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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 07/16/2021
Date Signed: 07/16/2021 04:25:29 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
04/20/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200420115651
FACILITY NAME:BELMONT VILLAGE ALBANYFACILITY NUMBER:
019200721
ADMINISTRATOR:MOROS, MICHELLEFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 191DATE:
07/16/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rachel Kelly, Senior Administrative Specialist
Merryn Oliveira, Director Memory Care Program		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff not following Dr. orders
INVESTIGATION FINDINGS:
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On 7/16/2021 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and delivery complaint findings for the above allegation. LPA met with Senior Administrative Specialist, Rachel Kelly and Director Memory Care Program, Merryn Oliveira.

During the investigation, LPA conducted interviews with facility staff, resident, and complainant. LPA obtained and reviewed physician’s report, facility notes, facility assessments/care plan (dated 1/28/2020, 2/20/2020, 5/5/2020, 5/7/2020, 5/12/2020, 5/14/2020, and 6/3/2020), and doctor's orders.

According to the doctor's order dated 2/3/2020, R1 should have a protein drink twice a day.
(Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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-20200420115651
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: 07/16/2021
NARRATIVE
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A second doctor's order dated 4/22/2020 was also given to the facility stating that R1 should be given the protein drink twice a day. However, facility assessments/care plans dated 2/20/2020 and 5/5/2020 did not include doctor's order for protein drink twice a day. Doctor's order for protein drinks was added into facility assessment/care plan dated 5/7/2020.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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
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
04/20/2020 and conducted by Evaluator Grace Luk
COMPLAINT CONTROL NUMBER: 15-AS-20200420115651

FACILITY NAME:BELMONT VILLAGE ALBANYFACILITY NUMBER:
019200721
ADMINISTRATOR:MOROS, MICHELLEFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 191DATE:
07/16/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rachel Kelly, Senior Administrative Specialist
Merryn Oliveira, Director Memory Care Program		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident lost significant amount of weight
Staff are not meeting residents incontinent needs
Staff are not following the care plan
Staff did not provided a copy of the care plan to the responsible person.
INVESTIGATION FINDINGS:
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On 7/16/2021 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and delivery complaint findings for the above allegations. LPA met with Senior Administrative Specialist, Rachel Kelly and Director Memory Care Program, Merryn Oliveira.

During the investigation, LPA conducted interviews with facility staff, resident, and complainant. LPA obtained and reviewed physician’s report, facility notes, facility assessments/care plan (dated 1/28/2020, 2/20/2020, 5/5/2020, 5/7/2020, 5/12/2020, 5/14/2020, and 6/3/2020), and weight log.

Resident lost significant amount of weight:
Interview with complainant revealed that R1 lost about 15 pound since admitted to the facility. However, R1's weight log started on 5/22/2020 which was a couple months (Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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-20200420115651
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: 07/16/2021
NARRATIVE
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after R1's admission to the facility. Interview with staff revealed that R1's menu was created and agreed upon by R1's responsible party. Facility care notes have documented R1's appetites on various days.

Staff are not meeting residents incontinent needs:
Interview with staff revealed that incontinence care is every 2 hours. Staff stated that R1 is check every 2 hours to see if she needs assistance to go to the bathroom. Staff stated that facility does not keep incontinence care notes and caregivers would verbalize care given at shift change.

Staff are not following the care plan:
Interview with staff revealed that showers have been given 3 times a week to R1. Staff stated that showers are usually given in the morning by AM shift caregivers. R1's facility assessment/care plan shows that showers are on Tuesdays, Thursdays, and Saturdays of each week.

Staff did not provided a copy of the care plan to the responsible person.:
Interview conducted by LPA T. White with complainant revealed that R1's responsible party received a copy of the care plan 2 day prior to admission. However, the care plan did not detailed R1's care needs.

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. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20200420115651
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2021
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidence by:
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Facility has agreed to conduct training on following doctor's order and submit staff sign-in sheet to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not following doctor's orders which poses a potential health and safety risk to the residents in care.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5