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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206861
Report Date: 03/13/2024
Date Signed: 03/13/2024 03:42:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
02/08/2024 and conducted by Evaluator Brianna Miranda
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240208123927
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: DATE:
03/13/2024
UNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Administrator Makaryan Hripsime (Kristina)TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Due to lack of supervision resident eloped from the facility

INVESTIGATION FINDINGS:
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On 03/13/2024 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Administrator (AD) Makaryan Hripsime (Kristina) was contacted.
1. The Department investigated the allegation: Due to lack of supervision resident eloped from the facility. On 2/9/2024 LPA spoke with AD who could not explain how R1 was able to elope from the facility without staff being aware R1 had left. LPA reviewed R1's physician report which indicates R1 is not able to leave the facility unassisted. AD stated when R1 was located they were sent to the hospital to be evaluated.
Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 9099D.

Exit interview was conducted and a copy of this report LIC9099 , LIC9099D, and appeal rights were provided to Administrator Makaryan Hripsime (Kristina).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
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 2
Control Number 24-AS-20240208123927
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BELMAR VILLA
FACILITY NUMBER: 107206861
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2024
Section Cited
CCR
87464(f)(1)
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87464 Basic Services
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). Health and Safety Code section 1569.2(c) provides:
(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
This requirement is not met as evidenced by:
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On 2/9/2024 AD had created an hour check in log for staff to check on resident hourly. Administrator will provide a statement regarding changes made to prevent future elopements.
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Based on observation, interview, and record review the licensee failed to follow physician orders by allowing the resident to elope from the facility unassisted. Facility did not know R1 left until R1's family arrived and was unable to locate R1 at the facility.
This poses an immediate health, safety, or personal rights risk to residents 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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2