019200721-8-4-2020-15-AS-HHUL-BSPUGJ-20200821153426

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 08/04/2020
Date Signed: 08/04/2020 12:21:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2020 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200618114149

FACILITY NAME:	BELMONT VILLAGE ALBANY		FACILITY NUMBER:	019200721
ADMINISTRATOR:	MOROS, MICHELLE		FACILITY TYPE:	740
ADDRESS:	1100 SAN PABLO AVE		TELEPHONE:	(510) 525-4554
CITY:	ALBANY	STATE: CA	ZIP CODE:	94706
CAPACITY:	225	CENSUS: 182	DATE:	08/04/2020
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Michelle Moros, Administrator		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Financial Abuse

INVESTIGATION FINDINGS:

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On 08/04/2020 at 11:45am, Licensing Program Analyst, L. Hall had an unannounced tele-visit via facetime to deliver the findings on the allegation to “financial abuse while in care of the facility”. LPA spoke with Michelle Moros, Administrator and explained the reason for the tele-visit.

Licensing Program Analyst, (LPA) L. Hall conducted the investigation regarding the above-mentioned allegation, "financial abuse “. On 06/26/2020, LPA spoke via telephone with R1 and W2 for this purpose.

Continued on LIC9099C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200618114149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELMONT VILLAGE ALBANY	FACILITY NUMBER: 019200721
	VISIT DATE: 08/04/2020

NARRATIVE

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Continued from LIC9099

R1 stated that no one has used his card to make any purchases besides W2 (co-account holder) and he was aware of the charges she had made. W2 stated that she did not make a fraud report to BofA. Due to R1 and W2 stating to LPA that the allegation of financial abuse did not occur, LPA found no evidence to support this claim.

Based on the information obtained the allegation is closed as UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with Michelle Moros, Administrator and a copy of will be emailed.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

LIC9099 (FAS) - (06/04)

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