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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 04:27:56 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
04/29/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200429113015
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:
03:00 PM
MET WITH:Rachel Kelly, Senior Administrative Specialist
Merryn Oliveira, Director Memory Care Program		TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff caused injury to resident
Personal Rights: Facility staff took resident's belongings.
INVESTIGATION FINDINGS:
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On 7/16/2021 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to delivery complaint findings for the above allegation. LPA met with Senior Administrative Specialist, Rachel Kelly and Director Memory Care Program, Merryn Oliveira.

During the course of the investigation, the Department conducted interviews with facility staff, witnesses, resident, and complainant. R1’s admission agreement, physician’s report, facility notes, facility assessments (dated 1/28/2020, 2/20/2020, 5/5/2020, 5/7/2020, 5/12/2020, and 5/14/2020), photos of injuries, medical records, and facility’s email correspondence (dated 4/28/2020 through 4/30/2020) were obtained and reviewed.

(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 3
Control Number 15-AS-20200429113015
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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The Department investigated and found that R1 sustained severe bruising due to improper handling during transfers. From documents obtained and reviewed, R1 has a history of bruising and taking baby Aspirin daily. R1’s responsible party had discussions with staff and administrator regarding R1’s propensity to bruise easily and effective handling practices to minimize R1 bruising. However, even after these discussions, R1 sustained severe bruising because of staff’s failure to utilize proper handling techniques. R1 reported the bruises were from staff grabbing her on the legs and arms possibly to keep her from falling. W1 stated that R1 is able to stand by herself without assistance. W1 witnessed an incident when R1 was lying in bed and taking a while to get out of bed, staff grabbed R1’s arm to help pull her up off the bed.

Interview with S1 revealed that an Amazon echo dot device was found in R1’s room. S1 stated that the device was removed on 4/28/2020 and returned to R1 on 4/30/2020. S1 stated that the device had audio capability which violated facility’s admission agreement. However, S1 later discovered that the device’s audio capability was disconnected. In the email correspondence with R1’s responsible party dated 4/28/2020, S1 stated the device was removed from R1’s room on 4/27/2020.

Based on the department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the LIC 9099D.

A $500.00 immediate civil penalty is being assessed on this day. Civil penalty determination related to serious bodily injury is pending.

Exit interview conducted. A copy of this report, civil penalty, 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 3
Control Number 15-AS-20200429113015
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 A
07/19/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:
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Facility has agreed to re-train all staff on proper transfer techniques when transferring residents. Facility will submit training materials and 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 resulting in R1 sustaining severe bruising due to improper handling during transfer which poses an immediate health and safety risk to the residents in care.
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A formal conference with CCLD will be schedule at a later time.

$500.00 immediate civil penalty is assessed.
Type B
07/30/2021
Section Cited
CCR
87468.1(a)(12)
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Personal Rights of Residents in All Facilities. To wear their own clothes; to keep and use their own personal possessions...
This requirement is not met as evidence by:
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Facility has agreed to re-train all staff on Personal Rights of Residents in All Facilities. Facility will submit training materials and 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 resulting in R1’s device removed from the room 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)
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