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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206861
Report Date: 01/23/2024
Date Signed: 01/23/2024 12:15:15 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, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2023 and conducted by Evaluator Alexandria Walton
COMPLAINT CONTROL NUMBER: 24-AS-20231004114010
FACILITY NAME:BELMAR VILLAFACILITY NUMBER:
107206861
ADMINISTRATOR:HRIPSIME MAKARYANFACILITY TYPE:
740
ADDRESS:2020 NORTH WEBER AVENUETELEPHONE:
(559) 486-5977
CITY:FRESNOSTATE: CAZIP CODE:
93705
CAPACITY:100CENSUS: 68DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Hripsime MakaryanTIME COMPLETED:
12:33 PM
ALLEGATION(S):
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Facility is not meeting resident's care needs resulting in multiple falls causing bruising
INVESTIGATION FINDINGS:
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On 01/23/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Front desk staff informed LPA that Administrator would arrive shortly and granted LPA access to a conferance room. Administrator, Hripsime Makaryan arrived a short time later.

Review of records and interviews conducted revealed that R1 required 1:1 care and needed constant supervision. Interviews conducted confirmed that R1 did not receive 1:1 care from facility staff 24 hours a day, 7 days a week from 10/2023 - 12/2023.

CONTINUED TO 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
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 24-AS-20231004114010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BELMAR VILLA
FACILITY NUMBER: 107206861
VISIT DATE: 01/23/2024
NARRATIVE
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Based on interviews and records review, the preponderance of evidence standard has been met, therefore the allegation: Facility is not meeting resident's care needs resulting in multiple falls causing bruising is SUBSTANTIATED.

A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division on the attached 9099D.

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Hripsime Makaryan, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 24-AS-20231004114010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BELMAR VILLA
FACILITY NUMBER: 107206861
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2024
Section Cited
CCR
87705(c)(4)
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87705: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4)There is an adequate number of direct care staff to support each resident’s... safety and health care needs as identified in his/her current appraisal.. This requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 87705 are met to the Fresno CCL office by the POC due date
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Based on interviews and record review, the licensee did not comply with section 87705 when the facility did not provide a 1:1 care staff to meet R1's needs as identified in R1's current appraisal, which is an potential health and safety risk to person's 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.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
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