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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 01/27/2023
Date Signed: 01/27/2023 11:35:46 AM

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
06/03/2020 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200603115707
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: DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Tamra Tsanos, Executive DirectorTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident has sustained multiple falls at the facility
Facility staff are not meeting resident's basic needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/27/23 at 10:05 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver complaint findings for the above allegations. This visit follows the 10-day complaint notification on 06/04/20 presented by LPA D. Panlilio on Facetime due to the COVID-19 shelter in place ordered by the Governor. LPA met with Tamra Tsanos, Executive Director (ED) and explained the reason for the visit.

Allegations:
Resident has sustained multiple falls at the facility
Facility staff are not meeting resident's basic needs
Investigation Findings: UNSUBSTANTIATED

...Continued on LIC9099C
Unsubstantiated
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: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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 2
Control Number 15-AS-20200603115707
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: 01/27/2023
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

During the investigation, LPAs interviewed three (3) Staff (ADM, S1, S2) and one (1) Witness (W1), collected and reviewed documents. Records and interviews revealed although R1 was a fall risk, R1 resided on the Independent Living side and was transferred to Assisted Living on . R1’s Admission Agreement signed 07/14/2017, effective 07/29/17, stated the following: Apartment Type: Large Sierra -IL, Apartment Number: 316, Service Plan Type: Independent Living. The facility’s Nurse Notes documented a history of witnessed and unwitnessed falls from 02/18/20 to 08/22/20; on 06/25/20, S2 recommended a higher level of care for R1 which would also more cost effective. S2 stated that they were calling R1's son very regularly but was adamant about R1 maintaining his/her independence. The facility's policy for head injuries is to call the medics immediately. R1’s son provided the facility with rubber non-skid products to reinforce R1’s bed legs and S2 witnessed a rug in place to mitigate the falls. Page sixty-eight (68) states R1 was assigned to apartment (apt) 223 in Memory Care but addendum was corrected to apt 331 for Assisted Living. R1 was receiving Hospice services and died 12/29/20.

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



Exit interview conducted. A copy of this report provided to Tamra Tsanos, ED
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2