaint Details
The complaint included three allegations: 1) Facility staff is insufficient to meet resident's needs; 2) Facility staff are not assisting resident with toileting needs in a timely manner; 3) Resident sustained multiple falls while in care. All allegations were found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 225
Census: 174
Number of staff interviewed: 5
Number of residents interviewed: 6
Date complaint received: Oct 8, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Pierfax | Executive Director | Interviewed during investigation and named in findings |
| Deborah Lee | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 174
Capacity: 225
Deficiencies: 0
Jun 28, 2025
Visit Reason
The visit was an unannounced complaint investigation regarding allegations that staff do not provide adequate food service to residents, specifically that residents have to wait two hours for their food which is often served cold.
Findings
Based on observations, interviews with staff and residents, and record reviews, the Licensing Program Analyst did not find sufficient evidence to support the allegation. Residents and staff denied the complaint, stating food is served hot and reheating is available if requested. No deficiencies were cited and the allegation was unsubstantiated.
Complaint Details
The complaint alleged inadequate food service with long wait times and cold food. Interviews with the Memory Care Director, six staff members, and six residents all denied the allegation. Observations confirmed lunch was served hot and of good quality. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 225
Census: 174
Number of staff interviewed: 6
Number of residents interviewed: 6
Complaint received date: Apr 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Vivian Villegas | Administrator | Facility administrator named in the report |
| Allicia Ballard | Memory Care Director | Interviewed during the investigation regarding the complaint |
| Judith Pierfax | Executive Director | Received a copy of the report during the exit interview |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 225
Deficiencies: 0
Jun 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff inappropriately pulled on a resident and did not address a resident's change in medical condition.
Findings
The investigation included interviews with staff, residents, and witnesses, and a review of training records. The evidence did not support the allegations, and the complaint was found to be unsubstantiated.
Complaint Details
The complaint alleged that staff inappropriately pulled on a resident's arm and that staff made fun of a resident when they requested medical attention. After investigation, including interviews and record reviews, there was insufficient evidence to substantiate these allegations.
Report Facts
Capacity: 225
Census: 35
Staff interviews: 3
Resident interviews: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Alicia Ballard | Memory Care Director | Facility representative met during the investigation and exit interview |
| Keith Kasin | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 225
Deficiencies: 0
Jun 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints alleging that facility staff did not provide a safe environment for residents and were not adequately trained.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Interviews with the Executive Director, residents, and staff, as well as a review of training records and a health and safety check, indicated that staff are trained and provide a safe environment for residents.
Complaint Details
The complaint alleged that facility staff did not provide a safe environment for residents and were not adequately trained, specifically regarding handling residents' medications. The investigation found these allegations unsubstantiated based on interviews, records review, and observations.
Report Facts
Capacity: 225
Census: 157
Resident Interviews: 13
Residents agreeing staff are trained: 12
Staff Interviews: 5
Staff agreeing they are trained: 5
Training Date: May 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Alicia Ballard | Memory Care Director | Facility representative met during the investigation and received the complaint report |
| Keith Kasin | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 197
Capacity: 225
Deficiencies: 0
Jun 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 10/14/2021 concerning resident charges for exterminator services, rough handling by staff, inappropriate staff speech, and untimely response to call buttons.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations. Interviews, record reviews, and staff training documentation supported that residents were not charged for exterminator services, staff did not handle residents roughly or speak inappropriately, and staff responded timely to call buttons. No deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents being required to pay for exterminator services, staff handling residents roughly, staff speaking inappropriately to residents, and staff not responding timely to call buttons. Multiple interviews with residents, staff, and witnesses, as well as document reviews, found no evidence to support these allegations.
Report Facts
Resident census: 197
Total capacity: 225
Staff training records: 14
Residents interviewed: 5
Residents interviewed initially: 3
Staff interviewed initially: 1
Witnesses interviewed: 2
Residents no longer at facility: 4
Staff no longer at facility: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Kasin | Executive Director | Met with Licensing Program Analyst during investigation |
| Alicia Ballard | Memory Care Director | Met with Licensing Program Analyst during investigation and received exit interview |
| Regina Cloyd | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Ulysses Coronel | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 225
Deficiencies: 0
Nov 26, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that the facility neglected the care of a resident.
