Westhills Villa Gardens

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained bedsore (stage 4 - unstageable) due to staff neglect.

On 04/08/2026, Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to initiate and deliver findings on the allegation listed above. LPA was greeted by Facility administrator and granted entry to the facility and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First Allegation: Resident sustained bedsore (stage 4 - unstageable) due to staff neglect. Licensing Program Analyst (LPA) Singh conducted a comprehensive review of facility records, confirming that Resident #1 (R#1) was receiving hospice and home health services specifically for wound care, repositioning, and assistance with activities of daily living (ADL). Additionally, all eight residents interviewed expressed complete satisfaction with their care, specifically noting that staff are always available for daily assistance and ensure that bedridden residents are regularly repositioned and helped with personal needs. LPA Singh observed thatthe state’s words, verbatim · CDSS document, Apr 8, 2026 · control 56-AS-20241016133606

Allegation investigated: Licensee is not providing resident's records to their representative as necessary.

On 3/19/2026, at 8:50 AM, Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to the facility to deliver findings for a complaint investigation. LPA Singh met with a staff,greeted and granted entry to the facility. Facility Administrator, Thelma Montebon, was informed, arrived during the visit and LPA Singh explained the purpose of the visit to the facility administrator. Allegation:Licensee is not providing resident's records to their representative as necessary. During the investigation, Licensing Program Analyst (LPA) Singh reviewed Statements, records, and interviews obtained did not provide sufficient information to corroborate the allegation.LPA Singh determined after reviewing all the records,interview with the licensee and staff that there was insufficient evidence to corroborate the allegation that the licensee failed to provide resident records to an authorized representative. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 19, 2026 · control 56-AS-20250709093102

Allegation investigated: Unqualified staff providing care to resident Staff did not assess resident upon admission

Licensing Program Analysts (LPAs) Sarina Ramirez and Andrew Martinez conducted an unannounced visit to the facility to conduct a complaint investigation into the above allegations. LPAs met with Administrator Thelma Montebon and discussed the purpose of the visit. Regarding allegation #1, Based on LPAs record review and interviews, staff are trained in providing appropriate care for all residents prior to starting their position. LPAs obtained pertinent documents to corroborate that staff are providing qualified care for residents. Regarding allegation #2, Based on LPAs record review, R1 was assessed prior to admission. Based on interviews, Administrator informed LPAs that all residents are assessed prior to admission to ensure compatibility. Therefore, the alleged allegations have been determined Unsubstantiated. Unsubstantiated; meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occuthe state’s words, verbatim · CDSS document, Dec 16, 2025 · control 56-AS-20251211083312

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident was physically assaulted by another resident in care. Staff yell at residents in care.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met with Administrator Thelma Montebon and discussed the purpose of the visit. Regarding allegation #1, Administrator informed LPA no residents have been in an altercation. LPA interviewed six (6) residents, all whom denied being in a physical altercation with other residents. Regarding allegation #2, staff deny yelling at residents. LPA interviewed six (6) residents all whom deny being yelled at by staff. Based on observation, interviews, and pertinent documents the allegations are unsubstantiated. An Unsubstantiated complaint means, that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Administrator Thelma Montebon and a copy of this report was provided at the conclusion of the visit. Unsthe state’s words, verbatim · CDSS document, Jun 19, 2025 · control 56-AS-20250612161612

Allegation investigated: Facility staff caused multiple injuries to residents in care. Facility staff left resident soiled for an extended period of time. Facility staff do not provide activities for residents.

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPAs met with Administrator Thelma Montebon and discussed the purpose of the visit. Regarding Allegation #1, Based on observations and interviews with staff and residents, it was alleged that Resident 1 (R1) sustained multiple injuries by staff. LPAs did not observe injuries on R1 nor other residents in care, however Staff (S1) explained R1 recently sustained a cut on their leg due to their wheelchair. LPAs conducted 6 resident interviews, which all denied sustaining injuries from staff while in care. LPAs conducted 3 staff interviews all which denied handling residents in a rough manner causing any injuries to residents. Regarding Allegation #2, LPAs conducted 6 resident interviews, 4 out of 6 residents stated they do not wear diapers, 2 out of 6 residents stated they do wear diapers; however they are able to cthe state’s words, verbatim · CDSS document, May 29, 2025 · control 56-AS-20250527124010

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not dispense resident’s medications as prescribed. Licensee did not ensure injections were administered by an appropriately skilled professional. Staff used resident’s personal medical device on another resident. Staff did not ensure centrally stored medications were not accessible to residents. Staff did not assist resident with care needs in a timely manner.

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met Administrator Alma Espinal and discussed the purpose of the visit. During today’s visit, LPA conducted observations, interviewed staff, residents, outside parties and obtained facility records. Regarding allegation #1, LPA conducted 6 resident interviews. 2 out of 6 residents were unable to respond whether or not they receive medication as prescribed. 4 out of 6 residents informed LPA they receive their medication as prescribed. LPA conducted 3 staff interviews. 2 out of 3 staff informed LPA they administer medication daily as prescribed. 1 out of 3 staff informed LPA they do not administer medication. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 12, 2025 · control 56-AS-20250206121636

Allegation investigated: Staff verbally abusing residents at the facility

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Alma Espinal, Administrator, and discussed the purpose of the visit. Regarding the allegation, staff verbally abusing residents at the facilty, six (6) out of seven (7) residents interviewed deny that staff verbally abuse them. Five (5) staff interviewed deny verbally abusing residents and have not witnessed other staff verbally abuse residents. Based on LPA observations, resident and staff interviews, the above allegation is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy of this report with Appeal Rights was provided to the Administrator at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 17, 2024 · control 56-AS-20240220130906

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.