019200721-11-30-2023-15-AS-KHOS-CYFRN3-20231212120941

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:30:29 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
07/14/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220714091744

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: 186	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Jeremy Gonzalez, Executive Director		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility failed to follow adequate COVID mitigation procedures

INVESTIGATION FINDINGS:

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On 11/30/23 starting at 9:40 AM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to deliver findings for the above allegation. AGPA met with Executive Director, Jesus Gonzalez and explained the purpose of the visit.

During the course of the investigation, AGPA obtained information, reviewed records, interviewed staff and attempted to interview residents and collected including but not limited to the following documents: Resident Roster, Staff Roster, Physician's Report, Care Plan, COVID-19 Outbreak Notification, and Email Communication.

It was alleged facility failed to follow adequate COVID mitigation procedures. During a tour of the dining room in memory care on 7/22/2022, AGPA L. Francisco and LPA K. Nguyen observed 5 residents on wheelchairs sitting in one round dining table and not physically distancing in accordance to local public health guidance and PIN 21-49-ASC

REPORT CONTINUES ON 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 15-AS-20220714091744

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BELMONT VILLAGE ALBANY	FACILITY NUMBER: 019200721
	VISIT DATE: 11/30/2023

NARRATIVE

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Based on AGPA and LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
07/14/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220714091744

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: 186	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Jesus Gonzalez, Executive Director		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility failed to provide notifications of COVID-positive results
Facility failed to provide adequate staffing levels
Unqualified Staff
Resident was left in soiled diaper and bedding at an extended period of time
Facility is not kept clean

INVESTIGATION FINDINGS:

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On 11/30/23 starting at 9:40 AM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to deliver findings for the above allegations. AGPA met with Executive Director, Jesus Gonzalez and explained the purpose of the visit.

During the course of the investigation, AGPA obtained information, reviewed records, interviewed staff and residents and collected including but not limited to the following documents: Resident Roster, Staff Roster, Physician's Report, Care Plan, COVID-19 Outbreak Notification, and Email Communication.

It was alleged facility failed to provide notifications of COVID-positive results. However, based on record review, AGPA obtained a copy of the COVID-19 notification letter and observed an email notification sent out to the resident's responsible parties in July of 2022.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 15-AS-20220714091744

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BELMONT VILLAGE ALBANY	FACILITY NUMBER: 019200721
	VISIT DATE: 11/30/2023

NARRATIVE

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It was alleged facility failed to provide adequate staffing levels. However, based on interview with staff, if a staff is unable to report to work, then residents assigned to that staff will be distributed to the staff that are scheduled to work. S3 and S4 stated that caregivers in assisted living would assist in memory care if needed to.

It was alleged there are unqualified staff working at facility. However, AGPA reviewed a sample of staff records on 7/20/23 and observed staff had completed the required training.

It was alleged resident was left in soiled diaper and bedding at an extended period of time. Interview with 5 staff revealed that residents are checked every 2 hours or as needed. S4 stated most caregivers are familiar with the residents that staff are assigned to and how frequently those assigned residents needs to be checked. AGPA attempted to interview 3 residents, but AGPA was unable to obtain additional information. AGPA was unable to prove or disprove allegation.

It was alleged facility is not kept clean. However, interview with staff revealed that dining room tables are cleaned after every meal.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to Executive Director.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20220714091744

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BELMONT VILLAGE ALBANY	FACILITY NUMBER: 019200721
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/07/2023 Section Cited CCR 87405(d)(2)	1 2 3 4 5 6 7	87405(d)(2) ADMINISTRATOR - QUALIFICATIONS AND DUTIES (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.	1 2 3 4 5 6 7	By POC date, Administrator agrees to review facility's infection control plan with all staff and submit a self-certification letter to CCLD.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation on 7/22/22, Licensee did not comply with the regulation cited above by not physically distancing residents in accordance to PIN 21-49-ASC and local public health guidance. AGPA and LPA observed 5 residents on wheel chairs in one round dining table in memory care which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5