Findings
The investigation included observations, interviews, and record reviews. The allegation was found to be unsubstantiated as there was no preponderance of evidence to prove the alleged neglect occurred, and the resident was assessed as independent in activities of daily living.
Complaint Details
The complaint alleged that a resident had an unwitnessed fall and was found on the floor soaked in urine. Interviews and record reviews showed the resident was independent and did not require assistance with daily living activities. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 18-AS-20241010091534
Capacity: 225
Census: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Sheryl McCaskill | Operational Specialist | Met with during the investigation and informed of the visit purpose |
| Monya Henry | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 117
Capacity: 225
Deficiencies: 0
Sep 10, 2024
Visit Reason
An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and compliant with safety and health regulations. Staff files and resident records were complete, emergency plans were updated, and no deficiencies were cited during the visit.
Report Facts
Staff files reviewed: 5
Resident files reviewed: 8
Fire drill date: 202408
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sheryl McCaskill | Operations Specialist | Met with Licensing Program Analyst during inspection and received report copy |
| Monya Henry | Administrator | Facility Administrator named in report header |
| Tricia Danielson | Licensing Program Manager | Named as Licensing Program Manager in report |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 225
Deficiencies: 0
Aug 8, 2024
Visit Reason
An unannounced complaint investigation was conducted following an allegation that a temporarily contracted employee denied medication administration to a resident on 07/19/2024.
Findings
The investigation included staff and resident interviews and record reviews. It was found that the resident self-administers medications and the allegation that staff denied medication administration was unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that Staff One (S1), a contracted employee, denied medication administration to Resident One (R1). The investigation found conflicting statements and insufficient evidence to substantiate the allegation. The complaint was deemed unsubstantiated.
Report Facts
Capacity: 225
Census: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Monya Henry | Executive Director | Facility representative met during the investigation |
| Rikesha Stamps | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 225
Deficiencies: 0
Jun 5, 2024
Visit Reason
The visit was conducted to investigate a complaint alleging that the facility is increasing rent more than 10% for Resident #1.
Findings
The investigation found that the facility provided proper 60-day written notice for rent increases and the signed admission agreement allowed for such increases. The complaint was determined to be unfounded.
Complaint Details
Complaint alleged that the facility increased rent more than 10% for Resident #1 after multiple increases in September 2023, February 2024, and a planned increase in July 2024. The allegation was investigated and found to be unfounded.
Report Facts
Capacity: 225
Census: 190
Dates of rent increase letters: Letters dated 4/26/2024, 2/7/2023, and 8/9/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monya Henry | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Jacqueline Shaw Ross | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jazmond D Harris | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 189
Capacity: 225
Deficiencies: 0
Jan 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation regarding an allegation that a staff member stole a resident's money.
Findings
The investigation found insufficient evidence to substantiate the allegation that a staff member stole resident's money. The resident in question had left the facility and no specific details or witnesses were provided to support the claim.
Complaint Details
The complaint was unsubstantiated due to lack of evidence, including no identified perpetrator, date, location, or amount stolen. The resident involved had left the facility and could not be interviewed.
Report Facts
Capacity: 225
Census: 189
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation |
| Monya Henry | Executive Director | Met with Licensing Program Analyst during investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 189
Capacity: 225
Deficiencies: 1
Jan 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that the facility is not maintained in good repair and that the facility does not conduct fire drills.
