Westmont of Chico-Compass Rose

Type of visit: Case Management - Other

On May 13, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility to conduct a scheduled pre-licensing inspection for a change of corporate structure (CHOCS) with residents in care. LPA met with Executive Director (ED), Cliff Keene, and Resident Services Director (RSD), Pomali Thitphaneth and explained the purpose of the visit. Comp 3 was waived due to the facility already being in operation. Administrators license is current and posted for public view. During the inspection, there were 27 residents and four (4) staff providing care. LPA observed residents participating in ana exercise class. LPA, RSD and ED toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms and bathrooms, courtyard, kitchen, and storage areas. All areas observed were found to be clean and in good repair. All walkways were free of obstructions. LPA observed each bedroom to have the required furnishings and working lights. LPA observed the facility to be at a comfortable temperature. There were various activities available for client recreation. LPA observed a calendar of activities posted for residents to view, as well as printed copies for resident rooms. Facility has a 2-day perishable and a 7-day non-perishable amount of food. All residents requiring a special diet are posted for kitchen staff to review. LPA observed all medications, sharps, and cleaning supplies to be locked away and inaccessible to clients in care. LPA observed a complete First Aid kit ready for use. LPA observed fire extinguishers, smoke detectors, and carbon monoxide detectors to be in working condition and last inspected by the local fire jurisdiction in February 2026. The facility is conducting emergency disaster drills monthly with the last drill being documented in April 2026. This facility has successfully completed the CHOCS Pre-licensing inspection. LPA will contact the Central Application Bureau and declare no objections to continuing with the licensing process. Exit Interview and copy of report was provided to Executive Director, Cliff Keene, via email.the state’s words, verbatim · CDSS document, May 13, 2026

Allegation investigated: Facility is not adequately staffed to meet the needs of the residents in care. Residents are not provided with adequate access to the facility's call system. Facility staff sleep while on shift.

Licensing Program Analyst (LPA) Michael Hood arrived at the care home and met with Executive Director (ED), Cliff Keene, to deliver findings regarding the complaint allegations listed above. During the investigation, LPA conducted interviews, toured the premises, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility is not adequately staffed to meet the needs of the residents in care. Relevant party reported that the care home only has one (1) staff member during night shift to assist the residents if needed. ** Report continued on 9099-C ** Unsubstantiated LPA conducted interviews with residents R1, R2, R3, and R4. No interviews conducted with residents indicated any concerns regarding staffing. Interviews conducted with staff members (S3, S4, S5, S6, and S7) and witness (W1) did not indicate any concerns regarding staffing. LPA observed Raw Time Entry Report for staff schedule. LPA observed the facility to have approximately 13 staff members working in a day. LPA observed that staff were scheduled accordingly to ensure at least one (1) staff member was on shift and to account for breaks and shift changes. Allegation: Residents are not provided with adequate access to the facility's call system. Relevant party reported that residents, including R1, may not have access to their call buttons. Interviews conducted with R1, R2, R3, R4, S3, S4, S5, S6, S7, and W1 did not indicate any concerns regarding the care home's call system. LPA observed call buttons with residents during interviews. LPA tested R1's call button and observed staff respond to R1's call button within three (3) minutes. LPA observed call buttons located in the bathrooms of each resident's apartment. LPA observed call logs for resident R1, R2, R3, R4, R5, R6, R7, and R8 and observed the longest response time was less than ten (10) minutes. Allegation: Facility staff sleep while on shift. Relevant party reported that staff member (S1) has been sleeping at the facility during their shift. Interviews conducted with R1, R2, R3, R4, S3, S4, S5, S6, S7, and W1 did not indicate any concerns regarding staff sleeping while on shift. LPA observed a Corrective Counseling Documentation indicating that, on December 16, 2025, S1 was observed to be sleeping while on duty. S1 denied sleeping during shift per document. Staff member (S2) denied observing S1 sleeping while on duty per document. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 59-AS-20251229100531

