Westhills Villa Gardens

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Thelma Montebon, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (30), a current census of (18). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. All Three (3) facility houses have sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities. The facility (Houses 1,2,3) are equipped with operating smoke detectors and carbon monoxide alarms, Fire Marshall conducted a visit on 03/17/26 with no deficiencies. Quick response fire protection also conducted an annual sprinkler test on 3/16/26 with no deficiencies. The facility has working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. In House #1 the hot water temperature in three (3) resident common bathrooms measured between 106.1 to 107.2 degrees F. Seven (7) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. In House #2 the hot water temperature measured 118 degree F, three (3) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. Continuation on LIC – 809C: In House #3 the hot water temperature measured 110 degree F, three (3) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility (House #1) has posted in a common area, Resident Rights, Staff Schedule, Monthly Menu, Monthly Activities, facility sketch, Emergency disaster plan with emergency telephone numbers, CCLD complaint poster, and Ombudsman poster. Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care. Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff working have current CPR/first aid training and background cleared. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. Four (4) residents medication were audited and administered per physicians orders, medication is being pre-poured too early, Technical Violation issued. Record Review: Four (4) Staff files reviewed were observed to be complete. Four (4) Resident files reviewed were observed to be complete. Last disaster drill conducted on 2/27/26. Based on observations and record review one (1) technical violation was discussed and no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report along with LIC 9102 was discussed and provided to Administrator Thelma Montebon at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 23, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

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 that the facility was clean and sanitary throughout the visit. Residents were seen resting comfortably in their beds or participating in seated exercises with the active assistance of staff members. Unsubstantiated Furthermore, eight (8) out of eight(8) residents verified that bedridden individuals are regularly repositioned and receive diligent assistance with toileting and other essential care needs, indicating that the facility is maintaining appropriate standards of supervision and physical support. Based on the evidence found during the investigation, the allegation listed Resident sustained bedsore (stage 4 - unstageable) due to staff neglect is deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed, signed and provided to Facility Administrator- Thelma Monteban, facility representative.the 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. Unsubstantiated The review revealed that Resident #1 (R#1) is under the legal authority of a public guardian/conservator who makes decisions on R#1's behalf. The facility successfully maintained communication with this conservator regarding R#1’s change in condition, including R#1's subsequent transfer to a hospital and a skilled nursing facility for a higher level of care. Furthermore, when R#1’s family requested records, the licensee provided the documentation to the family's legal counsel under the specific direction of the public guardian/conservator of Resident#1. Based on the evidence found during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report LIC9099 was discussed,signed and a copy provided to Facility Administrator Thelma Montebon at the conclusion of the visit.the 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 occur. An exit interview was conducted where this report was discussed, and a copy was provided to Administrator Thelma Montebon. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 16, 2025 · control 56-AS-20251211083312

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Magda Malcore initiated a case management based on complaint control#56-AS-20250709093102. LPA identified self, was granted entry and met with Administrator, Thelma Montebon. On 7/14/2025, LPA requested to view resident #1 (R1's) file at the facility. LPA was informed by Administrator Montebon that R1 has not been a resident since September 2024. R1's file was removed from the facility and currently at their headquarter office in Pasadena. Administrator stated that she called headquarters and will have the file available at the facility later today (7/14/25). A deficiency is being cited in accordance with Title 22, division 6, of the California Code of Regulations(CCR). An exit interview was conducted where this report was discussed and a copy provided with appeal rights to Administrator Montebon at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Jul 18, 2025

87506(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident...this requirement is not met as evidenced by: The licensee did not comply with the section cited above by not retaining former resident's record file at the facility for review for a minimum of three years after services, which poses a potentional health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2025

Plan of correction: The licensee/Administrator has agreed to provide resident records by POC due date.