Findings
The allegation that the facility is not maintained in good repair was substantiated due to an elevator being out of service for over a month, posing a potential health and safety risk. The allegation that the facility does not conduct fire drills was unsubstantiated as staff reported monthly fire drills with staff only, and records showed the last drill was conducted on 11/30/2023.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility is not maintained in good repair due to an elevator being out of service since December 2023. The allegation regarding fire drills was unsubstantiated due to insufficient evidence.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The elevator was in disrepair for over a month posing a potential health, safety, or personal rights risk to persons in care. | Type B |
Report Facts
Capacity: 225
Census: 189
Deficiency Type B: 1
Plan of Correction Due Date: Jan 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monya Henry | Executive Director | Met with Licensing Program Analyst during investigation and named in findings regarding elevator disrepair |
| Chinwe Nwogene | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rikesha Stamps | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 179
Capacity: 225
Deficiencies: 0
Sep 15, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations received regarding lack of care and supervision resulting in a resident injury from a fall, and failure of staff to seek timely medical attention for a resident.
Findings
The investigation found that resident #1 had an un-witnessed fall and was sent to the hospital for medical care on the same day. There was insufficient evidence to substantiate the allegations of lack of care and failure to seek timely medical attention, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on the evidence obtained. Allegations included lack of care and supervision causing injury from a fall and failure to seek timely medical attention. The resident was sent to the hospital on the same day of the incident.
Report Facts
Capacity: 225
Census: 179
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Monya Henry | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 225
Deficiencies: 1
Sep 11, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not distribute a resident's medication as prescribed.
Findings
The investigation found that Resident One's medication was not included on the Medication Administration Record for March 2022, and the facility's documentation did not reflect the prescribed medication. However, review of other residents' medication records showed no discrepancies, and interviews confirmed residents were receiving medications as prescribed. The allegation was substantiated based on the evidence.
Complaint Details
The complaint was substantiated, meaning the allegation was valid based on the preponderance of evidence.
Deficiencies (1)
| Description |
|---|
| Failure to distribute Resident One's medication as prescribed. |
Report Facts
Facility capacity: 225
Resident census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Monya Henry | Executive Director | Met with Licensing Program Analyst during the investigation and received report |
| Patrick Frazer | Administrator | Named as facility administrator |
| Rikesha Stamps | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 180
Capacity: 225
Deficiencies: 0
Sep 11, 2023
Visit Reason
An unannounced visit was conducted for a required annual inspection of the facility.
Findings
The Licensing Program Analyst toured the facility, reviewed safety and care measures, and conducted interviews. No deficiencies were observed during the visit.
Report Facts
Residents in assisted living units: 71
Residents in memory care: 34
Residents living independently: 75
Perishable food supply: 2
Nonperishable food supply: 7
Bedridden resident capacity: 25
Hospice waiver capacity: 25
Disaster drill date: Aug 31, 2023
Fire drill date: Aug 29, 2023
Inspection start time: 915
Inspection end time: 130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monya Henry | Administrator | Met with Licensing Program Analyst during inspection |
| Janette Romero | Licensing Program Analyst | Conducted the inspection visit |
| Joel Esquivel | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 225
Deficiencies: 0
Aug 7, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff attempted to change a resident's medical insurance without authorized representative's consent and that staff were not providing an itemized list of charges to the authorized representative.
Findings
The investigation found that the allegation of unauthorized insurance change was unfounded as the resident and family agreed to switch to the facility’s affiliated medical provider. The allegation regarding the itemized list of charges was unsubstantiated due to a delayed invoice caused by an incorrect email address, which was corrected.
Complaint Details
The complaint involved two allegations: 1) staff attempted to change a resident's medical insurance without consent, which was found to be unfounded; 2) staff did not provide an itemized list of charges, which was found to be unsubstantiated.
Report Facts
Capacity: 225
Census: 172
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Monya Henry | Executive Director | Met with Licensing Program Analyst during investigation |
| Patrick Frazer | Administrator | Facility administrator mentioned in report |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 225
Deficiencies: 0
Jun 2, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the licensee did not provide enough staff to meet resident needs in the Assisted Living area on May 25, 2023.
Findings
The investigation found that although staffing had to be reshuffled due to absences, residents did not notice a lack of staff or have concerns about care. Staff interviews and observations confirmed adequate staffing levels on the day of the allegation. The complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged insufficient staffing in Assisted Living on May 25, 2023 between 1:30pm and 3:30pm. The allegation was unsubstantiated after review of staffing records, staff and resident interviews, and observations.