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Cliff Keene, to follow-up regarding information obtained during a separate inspection conducted on April 29, 2026. LPA received a Corrective Counseling Documentation dated December 29, 2025 stating that, "On [December 26, 2025], a team member reported observing [staff member S1] sleeping for a period of time while on duty." LPA could not confirm if S1 was sleeping while on duty. LPA received images of S1 sleeping in the common areas of the facility. Per Section 87307 Personal Accommodations and Services, care home shall provide comfortable living accommodations and privacy for staff. Due to LPA's observations, per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809-D page. Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 29, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a) · Plan of correction due date: May 14, 2026

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: Based on LPA's observations, facility did not ensure that staff were not sleeping in the common areas of the care home, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Facility will ensure that staff do not sleep in the common areas of the care home. Facility will create a policy regarding staff breaks to ensure that staff are not sleeping in the common areas of the care home. Facility will submit a copy of the policy to LPA by POC due date of May 14, 2026.

Type of visit: Required - 1 Year

On April 6, 2026, Licensing Program Analyst (LPA) Kayla Adkison, arrived at the facility unannounced to conduct a Required Annual Inspection. LPA met with Pomali Thitphaneth, Resident Service Director (RSD) and Cliff Keene, Executive Director (ED), and explained the purpose of the visit. During the inspection, there were 26 residents and 5 (five) staff providing direct care. LPA observed residents watching movies, visiting with family members, and participating in craft projects. LPA, RSD and ED toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms and bathrooms, courtyard, kitchen, and storage areas. All areas observed were found to be clean and in good repair. LPA observed each bedroom to have the required furnishings and working lights. LPA observed the facility to be at a comfortable temperature. There were various activities available for client recreation. LPA observed a calendar of activities posted for residents to view, as well as printed copies for resident rooms. Facility has a 2-day perishable and a 7-day non-perishable amount of food. All residents requiring a special diet are posted for kitchen staff to review. LPA observed all medications, sharps, and cleaning supplies to be locked away and inaccessible to clients in care. LPA reviewed Medication Administration Records (MARs) and found them to be current and accurate. LPA observed a complete First Aid kit. LPA observed (3) three fire extinguishers which were last inspected in February 2026. Smoke detectors and carbon monoxide detectors were observed and found to be in working condition. The facility is conducting emergency disaster drills monthly with the last drill being documented in March 2026. Continued on LIC 809-C In the areas toured no immediate health, safety, or personal rights violations were observed. LPA reviewed a total of five (5) resident files and five (5) staff files which contained all the required documentation. All staff are fingerprint cleared and associated to the facility. All staff training is documented and in compliance with Title 22 regulations. Administrator's certificate is current and posted for public view. LPA obtained a copy of the most recent LIC 500, current liability insurance, and the facility's emergency disaster plan. No deficiencies are being cited as a result of this inspection and the facility is currently in compliance. Exit interview conducted. A copy of this report and was provided, via email, to Executive Director, Cliff Keene, via email.the state’s words, verbatim · CDSS document, Apr 6, 2026

Type of visit: Required - 1 Year

On April 24, 2025, Licensing Program Analyst (LPA) Kayla Adkison, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Resident Service Director (RSD), Pomali Thitphaneth, and explained the purpose of the visit. Administrator, Cliff Keene, arrived approximately 30 minutes later and joined the inspection LPA and RSD toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas for dinning and activities, four (4) resident bedrooms, four (4) resident restrooms, and the courtyard. LPA observed the facility to be clean, in good repair and odor-free. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA observed each resident bedroom to have the required furnishings. LPA observed calendar for monthly activities at the facility, and a daily posting of activities to help engage the residents. LPA observed the activities director conducting activities with several residents in the courtyard. LPA observed the kitchen to be clean and well stocked with a variety of food for residents. LPA observed a clear list of residents with restricted diets. Facility has a 2-day perishable and a 7-day non-perishable amount of food. LPA observed a locked closet which contained toxic chemical storage. The door to the laundry room is locked. LPA observed the medication to be locked and inaccessible to residents. LPA observed fire extinguishers which were last serviced in February 2025. The facility was in the middle of an active fire drill. LPA reviewed a total of six (5) residents' files and five (5) staff files which contained all of the required documentation. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Apr 24, 2025

Allegation investigated: Resident sustained a fracture while in care due to lack of care/supervision. Staff mismanaged resident's medication. A resident's personal rights were violated when staff did not prevent resident on resident intimidation, harassment, and/or harm.