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. Unsubstantiatedthe 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 change their own diapers, but staff assist when needed. LPAs conducted 3 staff interviews all which denied leaving residents in soiled diapers for a long period of time. Unsubstantiated Regarding Allegation #3, LPAs observed an activities calendar posted in the dining room. LPAs observed most of the residents were in the living room watching tv. Based on interviews most residents like to participate in their own activities, however staff encourage them to exercise and walk around. Based on observation, interviews, and pertinent documents the allegations are unsubstantiated. An Unsubstantiated complaint means, that although the allegations may have happened or is 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.the state’s words, verbatim · CDSS document, May 29, 2025 · control 56-AS-20250527124010

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Thelma Montebon, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (30), a current census of (19). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities The facility is equipped with operating smoke detectors/carbon monoxide alarms, Riverside County Fire last inspected 01/17/25, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in four (4) resident bathrooms measured between 105.4 and 117 degrees F. Ten (10) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, Resident Rights, Personal Rights, Staff Schedule, Monthly Menu, Monthly Activities, facility sketch, CCLD complaint poster, and Ombudsman poster. Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care. Continuation on LIC – 809C: Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. Record Review: Five (5) Staff files reviewed were observed to be complete. Five (5) Resident files reviewed were observed to be complete. Based on observations and record review two (2) technical assistance were discussed and no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report along with LIC 902 was discussed and provided to Administrator Thelma Montebon.the state’s words, verbatim · CDSS document, Apr 4, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

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. Unsubstantiated Based on LPA's observation and medication review, residents are receiving medication as prescribed by physician. Regarding allegation #2, R1 is the only resident who requires injections at the facility. An in home LVN nurse attends the facility three times a day to inject R1. LPA conducted 3 staff interviews. 3 out of 3 staff informed LPA they do not administer injections to residents. LPA conducted interview with in home nurse while at the facility and was informed they are the only person to administer injection to R1, LPA also observed in home nurse injecting R1 at the time of the visit. Regarding allegation #3, LPA conducted 3 staff interviews. 2 out of 3 staff informed LPA residents personal medical device is not used on other residents. 1 out of 3 staff informed LPA they are unaware which residents have a personal medical device. In home nurse informed LPA they are the one to use medical device on R1, and it is not used on any other resident. Regarding allegation #4, LPA observed centrally stored medications locked inaccessible to residents in care. Three (3) staff informed LPA medication is centrally stored and inaccessible to residents in care. Regarding allegation #5, LPA conducted 3 staff interviews. 3 out of 3 staff informed LPA they assist residents with care needs in a timely manner. LPA conducted 6 resident interviews, 2 out of 6 residents were unable to answer LPA's question. 4 out of 6 residents informed LPA staff assist with care needs in a timely manner. LPA obtained pertinent documents indicting the daily care needs that were provided to residents; such as diaper changes, showers, and medication distribution. Based on LPAs observations, record review, and interviews, the above allegations are Unsubstantiated; meaning 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 where this report was discussed and a copy was provided to Administrator Alma Espinal at the conclusion of the visit.the 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

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Maria Jasmin Dolores, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (30) and a current census of (21) residents in care. The facility has a hospice waiver for (30) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility has sufficient indoor space for resident activities. Outdoor activity space is fenced and sufficient for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathroom equipment were in operation condition. The hot water temperature in residents' bathrooms measured 105 to 118 degrees F; however, the facility did not ensure infection control practices were maintained by having uncovered trash containers with tissue in residents bathrooms. Resident’s bedrooms have sufficient lighting, operating signal system, and furniture in good repair. The facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, blankets, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, resident's personal rights and emergency telephone numbers. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas. Care & Supervision: Facility has 24-hour support staff. Record Review: Staff files reviewed were observed to be complete and included criminal record clearances or exemptions through the Department. Resident files reviewed were observed to be complete. Administrator’s certification expires on 7/15/2024. The facility did not have a current emergency drill conducted with staff on file. Medical Related Services: All medication is centrally stored and kept in a locked cabinet. The facility has a complete first aid kits with a first aid manual. Deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted where reports LIC809/LIC809-C/LIC809-D were discussed. Copies of the licensing reports with appeal rights were provided to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 5, 2024