Report Facts
Capacity: 225
Census: 178
Staffing levels: 5
Shifts staffing: 2
Shifts staffing: 3
Shifts staffing: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation |
| Sheila Dudley | Regional Sales Specialist | Met with Licensing Program Analyst during investigation and participated in exit interview |
| Mayra Alfaro | Resident Services Director | Interviewed by Licensing Program Analyst regarding staffing levels |
| Patrick Frazer | Administrator | Facility administrator named in report header |
| Joel Esquivel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 172
Capacity: 225
Deficiencies: 0
Apr 19, 2023
Visit Reason
The visit was an unannounced case management visit to follow up on the death of resident #1 (R1).
Findings
The Licensing Program Analyst reviewed documentation and conducted staff interviews regarding the death of R1, who was a new admit and died from a preliminary cause of a self-inflicted gunshot wound. No deficiencies were cited during this visit.
Report Facts
Facility capacity: 225
Census: 172
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mayra Alfaro | Resident Services Director | Met with Licensing Program Analyst and provided information regarding the death of resident #1 |
| Emerald Mobley | Resident Services Director of Memory Care | Provided information regarding the death of resident #1 |
| Javina George | Licensing Program Analyst | Conducted the unannounced case management visit |
| Joel Esquivel | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 225
Deficiencies: 0
Apr 13, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that a staff member sexually assaulted a resident while in care.
Findings
The investigation included interviews with residents, witnesses, and review of facility records. The staff member in question was not employed by the facility but by a third-party agency. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The allegation was that Staff One (S1) sexually assaulted resident R1 during massage services. S1 denied inappropriate touching and stated treatments were explained and consented to. Law enforcement concluded no elder abuse occurred. Four other residents reported no concerns. The allegation was unsubstantiated.
Report Facts
Capacity: 225
Census: 173
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation |
| Deborah Mullen | Licensing Program Manager | Oversaw the complaint investigation |
| Keith Kasin | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 168
Capacity: 225
Deficiencies: 0
Mar 13, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging illegal eviction of a resident in care.
Findings
The investigation found that a 30-day eviction notice was valid due to non-payment of rent, and the resident's belongings were still in the unit. The complaint was determined to be unsubstantiated based on interviews and documentation review.
Complaint Details
The complaint alleged illegal eviction issued to a resident. The investigation concluded the eviction was valid and compliant with Health and Safety code §1569.683, and the complaint was unsubstantiated.
Report Facts
Capacity: 225
Census: 168
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation |
| Deborah Mullen | Licensing Program Manager | Named in report as Licensing Program Manager |
| Vivian Villegas | Administrator | Facility Administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 1
Feb 15, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/07/2022 regarding inadequate hygiene supplies, pressure injury care, bathing assistance, and air conditioning disrepair at Westmont Village facility.
Findings
The investigation substantiated the allegation that the facility did not provide adequate hygiene supplies such as soap and paper towels to memory care residents, issuing a Type B citation. Other allegations regarding pressure injury care, bathing assistance, and air conditioning system disrepair were found to be unsubstantiated.
Complaint Details
The complaint investigation was substantiated for inadequate hygiene supplies but unsubstantiated for allegations related to pressure injury care, bathing assistance, and air conditioning system disrepair.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Soap and paper towels were not being provided to memory care residents, posing a potential health and safety risk. | Type B |
Report Facts
Facility capacity: 225
Visit start time: 1100
Visit end time: 1345
Plan of Correction due date: Feb 22, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Deborah Mullen | Licensing Program Manager | Oversaw the complaint investigation |
| Emerald Mobley | Memory Care Resident Services Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 0
Feb 1, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not provide proper medication assistance to a resident in care.
Findings
The investigation found that the resident had not yet received the prescribed narcotic medication due to mailing delays, but alternative pain medications and hospitalization options were offered. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged improper medication assistance to a resident. The allegation was found unsubstantiated after interviews with staff, the resident, and an outside witness confirmed the medication was ordered and alternatives were provided.