/25/2024, Licensing Program Analyst Jaynae Boyles made an unannounced visit to the facility and met with administrator. The purpose of this visit was to deliver the results of a complaint investigation. During the course of the investigation the administrator, and five staff were interviewed. LPA reviewed the following documents from the resident file: Physicians report (602), pre-appraisal, care assessment and needs and services plan for resident care. LPA reviewed incident reports, medical appointments, Medication Administration Record (MAR) and the physician orders while in placement at the facility. Based on interviews, observation and record review of R1’s file the allegations are Unsubstantiated. This agency has investigated the complaint alleging resident sustained a fracture while in care due to lack of care/supervision, staff mismanaged resident's medication, facility is unclean, a resident's personal rights were violated when staff did not prevent resident on resident intimidation, harassment, and/or harm. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. Unsubstantiated Resident sustained a fracture while in care due to lack of care/supervision. Based on staff interview statements, R1’s facility assessment, physician’s report, and care plan, LPA determined the following information. R1 did have a fall that occurred on 11/24/2023, which resulted in a hip fracture. R1’s care plan, physician’s report, and resident assessment does not indicate that R1 is a fall risk. R1 is able to ambulate with minimal assistance per R1’s assessments and reports. R1 has not had any prior falls during R1’s residency at the facility. All staff statements obtained indicate that R1 had no issues ambulating. Staff statements indicate that there’s on average three to four staff working during the first and second shifts at the facility. Furthermore, the LPA reviewed the staff schedule during the time of the fall and there were three to four direct care support staff/med tech scheduled to work. Staff mismanaged resident's medication. On May 25, 2023, R1 was showing signs of disorientation and the resident was treated at the hospital for a UTI. The facility received the prescription and administered the medication as informed. On June 16, 2023, R1 was showing signs of disorientation and the facility informed the primary care physician and subsequently a urinalysis was ordered. On June 21, 2023 the results of the testing indicated that the test result was negative. On June 21, 2023 an order for antibiotics was placed by the primary care physician, the facility filled the prescription and administered the medication. A resident's personal rights were violated when staff did not prevent resident on resident intimidation, harassment, and/or harm. Based on staff interview statements, there has been no indication of R1 experiencing intimidation, harassment and/or harm from other residents in care. Based on review of the daily charting by staff there was no indication of R1 experiencing intimidation, harassment and/or harm from other residents in care. Based on a review of the incident reports, no such incidents have been reported to the Department regarding R1.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 59-AS-20240205092652

Type of visit: Required - 1 Year

On 03/28/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Cliff Keene, and explained the purpose of the visit. LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas for dinning and activities, resident bedrooms, resident restrooms, and the courtyard. LPA observed the facility to be clean, in good repair and odor-free. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed each resident bedroom to have the required furnishings, window screens and working lights. LPA observed calendar for monthly activities at the facility, and a daily posting of activities to help engage the residents. The facility has a plethora of supplies to conduct the planned activities. Facility has a 2-day perishable and a 7-day non-perishable amount of food. LPA observed the kitchen to be clean and well stocked with a variety of food for residents. LPA observed clear postings for residents with restricted diets. LPA observed locked closets which contained toxic chemical storage. The door to the laundry room is locked. LPA observed the medication to be locked and inaccessible to residents. LPA observed several fire extinguishers, fire detectors, and carbon monoxide detectors throughout the facility which were last services in February 2024. LPA observed first aid kit to be complete and ready for emergency use. LPA reviewed a total of six (6) residents' files and six (6) staff files which contained all of the required documentation. Several topics were discussed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Apr 2, 2024