Other·September 23, 2020

PRINTED: 05/14/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA070000062 (X3) DATE SURVEY COMPLETED 09/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTLAND HOUSE 100 Barnet Segal Ln Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) C000 Initial Comments ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE C000 The COVID-19 Offsite Survey was reviewed by the California Department of Public Health. Representing the California Department of Public Health: 39949, Health Facilities Evaluator Nurse. A State Citation "B" was written. Licensing and Certification Division LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 9NDY11 TITLE (X6) DATE If continuation sheet 1 of 2 PRINTED: 05/14/2026 FORM APPROVED California Department of Public Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ CA070000062 (X3) DATE SURVEY COMPLETED 09/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WESTLAND HOUSE 100 Barnet Segal Ln Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) C4855 T22 DIV5 CH3 ART5-72539 Reporting of Outbreaks ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) C4855 (X5) COMPLETE DATE 09/25/2020 Any outbreak or undue prevalence of infectious or parasitic disease or infestation shall be reported to the local health officer in accordance with Section 2502, Article 1, Subchapter 4, Chapter 4, Title 17, California Administrative Code. This Statute is not met as evidenced by: The facility failed to timely report COVID-19 Survey data on three separate occasions. This failure resulted in incomplete data reported to the Department necessary to respond to the COVID-19 outbreak. These failures had the potential to compromise the residents' medical health and safety. During a record review on 9/4/2020, the facility failed to submit COVID-19 Survey data on the following dates: 1. 6/24/2020 2. 7/10/2020 3. 9/4/2020 According to the AFL (All Facility Letter) 2043.3, all SNF (Skilled Nursing Facility) to report daily COVID-19 facility data to the California Department of Public Health via an online survey. The facility failed to timely report COVID-19 Survey data on three separate occasions. This failure resulted in incomplete data reported to the Department necessary to respond to the COVID-19 outbreak. These failures had the potential to compromise the residents' medical health and safety. Licensing and Certification Division STATE FORM 6899 9NDY11 If continuation sheet 2 of 2