Report Facts
Facility capacity: 225
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation |
| Mayra Alfaro | Resident Services Director | Met during investigation and exit interview |
| Emerald Mobley | Memory Care Resident Services Director | Met during investigation |
Inspection Report
Complaint Investigation
Census: 164
Capacity: 225
Deficiencies: 2
Jan 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-01-05 regarding staff training on indwelling catheters and inappropriate resident restraint.
Findings
The investigation substantiated two allegations: staff were not properly trained on indwelling catheter care, and a resident was inappropriately restrained using bed sheets. One allegation regarding ineffective communication between staff and a resident was unsubstantiated. Two citations were issued related to the substantiated allegations.
Complaint Details
The complaint investigation was substantiated for allegations that staff were not properly trained on indwelling catheter care and that a resident was inappropriately restrained. The allegation that staff could not communicate effectively with a resident was unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff were not properly trained regarding indwelling urinary catheter care, including lack of documented training for some caregivers. | Type B |
| Resident was restrained by staff using bed sheets, violating residents' rights to be free from neglect and involuntary seclusion. | Type B |
Report Facts
Citations issued: 2
Capacity: 225
Census: 164
Plan of Correction Due Date: Jan 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Deborah Mullen | Licensing Program Manager | Oversaw the complaint investigation |
| Vivian Villegas | Administrator | Facility administrator met during investigation |
| Julio Ramirez-Mercado | Caregiver | Named in findings related to lack of catheter training and resident restraint |
| Melvina Vega | Caregiver | Named in findings related to catheter care training and resident restraint |
| Emerald Mobley | Memory Care Resident Services Director | Interviewed during investigation |
Inspection Report
Census: 163
Capacity: 225
Deficiencies: 0
Jan 6, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on a recent resident death.
Findings
No deficiencies were observed during the visit. The Licensing Program Analyst reviewed the death report submitted by the Resident Service Director and completed the death report for the Community Care Licensing division.
Report Facts
Staff present: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josephine Williams | Business Office Director | Met with Licensing Program Analyst during the visit |
| Venus Mixson | Licensing Program Analyst | Conducted the unannounced case management visit |
| Deserie Rodillo | Resident Service Director | Submitted the death report reviewed during the visit |
| Jazmond D Harris | Licensing Program Manager | Named in the report header |
Inspection Report
Follow-Up
Census: 154
Capacity: 225
Deficiencies: 2
Nov 16, 2022
Visit Reason
Subsequent case management visit conducted regarding complaint investigation 18-AS-20221026090245 to verify correction of previously cited deficiencies.
Findings
The administrator failed to correct deficiencies related to Personal Rights of Residents and Managed Incontinence cited on 11/2/2022, as proof of required training was not submitted by the due date. Two civil penalties totaling $1,000 were assessed.
Complaint Details
Visit was related to complaint investigation 18-AS-20221026090245. Deficiencies were not corrected as required, resulting in civil penalties.
Deficiencies (2)
| Description |
|---|
| Deficiency for section 87468.1(a)(2) Personal Rights of Residents not corrected. |
| Deficiency for section 87625(b)(2) Managed Incontinence not corrected. |
Report Facts
Civil penalties: 1000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the case management visit and observed deficiencies. |
| Vivian Villegas | Administrator | Met with Licensing Program Analyst during visit; named in findings regarding failure to correct deficiencies. |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 225
Deficiencies: 6
Nov 2, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-10-26 regarding resident care issues including laundering needs, wet diapers, housekeeping, staff communication, staffing sufficiency, meal provision, and safety environment.
Findings
The investigation substantiated three allegations: failure to meet residents' laundering needs, residents left in wet diapers for extended periods, and failure to meet housekeeping needs. Four other allegations related to staff communication, staffing sufficiency, meal provision, and safety environment were unsubstantiated. The facility was issued three citations under Title 22.
Complaint Details
The complaint investigation was initiated based on allegations received on 2022-10-26. The investigation was conducted unannounced on 2022-11-02. Some allegations were substantiated, including failure to meet laundering, diaper changing, and housekeeping needs. Other allegations regarding staff communication, staffing sufficiency, meal provision, and safety environment were unsubstantiated.
