Westmont of Cypress

Allegation investigated: Staff failed to address bed bug infestation in residents room

Licensing Program Analyst (LPA) Jenifer Tirre, met with Executive Director Nancy Rodriquez for the purpose of delivering findings for the above allegations. The investigation consisted of records obtained, observations and interviews conducted. On July 25, 2023, the department received allegations that Staff failed to address bed bug infestation in residents room. The investigation was completed by the department and revealed the following: Per documents received and reviewed, The Department received an Incident Report dated 7/18/2023. Incident report stated that inside Resident 1’s (R1) room a bed bug was found in apartment. Report stated that Staff contact pest control company which came out following day 7/19/2023 to collect specimen, inspected room and found an additional bed bug. Facility worked with pest control and scheduled additional heat treatments. Per pest control company Orkin’s records: facility had an existing contract with company and prior to incident pest control came out on 5/15/2023, 3/6/2023, 2/27/2023 to do a service inspection on multiple rooms in which results showed no live bed bug evidence found, all rooms negative for bed bug activity. CONTINUED ON 9099C Unsubstantiated Per Orkin Services a Commercial Special Service Agreement conducted on 7/25/2023, pest control company completed full chemical treatments as well as proactive chemical protection treatments on multiple apartments surrounding R1’s apartments. Per records, pest control came out again on 9/22/2023 and found negative activity for bed bugs. Per observations Department conducted an initial 10 day visit on 8/1/2023, during visit multiple resident bedrooms were observed including R1’s room, during visit, no bed bugs were found. Per interviews conducted the following was revealed: Interviews conducted with three staff members stated that they were informed that R1 had bed bug found on residents body during night shift. Staff stated Pest Control company was contacted and came out following day. Staff interviews stated that Pest Control inspector came out and inspected R1’s room as well as several other rooms. Per staff interviews only R1’s room was found to have bed bug activity. Staff stated that pest control did service heat treatments for R1’s room as well as surrounding rooms. Staff stated that pest control also conducted follow up treatments. Staff temporarily relocated R1 during treatments, bathed R1 as well as cleaned R1’s bedding and clothing to prevent any additional spreading of eggs or bugs as per recommended by Pest Control. Per interview conducted with Pest Control inspector, Inspector stated they conducted a visit the next day and confirmed R1’s room was the only room they observed to have active bed bugs. Inspector stated they did heat treatments as well as preventative treatments to R1’s room as well as additional rooms surrounding area. Inspector stated that source of bed bugs was R1’s bed spring where eggs had hatched. Inspector stated notified staff and had box spring removed. Inspector stated they have conducted follow up treatments for R1’s room and as part of protocol had K9 Dogs come out to sniff if any more bugs are active in area before having R1 move back to their room. Inspector stated that room was cleared. Inspector confirmed that only R1’s room was impacted by bed bugs. Based on information gathered from complaint investigation, the allegation of Staff failed to address bed bug infestation in residents room was deemed UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur as reported. An exit interview was conducted with Executive Director and copy of report was provided.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 22-AS-20230725155928

Allegation investigated: Staff does not respond to resident's call for assistance in a timely manner.

On 04/21/2026, Licensing Program Analyst (LPA) contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 01/23/2024. Staff does not respond to resident's call for assistance in a timely manner. Interviews conducted indicated that there are times where residents have to wait longer periods of time for help while other times are shorter. It is based on the caregiver status and if they are helping other residents at that moment. Staff attempt to help all residents as quickly as possible but sometimes it can be challenging. Residents are not upset with the wait times and understand as staff are having to help different residents at different times. Therefore, the allegation staff does not respond to resident’s call for assistance in a timely manner is unsubstantiated. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 21, 2026 · control 22-AS-20240123145605

Allegation investigated: Staff did not seek medical attention for resident in care. Staff did not continue to treat resident's injury. Lack of supervision resulting in resident leaving the facility. Staff is not assisting with resident's laundry needs. Staff leave resident's room unclean. Staff are not disposing resident's urine containers. Staff is not assisting with resident's hygiene needs. Facility is not following COVID-19 procedures.

On 04/21/2026, Licensing Program Analyst (LPA) Cassandra Mikkelson contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 09/08/2022. Continued on 9099- C page Unsubstantiated Staff did not seek medical attention for resident in care. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff did not continue to treat resident's injury. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Lack of supervision resulting in resident leaving the facility. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff is not assisting with resident's laundry needs. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff leave resident's room unclean. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff are not disposing resident's urine containers. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Staff is not assisting with resident's hygiene needs. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Facility is not following COVID-19 procedures. Based on the information obtained during the course of the investigation, the Department is unable to determine the validity of the allegation listed above. Therefore, the allegation listed is unsubstantiated. Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 22-AS-20220908100901

