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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 01/19/2023
Date Signed: 01/19/2023 06:06:54 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
04/07/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220407162352
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: 184DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rachel Kelly, Assistant Executive director TIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Resident developed skin tears while in care.
Resident developed an infection while in care.
Medical treatment was not sought for resident in a timely manner.
Resident's medical records are not being maintained properly
INVESTIGATION FINDINGS:
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On 01/19/2023 at 10:15AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Rachel Kelly, assistant executive director and explained the reason for the visit.
During the course of the investigation, the Department conducted interviews with staff, residents, health providers, and complainant. Medical records and facility file, incident report, and facility’s correspondence with health providers were obtained and reviewed.

Allegation: Resident developed skin tears while in care.
Based on interview and records review, on 02/24/2022 facility staff reported that R1 sustained skin tear on her shin while staff was transferring R1 from wheelchair to the shower. Records review and interview stated that basic first aid was rendered to R1’s skin tear. Based on interviews with staff, R1 has very fragile skin that she needs to use shin guard.
…Continues to LIC9099C…
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
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 6
Control Number 15-AS-20220407162352
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: 01/19/2023
NARRATIVE
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Allegation: Resident developed an infection while in care.

Based on records review, on 3/2/2022 R1 was taken to urgent care, records review revealed that R1 was diagnosed of infection.

Allegation: Medical treatment was not sought for resident in a timely manner.

Based on interview and records review, on 2/24/2022 at 10:00AM staff informed facility nurse that R1 was sustained skin while staff transferring her from wheelchair to the shower. Basic first aid was rendered, and family was informed. However, R1 was not sent out to urgent care nor 9-1-1 not until around 3:00PM 02/24/2022.

Allegation: Resident's medical records are not being maintained properly



During the course of the investigation, records review revealed that facility failed to update a new physician’s report for R3, the last physician’s report was dated 04/2021.

The preponderance of evidence has been met. Therefore, the allegations above are substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20220407162352
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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities
a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 2) 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 02/03/2023.
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Based on investigation, licensee did not comply with the section cited above resulting R1 sustaining skin tear due to improper handling during transfer which poses an immediate health and safety risk to the residents in care.
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$500.00 immediate civil penalty is assessed.
Type B
02/03/2023
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional.....

This requirement is not met as evidenced by:
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Facility will train all staff on documenting residents' observation and will submit staff sign-in sheet to CCLD by POC date.
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Based on interview and records review, the licensee did not comply with the section cited above by not properly observing resident's changes in condition.
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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: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20220407162352
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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care
The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including...

This requirement is not met as evidenced by:
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Facility will train all staff on the regulation cited above, a cpy of training with staff names and signatures will need to be submitted to CCL by POC date.
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Based on record review and interviews, Licensee did not comply with the regulation above, facility failed to take R1 medical facility or to call 9-1-1 in timely manner after sustaining skin tear, which poses an immediate health and safety risk to residents in care.

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Type B
02/03/2023
Section Cited
CCR
87705(c)(5)
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CARE OF PERSONS WITH DEMENTIA
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5)Each resident with dementia shall have an annual medical assessment as specified...least annually..
This requirement was not met as evidenced by:
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Assistant Executive Administrator agreed to submit a up to date physician's report for R3, to CCL by POC date.
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Based on record review, Licensee did not comply with regulation cited above. On 01/19/2023 LPA observed R3's medical assessment was last completed on 04/2021 which poses a potential health and safety risk to persons 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: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
04/07/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220407162352

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: 184DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rachel Kelly, Assistant Executive director TIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Resident sustained multiple unexplained bruises while in care
Resident developed a rash while in care
Incidents involving resident are not being reported to their Resident Representative
Admissions agreement is not being adhered to
Resident's toileting needs are not being met while in care
Medications are not being administered to resident according to their physician's orders.
Insufficient staff
INVESTIGATION FINDINGS:
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On 01/19/2023 at 10:15AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Rachel Kelly, assistant executive director and explained the reason for the visit.
During the course of the investigation, the Department conducted interviews with staff, residents, health providers, and complainant. Medical records and facility file, incident report, and facility’s correspondence with health providers were obtained and reviewed.
Allegation: Resident sustained multiple unexplained bruises while in care

Based on the records review, R1’s assessment done on 02/27/2020 and re-assessment, it was indicated that R1 has a fragile skin and bruises easily and staff was ordered to be gentle while rendering care to resident. Records review also revealed that staff reported informed family about their observation on R1’s discoloration of right thigh and knee, staff applied cream per doctor’s order.
…Continues to LIC9099C…
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20220407162352
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: 01/19/2023
NARRATIVE
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Allegation: Resident developed a rash while in care
Records review revealed that on 04/04/2022, staff observed redness on R1’s skin, family was notified and R1’s physician was notified. Nurses’ notes revealed that staff followed as needed doctor’s order to apply nystatin powder on the affected area.

Allegation: Incidents involving resident are not being reported to their Resident Representative
Based on interview and records review; staff notified R1’s family when there is a new observation or any change of condition.

Allegation: Admissions agreement is not being adhered to
During the investigation, RP did not specific deficiency that was called out regarding admission agreement. LPA conducted records review, based on records review admission agreement was completed according to regulations.

Allegation: Resident's toileting needs are not being met while in care
During the course of investigation, records review revealed that R1 had toileting assistance of taking her to the bathroom 2-3X while awake and at least 5x during night shift. Interview with staff revealed that residents who needs incontinence care is checked 3-4 times per shift on residents with incontinence care/toileting needs. However, when residents have a bowel movement or an accident, staff will change and clean residents right away. During LPA’s visit, LPA could not interview R1 since she no longer at the facility.

Allegation: Medications are not being administered to resident according to their physician's orders.
Based on records review, medication administration records (MAR) revealed that staff gave R1’s medication according to physician’s order. R1’s MAR revealed there was no miss medications and discontinued medication was stopped per doctor’s order. LPA attempted to interview R1 regarding this allegation however R1 no longer at the facility.

Allegation: Insufficient staff
LPA reviewed staff schedule for the facility, facility has Med Tech, support staff and other agency staffing available on schedule. Facility had sufficient staffing for all three (3) shifts. Residents were observed calm and comfortable in their surroundings. LPA conducted interview with staff and reported that facility and had no issues, staff also mentioned that is someone called and sick, management tries to ask assistance from assisted living department to provide assistance on the memory care unit.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.
Exit interview conducted, appeal rights and copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6