Severity Breakdown
Type B: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility is not meeting residents laundering needs; laundry is often missed for several residents. | Type B |
| Residents are left in wet diapers for extended periods; 5 of 6 incontinent residents were not properly assisted with diaper changes. | Type B |
| Facility is not meeting residents housekeeping needs; urine-soaked floors were left uncleaned when staffing was short. | Type B |
| Personal Rights of Residents not met: residents were not accorded safe, healthful, and comfortable accommodations. | Type B |
| Managed Incontinence requirements not met: incontinent residents were not checked during known incontinent periods including night. | Type B |
| Personnel requirements not met: staffing often short, affecting cleanliness and resident care. | Type B |
Report Facts
Residents incontinent and not properly assisted: 5
Capacity: 225
Census: 152
Citations issued: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Deborah Mullen | Licensing Program Manager | Oversaw the complaint investigation. |
| Vivian Villegas | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation. |
| Deserie Rodillo | Resident Services Director | Met with Licensing Program Analyst during the facility tour. |
Inspection Report
Annual Inspection
Census: 153
Capacity: 225
Deficiencies: 0
Oct 19, 2022
Visit Reason
An unannounced annual inspection was conducted with an emphasis on infection control to assess compliance with Community Care Licensing guidelines.
Findings
The inspection found no deficiencies; however, four technical assistances were provided regarding infection control measures such as signage, hand hygiene supplies, PPE use, and COVID-19 protocols.
Report Facts
Technical Assistances: 4
Staff present: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vivian Villegas | Administrator | Met with Licensing Program Analyst during the inspection |
| Yolanda Delgado | Licensing Program Analyst | Conducted the inspection |
| Jazmond D Harris | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 225
Deficiencies: 0
Sep 7, 2022
Visit Reason
The visit was an unannounced case management health and safety visit conducted in conjunction with complaint 18-AS-20220907102851.
Findings
No imminent health or safety concerns were observed during the visit. The facility had sufficient staff, utilities were functioning properly, and food and medication supplies met requirements. No deficiencies were cited.
Complaint Details
The visit was conducted in response to complaint 18-AS-20220907102851. No immediate threats to health, safety, and welfare were found, and no deficiencies were cited.
Report Facts
Residents in memory care during visit: 25
Total residents in facility: 145
Facility capacity: 225
Food supply requirement: 2
Food supply requirement: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Kasin | Executive Director | Met with Licensing Program Analyst during the visit |
| Deserie Rodillo | Resident Care Director | Met with Licensing Program Analyst and was informed of visit purpose |
| Jesse Gardner | Licensing Program Analyst | Conducted the case management health and safety visit |
| Deborah Mullen | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 225
Deficiencies: 0
May 5, 2022
Visit Reason
The visit was an unannounced complaint investigation initiated due to allegations including residents not having access to a telephone, facility disrepair, and non-compliance with the admissions agreement.
Findings
The investigation found that the allegations were unsubstantiated. Residents in the licensed Assisted Living area had full phone service and no issues with internet or TV service. Toilets and stoves were found to be operational. The issues reported were limited to an independent area not licensed with Community Care Licensing.
Complaint Details
The complaint involved multiple allegations: lack of telephone access for residents, facility disrepair, and failure to abide by the admissions agreement. The investigation included interviews with 14 residents and staff, document reviews, and facility tours. All allegations were deemed unsubstantiated due to lack of evidence or because the issues affected only unlicensed areas.
Report Facts
Capacity: 225
Census: 140
Number of residents interviewed: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation |
| Josephine Williams | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Maria Rossi | Regional Director of Operations | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 130
Capacity: 225
Deficiencies: 0
Sep 13, 2021
Visit Reason
An unannounced annual inspection was conducted with an emphasis on infection control to evaluate the facility's compliance with Community Care Licensing guidelines.
