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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 02:25:49 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
02/28/2022 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220228122240
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:
08:00 AM
MET WITH:Director of Resident Care Services,
Ann Margaret Zavela.
TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff stole resident's belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst/Retired Annuitant (LPA/RA: Elizabeth Ceniceros) conducted an unannounced subsequent visit to the facility at 8:00 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 resident and facility staff rosters (February 2021 & April 2022) and reviewed “Personal Property Procedures” (LIC 9059), “Resident Theft and Loss Record” (LIC 9060), and former Staff #1's personnel file. LPA/RA Ceniceros toured the facility and observed the posted "Theft and Loss" Program (photo).
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-20220228122240
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 there was no report made to the facility by one of the residents nor one of the resident's responsible person(s) regarding stolen property (ring) from a resident; as reported by the Reporting Party. Reporting Party stated that it was hearsay that she was informed of the incident by former Staff #2 (FS2: Marquisha Jeter) that former Staff #1 (FS1: Morgana Jeter, Caregiver) told her (FS2) that she (FS1) had stolen property (ring) from a resident at the facility. ED/A1 Arp confirmed (via landline) that no incident had been reported to facility staff of stolen property (ring) by a staff member from one of the facility's resident(s). ED/A1 Arp confirmed that the facility has their "Theft and Loss" Program posted in the facility. LPA/RA Ceniceros toured the facility together with Staff #1 and observed the posted "Theft and Loss" Program (photo). LPA/RA Ceniceros interviewed five (5) facility staff members (S1-S5); and, the majority had not heard or received a report from a facility resident(s) of stolen property (ring) from the resident(s) possession. LPA/RA Ceniceros interviewed five (5) residents (R1-R5) who reported that they had not had personal property (ring) stolen from their possession by a facility staff member.

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 PERSONAL RIGHTS: Staff stole resident's belongings is found to be 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