<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 12/12/2024
Date Signed: 12/12/2024 03:45:49 PM

Substantiated


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
07/16/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240716140724
FACILITY NAME:BELMONT VILLAGE ALBANYFACILITY NUMBER:
019200721
ADMINISTRATOR:BLACKWELL,CAROLFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 186DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH: Jesus Gonzalez, Executive Director (ED)TIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/12/24 around 10:40 AM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to deliver the finding for the complaint investigation. LPA met with Jesus Gonzalez, Executive Director (ED) and explained the purpose of the visit.

During the investigation LPA interviewed ED, Staff (S1, S2, S3, S4, S5) Witnesses (W1, W2, W3, W4) obtained a resident roster, and requested the following for Resident #1 (R1): current Physician's Report, Admission Agreement, ID/Emergency Contact information, hospice care plan, care notes, incident reports, hospice notification, facility's regulations and documentation regarding Stage 3 and Stage 4 pressure wounds, emails and/or written communications to R1's family regarding pressure wounds.

Allegation: Illegal eviction
SUBSTANTIATED
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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 3
Control Number 15-AS-20240716140724
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: 12/12/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
...continued from LIC9099.

Interviews conducted with the ED, S1, S2, S3, S4, S5, W1, W2, W3, & W4 confirmed that emergency services were initiated for R1 to be transported to Alta Bates Medical Center in Berkeley, CA for a stage 3 to 4 pressure wound. S2 stated that on July 14, 2024 a nurse’s aide (S4) called the paramedics, R1 was on hospice, under hospice care, and was being transported for 1st aid; W2 was present. W4 stated that W1 and W2 were blindsided; W1 and W2 did not know that the facility would not allow R1 to return after treatment of the wound on 07/14/24. W1, R1’s Power of Attorney (POA), was not present and was out of the country at that time. W4 further stated that S2 outright refused to accept R1 back to the facility although R1 was under the care of hospice. With the efforts of W4, R1 was successfully placed at another Residential Care for the Elderly (RCFE) in Pinole, CA with the services of Sutter VNAH Alameda Hospice. S2 did not seek counsel for joint determination from the Community Care Licensing Department (CCLD), the resident, R1’s Power of Attorney (POA), the hospice agency, physician, and licensee to determine that R1’s continued retention at the facility would pose a health and safety risk. Based on interviews and records reviewed, the preponderance of evidence for the violation has been met; therefore, the allegation is SUBSTANTIATED.


Deficiencies cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided to ED.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240716140724
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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2024
Section Cited
CCR
87224(i)
1
2
3
4
5
6
7
87224 Eviction Procedures (i)…a ... resident receiving hospice services ... resident's condition has changed ... joint determination has been made by the Department, the resident or resident's health care surrogate decision maker, the resident's hospice agency, a physician...
- This requirement was not met as evidenced by:
1
2
3
4
5
6
7
ED agreed to provide in-service training to all staff that are involved in decision making procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.
8
9
10
11
12
13
14
Based on interviews and records reviewed, Licensee failed to ensure the facility sought joint determination before denying R1’s return to the facility after being released for treatment of emergency services which posed an immediate health and safety risk to residents 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3