019200721-9-26-2024-15-AS-KHOS-DA9RBX-20241021125329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 09/26/2024
Date Signed: 09/26/2024 06:40:49 PM

Unsubstantiated

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
11/15/2023 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20231115153223

FACILITY NAME:	BELMONT VILLAGE ALBANY		FACILITY NUMBER:	019200721
ADMINISTRATOR:	BLACKWELL,CAROL		FACILITY TYPE:	740
ADDRESS:	1100 SAN PABLO AVE		TELEPHONE:	(510) 525-4554
CITY:	ALBANY	STATE: CA	ZIP CODE:	94706
CAPACITY:	225	CENSUS: 182	DATE:	09/26/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Ciara Flores, Memory Care Coordinator Jesus Gonzalez, Executive Director		TIME COMPLETED:	06:55 PM

ALLEGATION(S):

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Residents are being neglected during overnight shift while in care
Staff are not meeting the needs of the residents
Staff are yelling and mistreating residents
Staff are placing residents in an unsafe environment

INVESTIGATION FINDINGS:

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On 9/26/2024 at 2:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with Executive Director (ED), Jesus Gonzalez and explained the purpose of the visit. ED was unable to stay to sign the reports and stated that Memory Care Coordinator, Ciara Flores will sign CCLD reports

During the investigation, LPA interviewed 5 residents and 5 staff. LPA reviewed and obtained documents including staff roster with contact information, staff schedule, physician's report, emergency information, service plan, care notes, and incident reports.

(Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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-20231115153223

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: 09/26/2024

NARRATIVE

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Residents are being neglected during overnight shift while in care
Interview with residents revealed that staff would always respond to call buttons. R1 stated that overnight staff would come and check on R1 and pendent response time varies. Interview with staff indicated that if one staff cannot respond to call button, then another staff would get the call and would respond to the call button.

Staff are not meeting the needs of the residents
Interview with residents indicated that staff are good about assisting residents with ADL (Activities of Daily Living) care. R1 stated that staff assist with diaper changes and would always get help from staff. Interview with staff revealed that residents are checked for incontinence care at the beginning and end of each shift. S4 stated residents diaper changes are about 2-3 times per shift, but some residents are checked more frequent.

Staff are yelling and mistreating residents
Interview with residents revealed that staff are nice to residents and have not witnessed staff yell or scream at residents. R8 stated that staff treats resident well.

Staff are placing residents in an unsafe environment
Interview with residents and staff revealed that when staff mop the floors, there are yellow triangle signs that is put up warning of wet floors. Staff stated these signs are available at each floor for staff to put on the floor after mopping the floors.

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

No deficiencies are being cited on this date.

Exit interview conducted with Ciara Flores. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC9099 (FAS) - (06/04)

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