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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206861
Report Date: 09/01/2023
Date Signed: 09/01/2023 12:24:42 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
05/12/2023 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230512123128
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: 72DATE:
09/01/2023
UNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Administrator, Hripsime MakaryanTIME COMPLETED:
12:33 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide comfortable accommodations for a resident
Staff are not addressing a resident's change in medical condition
No home health plan on file for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/01/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Hripsime Makaryan.

The Department investigated the allegations that staff did not provide comfortable accommodations for a resident, staff are not addressing a resident's change in medical condition, and facility did not have a home health plan on file for resident, and based on interviews and records reviewed, the allegations are SUBSTANTIATED. Based on interviews and records reviewed, R1 had been receiving home health services for wound care on R1’s foot however between 5/1/23 thru 5/10/23, home health did not conduct any visits to provide wound care and facility did not seek medical attention for R1’s wound.

CONTINUED TO 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
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 5
Control Number 24-AS-20230512123128
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: 09/01/2023
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
It was also determined that facility did not have a copy of the home health care plan for R1, and that when a nurse from home health arrived to facility on 5/11/23, R1 was observed to be laying on a plastic covered mattress with no bedding, one sock on their feet, and the wound to not be dressed.

Deficiencies cited in the attached 9099D for violation of Title 22, Sections 87465, 87468.1, and 87609.

Appeal rights provided and exit interview conducted with Administrator, Hripsime Makaryan whose signature confirms receipt of documents.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20230512123128
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: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/02/2023
Section Cited
CCR
87465(a)(2)
1
2
3
4
5
6
7
87465(a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need…
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to submit a plan detialing the steps the facility will take to ensure the requirements for section 87465(a)(2) are met to the Fresno CCL office by the POC due date
8
9
10
11
12
13
14
Based on interviews and record review, this requirement was not met between 5/1/23 and 5/10/23, when home health did not conduct any wound care visits and facility and did not seek medical treatment to meet R1’s needs, which is an immediate healthy and safety risk to persons in care
8
9
10
11
12
13
14
Deficiency Dismissed
Type B
09/22/2023
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
87468.1(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment... This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to submit a plan detialing the steps the facility will take to ensure the requirements for section 87468.1(a)(2) are met to the Fresno CCL office by the POC due date
8
9
10
11
12
13
14
Based on interviews, This requirement was not met when on 5/11/23, a home health nurse conducted a visit and observed R1 to be laying on a plastic covered mattress with no bedding, one sock on their feet, and the wound on their foot to be undressed.
8
9
10
11
12
13
14
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20230512123128
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: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/22/2023
Section Cited
CCR
87609(b)(4)
1
2
3
4
5
6
7
87609(b)(4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).
1
2
3
4
5
6
7
Licensee agrees to submit a plan detialing the steps the facility will take to ensure the requirements for section 87468.1(a)(2) are met to the Fresno CCL office by the POC due date
8
9
10
11
12
13
14
Based on interviews and records review, This requirement was not met when the investigation revealed that facility did not have a copy of the home health care plan and was therefore unaware of home health and facility responsibilities related to R1’s medical condition.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
05/12/2023 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230512123128

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: 72DATE:
09/01/2023
UNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Administrator, Hripsime MakaryanTIME COMPLETED:
12:33 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in a resident sustaining a pressure injury
Resident sustained an unexplained injury while in care
Staff do not properly maintain the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/01/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Hripsime Makaryan.

The Department investigated the allegations that staff neglect resulted in resident sustaining a pressure injury, that resident sustained an unexplained injury while in care, and that facility was not property maintained, and based on interviews and records reviewed, there is not a preponderance of evidence to prove or disprove the allegations occurred therefore the complaint is UNSUBSTANTIATED. The wound on R1’s foot was not diagnosed as a pressure injury, it was not determined what caused the bruise on R1’s leg, and no further information was provided in reference to facility not being properly maintained.

No deficiencies cited. Exit interview conducted with Administrator, Hripsime Makaryan.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
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 5