Type of visit: Case Management - Incident

On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management visit to follow up on an incident report Department received. LPA discussed purpose of visit with Executive Director (ED) Nancy Rodriguez. On January 6, 2026, department received an incident report with elopement incident that occurred on December 25, 2025. According to incident report Resident 1 (R1) had left facility and around 6:19 AM facility staff received a call by nearby Hotel that R1 was in their hotel lobby. Report stated that resident was last checked in their room during 5:00AM rounds. LPA Tirre discussed incident with ED Rodriguez who stated that R1 resided in second building located at 4775 Katella to which R1 would come back and forth to main building steps away (located 4889 Katella) to eat in dining area. R1 was able to exit building but apparently did not have key Fob to get back in facility that morning, prompting R1 to walk over next door to nearby hotel. Main building doors are locked to the public from 8PM to 7AM, residents and staff have access with Key Fobs or pass code. LPA Reviewed R1’s recent Physician’s Report dated 7/30/2025, has R1 with diagnosis of Encephalopathy unspecified with abnormalities of gait mobility, muscle weakness, mild cognitive impairment, history of falling and hyperlipidemia. R1’s Physicians Report under capacity for self care is marked not able to leave facility unassisted. R1’s Care Plan states Resident is independent and needs no assistance with care. Based on information gathered, facility did not adequately supervise resident and the following is being cited on 809 D-page per California Code of Regulations (title 22 Division 6 Chapter 8). An exit interview was conducted with Executive Director Rodriguez. A copy of report and Appeal Rights were provided to facility Representative.the state’s words, verbatim · CDSS document, Jan 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 20, 2026

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code and Health and Safety Code Section 1569.2(c). This requirement is not being met as evidenced by: Based on interview conducted and records reviewed Licensee failed to ensure care and supervision were provided to R1. R1 eloped out of facility on 12/25/25 and was found in a nearby Hotel Lobby This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: Licensee to submit a Inservice training on ensuring residents are unable to elope out of facility. Licensee to forward proof to LPA by POC due date 1/20/26

Type of visit: Required - 1 Year

On December 8, 2025, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Executive Director Nancy Rodriguez were available to assist with the facility inspection. The facility is licensed for one hundred fifty two (152) non-ambulatory residents with approved hospice waiver for twenty five (25) residents. Currently, there are nine (9) Hospice residents present during today’s visit. Facility has two buildings, the first is a three story with one hundred (100) apartments housing Assisted Living residents. The second building is a two story with a Memory Care located on first floor with twenty (20) apartments and second floor with fourteen apartments housing Assisted living residents. Every apartment has a private restroom. At around 8:45 AM, LPA conducted a tour of the physical plant accompanied by Executive Director Nancy Rodriguez, and the following was observed: Facility has a swimming pool located on first floor outside of main dinig room area. Pool has a secured gate which meets licensing requirements. Facility has a kitchen and bistro area located on first floor. Facility also has a activities room, movie theater, salon and common area living room all located on first floor. During inspection, resident rooms were visited and rooms had beds and bedding supplies which were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were operational with water temperature measured between 117.8 to 119.6 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility. CONTINUED ON 809C LPA observed the facility to be furnished at the time of the visit. Sharps objects were stored and not accessible to residents in care. The kitchen was inspected, and sufficient perishables and non-perishable food was maintained adequately. Facility has a storage area for emergency food and water which had adequate supply of food. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of the Medication Records Administration (MAR) was conducted, LPA reviewed ten (10) Medication records and LPA observed the records are in compliance. LPA observed First Aid Kit was maintained. The last fire drill was conducted on June 25, 2025. LPA observed records from Trasom Fire and Security dated February 10, 2025 which showed equipment testing for fire alarm system and extinguishers as operational and passed inspection. A review of thirteen residents (R1-R13) service files and eight staff (S1-S8) personnel files revealed to be complete. The facility has the current administrator's certification on file for Nancy Rodriguez # 7010206740 - Expiration 05/6/2027. No deficiencies during this inspection visit. An exit interview was conducted with Executive Director Nancy Rodriguez, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 8, 2025

Allegation investigated: Staff do not ensure resident medications are given as prescribed

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to initiate complaint investigation and deliver findings into the above allegations. LPA explained the reason for the visit with Executive Director Nancy Rodriguez. During the course of the investigation, LPA toured facility, reviewed resident records, and conducted staff interviews. During investigation LPA requested pertinent documentation such as Resident Medication Administration Record, Needs & service plan, Active medication list, and Discharge paperwork and orders. Regarding the allegation Staff do not ensure resident medications are given as prescribed, during visit LPA reviewed Resident 1’s (R1) records and observed that on 9/25/25 R1 went out of facility to Rehabilitation center for physical therapy, recommended durable medical equipment, speech therapy, occupational therapy and pain management. Discharge Paperwork from Rehabilitation center dated 10/3/25 stated that R1 did not have prescriptions refilled and R1 was to follow up with Primary Care Physician. CONTINUED ON 9099C Unfounded On R1’s Rehabilitation discharge paperwork, Medication Ibuprofen was not listed as an active medication. LPA reviewed R1’s Medication Administration Record (MAR) dated from September 1, 2025 to November 14, 2025 and observed that R1 had an active order for Ibuprofen 200mg from 8/21/25 to 10/4/25. Facility MAR confirms R1 was given medication 8/21/25 to 9/25/25. Facility MAR notes that R1 did not receive Ibuprofen medication from 9/26/25- 10/3/25 due to R1 being out of facility. On 10/3/25, R1’s Service plan was updated and resident was assessed upon return from Rehabilitation facility. R1’s Updated Service plan states that R1 is actively on Medication Management, on med passes 4x a day and requires assistance with medications. LPA reviewed a Physician’s Medication Discontinuation order for Ibuprofen 200mg to be discontinued on 10/4/25. R1’s MAR notes from 10/4/25 to 10/31/25 Ibuprofen was discontinued and not administered to R1. Based on staff interviews, four of four staff stated that there has been no known medication errors regarding R1. Interviews with Four of four staff state that Medication Technicians, resident service director, resident service coordinator, memory care director and Caregiver staff that are medication trained are allowed to administer medications to residents. Staff interviews confirmed that discontinued orders need to be a physical hard copy from Physician or Nurse Practitioner and no verbal orders can be accepted. Based on records reviewed and interviews conducted, this agency has investigated the complaint alleging Staff do not ensure resident medications are given as prescribed. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and / or is without reasonable basis. An exit interview was conducted with Executive Director Nancy Rodriguez and a copy of this report was reviewed and provided at the time of this visit.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 22-AS-20251105230139

