Westchester Gardens

Type of visit: Case Management - Other

On September 17, 2026 Licensing Program Analysts (LPAs) B. Miranda and H. Vang arrived at the facility unannounced. LPAs met with Administrator (AD) Vilma Hernandez Perez. Case management visit is being conducted due to facility submitting an incident report stating R1's puree at day program had bones. AD stated they spoke with staff S1 who stated they accidentally did not strain the puree before packing for R1 to take to day program. LPA asked AD if bone is normally added with the puree and AD state no, but there was a piece of chicken breast with the bone stuck. LPA reviewed R1's Physician Report which lists Special Diet as "Diabetic Diet, Puree". LPA reviewed S1's current training which did not consist of special diets or puree training. Case management is also being conducted for R2 who was given the wrong medication. R2 was given Mounjaro instead of Dupixent. AD explained S2 was under the impression the correct medication was given. AD provided training verification for LPA to review while at the facility. Deficiencies were cited during todays visit. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights will be emailed to then Administrator Vilma Hernandez Perez by today.the state’s words, verbatim · CDSS document, Sep 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(7) · Plan of correction due date: Sep 18, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Based on observation, interview, and record review, the facility did not comply with the regulation listed above due to facility providing R1 Puree with bone, which poses an Immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: Kitchen Manager informed LPA S1 was give 1:1 and in- service was conducted. Verification will be provided to the Dept by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Sep 18, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, interview, and record review, the facility did not comply with the regulation listed above due to R2 being given Mounjaro instead of Dupixent, which poses an Immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: Administrator provided training verification for staff while LPA was at the facility. POC will be cleared.

Type of visit: Case Management - Incident

On August 13, 2026 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management visit regarding an incident previously reported by the facility. LPA met with Vilma Hernandez Perez. The facility reported on July 19, 2026 staff spoke inappropriately to R1. Facility reported there was a voicemail of the incident. The facility provided LPA with the voicemail. LPA requested a full copy of S1's staff file. Vilma stated R1 has a psychiatric team, and they did come out to see R1 the same week the incident occurred. Vilma stated staff and police spoke with R1 who stated they felt better now that S1 was no longer in the facility. During the visit LPA interviewed R1 who stated they do feel safe at the facility. Facility provided the following documents to LPA during the visit: R1's physician report and communication log since the incident S1's complete staff file Copies of in-service and staff training Citation was issued under Personal Rights of Residents in All Facilities. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Vilma Hernandez Perez.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Aug 14, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. Based on observation, interview, and record review, the facility did not comply with the regulation listed above, which poses an Immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Facility terminated S1. In-service was conducted regarding elder abuse and reporting requirements. During the visit Vilma provided verification to LPA to clear POC during the visit.

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 36 Census (if any clients in care): COMP II Participants: DANA ANDERSON/ADMINISTRATOR Interview Method: Telephone interview On 2/23/26], administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Apr 2, 2026

Type of visit: Prelicensing

On 03/04/2026, Licensing Program Analysts (LPAs) Daiquiri Boyd and Brianna Miranda made a scheduled visit to the facility to conduct a Pre-Licensing Inspection. LPAs met with Licensee Katherine Johnson and Administrator Dana Anderson to complete this inspection. LPA entered the facility through the main front entry. Facility has linen stored in the main hallway closet. There is a room that has backfill for medications and is used for staff. There is a locked room in the hallway that stores the diabetic supplies, as well as a sharps container and a locked refrigerator. Medications are kept locked in a movable medication cart. LPAs observed food storage closet off of the courtyard area, as well as a separate laundry room that is kept locked. LPAs observed a 3 day supply of perishables and a 7 day supply of non-perishables. Sharps were locked in the kitchen area. A sample of resident rooms were toured and water was found to be at 114.4 degrees F. There is a large dining area with table and chairs and a TV on the wall. There is a sliding glass door in the dining room that leads outside to a patio with a table and chairs. The office is located in the main hall. LPAs found all hallways and exits unobstructed. All resident rooms have appropriate furnishings and were in good repair. Staff binders and resident binders were reviewed. Plan of Operation, Disaster Plan, and Infection Control Plan was reviewed. Fire Extinguishers were observed located throughout the facility and were last serviced on 01/19/2026. Fire system is a smoke and fire detector as well as a pull system. Fire system test documentation was reviewed and found to be in compliance. LPAs did not observe carbon monoxide detectors in the facility. LPAs observed Room 11's shower to have mold. Licensee stated she will send pictures of the carbon monoxide detectors and the clean shower by tomorrow. Pre-Licensing is complete and this facility has no deficiencies.the state’s words, verbatim · CDSS document, Mar 4, 2026

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 36 Census (if any clients in care): COMP II Participants: KATHERINE JOHNSON AND YAMILET MALDONADO Interview Method: Telephone interview On 12/15/25, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 15, 2025