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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 03/24/2023
Date Signed: 03/24/2023 05:44:38 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
12/09/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211209165152
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: 183DATE:
03/24/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tamra Tsanos, Executive Director
Rachel Kelly, Assistant Executive Director		TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not prevent inappropriate behavior between residents
INVESTIGATION FINDINGS:
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On 3/24/2023 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Executive Director, Tamra Tsanos and Assistant Executive Director, Rachel Kelly.

During the course of investigation, LPA interviewed 6 residents, 11 staff, witness, and complainant. LPA also obtained and reviewed resident files including: physician's report, care plan, care notes, and email correspondences.

Interview with witness revealed an incident occurred in December 2021 where R1 swung opened a bathroom door and R2 was hit by the door. Interview with staff indicated no one witnessed aggressive behaviors from R1. Staff stated that R1 is straight forward and speaks R1's mind. Email correspondences shows that family's were contacted regarding R1's behavior. (Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
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-20211209165152
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: 03/24/2023
NARRATIVE
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LPA observed that R1 was re-evaluated in December of 2021 after the incident. S2 stated options were discussed with R1's family to prevent future incident and staff are always observing residents to see if assistance is needed.

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

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2