Findings
The inspection found no deficiencies. Observations included proper signage, sufficient hand hygiene supplies, adequate cleaning and disinfecting provisions, proper use of face coverings, and a designated infection control lead. The facility has plans in place for COVID-19 testing, isolation, cleaning, and monitoring residents.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Kasin | Executive Director | Met during inspection and named in report. |
| Mallika Purohit | Resident Services Director Specialist | Met during inspection and named in report. |
| Tricia Danielson | Licensing Program Analyst | Conducted the inspection. |
| Reyna Lacey | Licensing Program Manager | Named in report. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 225
Deficiencies: 0
Aug 4, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident sustained a fall while in care and that facility staff did not notice a change in the resident's condition.
Findings
The investigation found that the resident was assessed as a fall risk and the fall incident was unwitnessed but staff followed proper care procedures. Staff also assessed and documented the resident's change in condition and obtained home health services. The allegations were deemed unsubstantiated due to insufficient evidence.
Complaint Details
The complaint involved allegations that a resident sustained a fall while in care and that facility staff did not notice a change in the resident's condition. The allegations were found to be unsubstantiated.
Report Facts
Capacity: 225
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Monya Henry | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 225
Deficiencies: 2
Jul 9, 2021
Visit Reason
The visit was conducted to address a deficiency observed during the investigation of Complaint #18-AS-20190919104522, which alleged that facility staff lacked proper training.
Findings
The investigation found a lack of proper record keeping regarding staff training documentation. The facility was unable to provide proof of training for nine of eleven staff records, and initial or annual training records were not observed on file or provided. This posed a potential health and safety risk to residents.
Complaint Details
Complaint #18-AS-20190919104522 alleged facility staff lacked proper training; the investigation substantiated a lack of training documentation for nine of eleven staff records.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensees did not maintain verification of required staff training and orientation in personnel records. | Type B |
| Initial training, nor annual training, was not observed on file and could not be provided by facility staff. | Type B |
Report Facts
Staff records lacking proof of training: 9
Total staff records audited: 11
Facility census: 116
Facility capacity: 225
Plan of Correction due date: Jul 30, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Kasin | Executive Director | Met during the visit and participated in the exit interview. |
| Stephanie Torres | Licensing Program Analyst | Conducted the unannounced visit and investigation. |
| Nedra Brown | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
| Panida Ferris-Locke | Previous Executive Director | Mentioned as previous ED who adopted staff from the prior facility. |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 225
Deficiencies: 0
Jul 9, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2019-09-19 regarding staffing sufficiency, food service adequacy, staff training, and provision of activities at the facility.
Findings
All allegations were investigated through staff and resident interviews, record reviews, and observations. The allegations of insufficient staffing, inadequate food service, and improper staff training were deemed unsubstantiated due to lack of sufficient evidence. The allegation that the facility does not provide activities was deemed unfounded based on observations and interviews.
Complaint Details
The complaint included allegations that the facility had insufficient staff to meet residents' needs, failed to provide adequate food service, staff were not properly trained, and the facility did not provide activities. After investigation, the staffing, food service, and training allegations were unsubstantiated, and the activities allegation was unfounded.
Report Facts
Staff records audited: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Torres | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit. |
| Keith Kasin | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview. |
| Panida Ferris-Locke | Administrator / Previous Executive Director | Provided information regarding staffing and training records. |
Inspection Report
Complaint Investigation
Capacity: 225
Deficiencies: 0
Feb 16, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that due to neglect, a resident was physically assaulted by another resident while in care.
Findings
The investigation found that Resident #1 was found on the floor with Resident #2 hitting Resident #1's ankle area with a cloth slipper. Both residents were assessed with no injuries found. Resident #1 was taken to a medical facility as a precaution and returned the same day with no new orders or medical findings. The allegation was deemed unsubstantiated due to insufficient evidence of neglect or assault.
Complaint Details
The complaint was unsubstantiated. The allegation that due to neglect, a resident was physically assaulted by another resident was not supported by evidence.
Report Facts
Capacity: 225
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Monya Henry | Executive Director | Met with Licensing Program Analyst during investigation |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
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