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 152 non-ambulatory residents. Facility has an approved hospice waiver for 25 residents. Facility has 114 residents in care including 20 in the Memory Care Unit. Facility consists of two separate buildings for both Assisted Living and Memory Care. Executive Director (ED) Nancy Rodriguez arrived shortly to conduct facility tour. ED has a valid certificate that expires on 5/7/2025. ED provided updated liability insurance that expires on 9/15/2025. LPA along with ED toured the facility at 8:45 AM. LPA toured the physical plant, checked food service, and facility documentation. LPA observed a cafe area, kitchen, dining room, library, fitness room, activities room, salon and movie room in the main building. Resident units had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and showers was free of mold/mildew. Water temperature measured between 105 degrees F and 120.5 degrees F in all bathrooms tested. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Egress exit alarms were operational during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Fire/Smoke alarm system was serviced by a third party company on 2/10/2025. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts monthly emergency drills with the last drill conducted on 2/26/2025. The activity program is displayed in multiple locations throughout the facility and tailored to the needs of independent and memory care residents respectively. LPA observed residents relaxing in the facility's common areas, partipating in activities or in their respective bedrooms. Outside grounds were toured. Walkways around the pool were adequately fenced and clear of hazards.There is shaded outdoor seating for residents. LPA observed the emergency food and water supply. LPA reviewed ten resident files and five staff files. CONTINUED ON LIC809C DATED 3/10/2025 All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders. Four out of five staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in two medications rooms, one in each building. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Mar 10, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff are not delivering meals to the resident timely

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegation above. LPA Haley was greeted, granted entry, and explained the reason for the visit. During the visit LPA Haley toured the facility, interviewed staff, residents, and collected and reviewed relevant documents. Regarding the allegation: Staff are not delivering meals to the resident timely. 11 of 12 individuals interviewed including facility residents and staff were unable to corroborate the allegation above. During an interview with multiple staff members, it was discovered staff took orders for breakfast and lunch a day early so meals could be prepared and served at a reasonable time. Multiple staff members did acknowledge there were some residents who complained they did not receive their food, but after checking a master list of orders and meals delivered to residents, the resident received a meal every time. Continued on LIC9099C Unsubstantiated Staff 3 (S3) explained there are some confused residents in the building and even before residents were isolated during the outbreak, some residents would come down to the kitchen and claim they never ate due to their confusion. All the residents interviewed during the investigation denied the allegation and did not have a problem with the food service during the isolation period. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation: Staff are not delivering meals to the resident timely. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 22-AS-20240724082752

Allegation investigated: Staff is not meeting the need of the resident Staff do not answer resident calls for assistance timely

Regarding the allegation: Staff is not meeting the need of the resident. 12 of 12 individuals interviewed including facility residents and staff were unable to corroborate the allegation above. All 7 residents interviewed denied the allegation. When residents were asked if staff assist them when needed, Resident 5 (R5) said, yes, but I don’t call. We all need assistance here… before adding, staff do a good job. Resident 7 (R7) was asked about receiving assistance from staff, and said, I’m what they call independent. I don’t have one of those (referring to a call button). When Resident 6 (R6) was asked the same question about receiveing assistance from the staff, R6 stated, they always have. Regarding the allegation: Staff do not answer resident calls for assistance timely. Continued on LIC9099C Unfounded 12 of 12 individuals interviewed including facility residents and staff were unable to corroborate the allegation above. All 7 residents interviewed denied the allegation. When Resident 3 (R3) was asked about staff responding to request for assistance, R3 held up a call button and said, yes, all the time. Resident 2 (R2) was asked the same question and the R2 said, yes... very quickly. Based on the information gathered through interviews the following allegations: Staff is not meeting the need of the resident and Staff do not answer resident calls for assistance timely, are deemed unfounded, meaning the allegations are false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 22-AS-20240724082752