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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608291
Report Date: 04/07/2022
Date Signed: 04/07/2022 02:48:58 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2021 and conducted by Evaluator Elizabeth Ceniceros
COMPLAINT CONTROL NUMBER: 11-AS-20210521113934
FACILITY NAME:BELMONT VILLAGE WESTWOODFACILITY NUMBER:
197608291
ADMINISTRATOR:ARP, JAMESFACILITY TYPE:
740
ADDRESS:10475 WILSHIRE BLVDTELEPHONE:
(310) 475-7501
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY:240CENSUS: DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Director of Resident Care Services,
Ann Margaret Zavela.
TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility changed resident's medication without consent.
INVESTIGATION FINDINGS:
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Licensing Program Analyst/Retired Annuitant (LPA/RA: Elizabeth Ceniceros) conducted an unannounced subsequent visit to the facility at 11:00 a.m. and was greeted by Staff #1 (S1: Director of Resident Care Services, Ann Margaret Zavela); as Executive Director/Administrator (ED/A1: James Arp) was unavailable at the time of this visit. LPA/RA spoke to ED/A1 Arp (via landline) prior to entering the facility to conduct a risk assessment. ED/A1 Arp informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA/RA Ceniceros explained the purpose of today's visit is to deliver the findings pertaining to the above-mentioned allegation.

Licensing Program Analyst (LPA) Troy Agard conducted the unannounced, initial 10-Day visit on 03/02/22. During today’s visit, LPA/RA Ceniceros obtained facility staff roster, residents roster, Resident #1’s Emergency Contact & I.D. Information, Physician’s Report, Medication Administration Record (May 2021), New Patient Intake Form & Signed Consent Letter (dated 03/23/21), Prescription Order (dated 05/14/21), and Destruction Order (dated 05/20/21). LPA/RA Ceniceros toured the facility’s memory care unit, medication room, and observed the computerized system utilized to store residents medication administration record.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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 11-AS-20210521113934
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BELMONT VILLAGE WESTWOOD
FACILITY NUMBER: 197608291
VISIT DATE: 04/07/2022
NARRATIVE
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Regarding Allegation #1: this investigation revealed that the facility administered the medication (Xanax) to Resident #1 (R1) that was prescribed by one of the facility’s attending group physicians (neurologist). Reporting Party stated that it had not been communicated to Resident #1’s (R1’s) Responsible Person (RP) or Primary Care Physician (PCP), Dr. Elizabeth Whitman, MD. While visiting R1 at the facility on 02/01/2021, R1's RP was looking for a "new" neurologist for R1 due to the resident's multiple behaviors. R1's RP had approached ED/A1 James Arp in regards to the facility's attending group physicians (neurologists) who conduct evaluations on residents. ED/A1 brought R1's RP an application and consent form (with a list of physicians that also included R1’s PCP). ED/A1 introduced R1's RP to Dr. Yul Rapoport, MD (Neurologist); and, R1's RP approved of the Neurologist because the consent form was signed on 03/23/21. R1’s RP admitted to signing the consent (with the understanding that R1 is to continue seeing the PCP). R1’s RP later found out that one of the facility’s attending group physicians had prescribed the medication (Xanax) to R1 without consent. Staff #4 had discussed to R1's RP to administering R1's medication (Xanax) once; of which, there was no further discussion. LPA/RA Ceniceros inspected the facility’s Med Tech Room and observed the facility's computerized system for residents medication administration record. LPA/RA observed the medication (Xanax) was prescribed to R1 by Neurologist (Dr. Yul Rapoport, MD); and, discontinued by Primary Care Physician, Dr. Elizabeth Whitman, MD on 05/20/21. LPA/RA Ceniceros interviewed five (5) facility staff members (S1-S5) who indicated that R1's medication (Xanax) was administered to the resident - based on the physician's order on file (dated 05/14/21) once a day, as needed for multiple behaviors - until it was discontinued on 05/20/21. LPA/RA Ceniceros interviewed five (5) residents; and, the majority had not experienced an issue with the facility’s attending group physicians’ changing his/her medication or ED/A1 not consenting to his/her responsible person(s).

Based on interviews, observations, evidence gathered, information and documentation obtained and reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of MEDICATION: Facility changed resident’s medication without consent is UNSUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report was provided to Staff #1 Director of Resident Care Services, Ann Margaret Zavela; as the Executive Director/Administrator (James Arp) was unavailable at the time of this visit.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2