019200721-12-17-2024-15-AS-HHUL-DJ7NFD-20250702102518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 12/17/2024
Date Signed: 12/17/2024 01:51:34 PM

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
09/02/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20210902091458

FACILITY NAME:	BELMONT VILLAGE ALBANY		FACILITY NUMBER:	019200721
ADMINISTRATOR:	MOROS, MICHELLE		FACILITY TYPE:	740
ADDRESS:	1100 SAN PABLO AVE		TELEPHONE:	(510) 525-4554
CITY:	ALBANY	STATE: CA	ZIP CODE:	94706
CAPACITY:	225	CENSUS: 137	DATE:	12/17/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Erik Holzherr/Assistant Executive Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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-Resident (R1) lost a large amount of weight while in care.

-Facility did not contact resident's (R1) representative on status of resident's health.

-Facility did not adhere to the resident's (R1) care plan.

-Resident did not receive medical care in a timely manner.

INVESTIGATION FINDINGS:

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On this day, 12/17/24, at 12:30 pm Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Assistant Executive Director Erik Holzherr, and informed the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff (S1, S2, S3, S4, S5, S6, S7, S8, S9), resident (R4) and former executive director on 9/08/21, 4/17/23, 4/26/23, 5/15/23, 9/17/24 and 10/25/24. Resident’s family member (FM) was also interviewed. Resident (R1)’s record was reviewed and copies including but not limited to the following were obtained: LIC602A Physician’s Report; medical record; Unusual Incident Reports (UIRs); death report; weight record; doctor’s visit notes; health provider/medical professional’s correspondence to the facility; Medication Administration Record; doctor’s order of medications

...continued on 9099C (page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

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-20210902091458

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: 12/17/2024

NARRATIVE

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Page 2

Allegation: Resident (R1) lost a large amount of weight while in care.
FM stated R1 lost 40 lbs while in facility’s care. Two of the 9 staff who provided care to R1 were interviewed. These 2 staff stated they noticed R1 losing weight but R1 at times refused to eat. When R1 refused to eat, they either changed the food, provide options or switch caregiver. Two facility LVNs and facility RN stated if resident lose weight they inform the resident’s primary care physician. Review of medical records showed that prior to R1’s passing away, R1 had appointments with medical professional of which FM brought up the issue of R1 losing weight; however, R1’s weight was not recorded due to the visits were virtual. On 4/07/21, the medical professional sent correspondence to the facility and requested to send R1’s weekly weight record. Weekly weight records from 4/05/21 to 7/23/21 ranged from 112 lbs to 120 lbs. LIC602A dated 5/04/21 showed R1 weight was 118 lbs. LPA was not able to interview R1 as R1 was no longer at the facility when complaint was received. Therefore, the allegation is unsubstantiated.

Allegation: Facility did not contact resident's (R1) representative on status of resident's health.
FM stated that on 8/03/21, day prior to R1 passing away, FM went to the facility and found R1 unresponsive with sunken cheeks and mouth open, and that the facility did not inform FM. Review of records showed that prior to R1’s death, facility’s hospice visit note dated 8/03/21 showed hospice agency staff were at the facility with FM. All 3 caregivers interviewed stated if there’s a change in resident’s condition, they inform the facility med-tech and/or nurse. All 4 facility nurses including Director of Resident Care Services (DRCS) stated they inform the resident’s family/responsible person and primary care physician (pcp) of the changes in resident’s conditions. DRCS also stated she conducts care conference with the resident's family and/or responsible person to discuss and let them know that she will contact the pcp. One of the facility nurse (S2) stated that if resident is on hospice and actively dying, they call hospice staff and resident's family to inform of the change in condition. Resident (R4) stated that the facility staff are good in providing update for him and his wife who is also a resident of the facility. Therefore, the allegation is unsubstantiated.

.....continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20210902091458

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: 12/17/2024

NARRATIVE

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Page 3

Allegation: Facility did not adhere to the resident's care plan.
FM stated that it is in the care plan that staff agreed to weigh R1 regularly, but this did not happen. FM also stated the staff were not giving R1 pain pills and that FM fought to have staff continue the pain management.

All staff interviewed stated that residents in the Memory Care are weigh every month. R2’s husband stated that R2 is weighed every month. Review of R1 record showed that on 4/07/21, R1’s medical professional sent correspondence to the facility and requested to send R1’s weekly weight records. Records from 4/05/21 to 7/23/21 showed R1 was weighed once a week. Review of resident’s record showed there were changes over time in R1’s doctor’s order of pain medications and the medications were administered. Therefore, the allegation is unsubstantiated.

Allegation: Resident did not receive medical care in a timely manner.
FM stated that on 8/03/21 FM came to the facility and found R1 unresponsive, with sunken cheeks and mouth open. R1 was taken to the hospital and died on August 4, 2021. FM also stated that FM believes that R1 should have been taken to the hospital sooner. Review of records showed R1 was placed and admitted on hospice care on 7/02/21 due to advanced dementia and failure to thrive. Staff interviewed stated that if resident is on hospice and actively dying, they call the hospice agency unless the resident fall or sustained head trauma, 9-1-1 is called. Records showed R1 was visited by hospice on the following dates: 7/06/21 to 7/09/21; 7/14/21 to 7/23/21; 7/26/21 to 7/30/21; 8/03/21. Death Report showed R1 passed away on 8/04/21 and death certificate showed senile degeneration of the brain as cause of death.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

LIC9099 (FAS) - (06/04)

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