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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608291
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:29:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2025 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250218153221
FACILITY NAME:BELMONT VILLAGE WESTWOODFACILITY NUMBER:
197608291
ADMINISTRATOR:SCHROEDER, CHRISFACILITY TYPE:
740
ADDRESS:10475 WILSHIRE BLVDTELEPHONE:
(310) 475-7501
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY:240CENSUS: 175DATE:
03/06/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Chris Schroeder/Executive DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff is not providing adequate food service to residents.
Facility staff are not ensuring safe handling of food.
Facilty staff discourge Residents from reporting.
Facilty staff yell at Residents.
Facility staff do not ensure facility is kept clean.
INVESTIGATION FINDINGS:
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On 3/6/2025 at approximately 8:30 AM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Chris Schroeder / Executive Director. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (F#1-F#4), (C#1-C#4), (O#1-O#5), Resident’s interviews (R#1-R#15) and Witnesses Interviews (W#1-W#14). LPA obtained and reviewed the following documents: Copies of facility menu for December 2024, January, February and March 2025, Copies of staff training regarding food handling, copies of facility cleaning schedule and copies of administrator training regarding personal rights of residents, copies of safe-serve certification for serving staff and an inspection of (15) residents rooms: 203, 529, 430, 428, 306, 622, 612, 305, 431, 513, 318, 504, 527, 327, 414 and (5) public restrooms and facility in-service training regarding Residents Personal Rights dated (3/13/24).

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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 7
Control Number 11-AS-20250218153221
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE WESTWOOD
FACILITY NUMBER: 197608291
VISIT DATE: 03/06/2025
NARRATIVE
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Investigation Revealed the Following:

Allegation: Facility staff is not providing adequate food service to residents.

The details of the complaint alleged that facility staff is not providing enough food for the residents in care.



On March 6, 2025, at approximately 12:00 PM, during the records review, LPA Iniguez observed copies of the facility menu from December 2024, January, February, and March 2025; LPA Iniguez observed on the menus a variety of well-balanced meals provided to the residents in care with breakfast, lunch and dinner served daily and a standby menu that offers a variety of salads, sandwiches, wraps, omelets, starters, sides, entre, deserts, and beverages available upon residents requests.

On March 6, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), he stated that the facility provides three meals per day: breakfast, lunch, and dinner, plus all the snacks the residents want. In addition, (A#1) stated that the amount and quality of food served at the facility are adequate for the residents in care.

On March 6, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#13), (13) out of (13) stated that the facility provides three meals per day and good quality.

On March 6, 2025, at approximately 9:00 AM, during interviews with facility staff (F#1-F#5, C#1-C#5, and O#1-O#5), (15) out of (15) stated that the facility provides three meals per day: breakfast, lunch and dinner, also, they stated that the food provided by the facility is adequate to the residents in care.

Evaluation Report continues LIC 9099-C...
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20250218153221
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE WESTWOOD
FACILITY NUMBER: 197608291
VISIT DATE: 03/06/2025
NARRATIVE
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On February 26, 2025, during interviews with witnesses (W#1-W#14) at approximately 9:00 AM, (13) out of (14) stated that the facility provides adequate, high-quality meals for their parents and the other residents in care.

Allegation: Facility staff are not ensuring safe handling of food.

The details of the complaint alleged that facility staff is not handling food in a safe way.



On March 6, 2025, at approximately 12:00 PM, during the records review, LPA Iniguez observed (F#1-F#5) the California Food-Handler Training Certificate Program; all the certificates are current.

On March 6, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), he stated that the serving staff receives outside and inside training regarding food handling by the California Food-Handler Training Program that is due every three years.

On March 6, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#13), (12) out of (13) stated that they had not observed facility servers putting their fingers on the food.
On February 26, 2025, during interviews with witnesses (W#1-W#14) from approximately 9:00 AM, (14) out of (14) stated that they had never witnessed serving staff putting their fingers on the residents’ meals.

On March 6, 2025, at approximately 9:00 AM, during interviews with serving staff (F#1-F#5) (5) out of (5) stated that they are certified food handlers by the California Food Handler Training Program that is for the amount of three years. In addition, (5) out of (5) servers stated that they have never put their fingers or hand on the prepared meal for the residents.

Evaluation Report continues LIC 9099-C...
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20250218153221
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE WESTWOOD
FACILITY NUMBER: 197608291
VISIT DATE: 03/06/2025
NARRATIVE
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Allegation: Facility staff discourage Residents from reporting.

The details of the complaint alleged that administrator is discouraging residents and family to call licensing.



On March 6, 2025, at approximately 2:00 PM, during records review, LPA Iniguez observed the facility's in-service training (dated 3/13/24) regarding Residents' Personal Rights. LPA observed that the facility administrator (A#1) took the training.

On March 6, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), he stated that he has never discouraged residents or their families from contacting the Community Care Licensing Department for complaints.

On March 6, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#13), (13) out of (13) stated that they have never witnessed facility administrator (A#1) discouraging them or their families submitting a complaint to Community Care Licensing.

On March 6, 2025, at approximately 9:00 AM, during interviews with office staff (O#1-O#5), (5) out (5) stated that they have never witnessed facility administrator (A#1) discouraging residents and their families calling Community Care Licensing.

On February 26, 2025, during interviews with witnesses (W#1-W#14) at approximately 9:00 AM, (14) out of (14) stated that they have never been discourage by (A#1) to call Community Care Licensing Department.

Evaluation Report continues LIC 9099-C...
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20250218153221
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE WESTWOOD
FACILITY NUMBER: 197608291
VISIT DATE: 03/06/2025
NARRATIVE
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Allegation: Facility staff yell at Residents.

The detail of the complaint alleges that facility administrator yells at family from residents in care.



On March 6, 2025, at approximately 2:00 PM, during records review, LPA Iniguez observed the facility's in-service training (dated 3/13/24) regarding Residents' Personal Rights. LPA observed that the facility administrator (A#1) took the training.

On March 6, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), he stated that he has never yelled at residents in care or their families.

On March 6, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#13), (13) out of (13) stated that they had never witnessed facility administrator (A#1) yelling at them or their families.

On March 6, 2025, at approximately 9:00 AM, during interviews with office staff (O#1-O#5), (5) out (5) stated that they have never witnessed facility administrator (A#1) yelling or screaming to the residents in care or their families.

On February 26, 2025, during interviews with witnesses (W#1-W#14) at approximately 9:00 AM, (14) out of (14) stated that they have never been yelled or their parents by (A#1).

Allegation: Facility staff do not ensure facility is kept clean.

The detail of the complaint alleges that facility staff does not ensure residents rooms and public bathrooms are kept clean.




Evaluation Report continues LIC 9099-C...
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20250218153221
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE WESTWOOD
FACILITY NUMBER: 197608291
VISIT DATE: 03/06/2025
NARRATIVE
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On March 6, 2025, at approximately 1:00 PM, LPA Iniguez observed and review the facility’s housekeeping cleaning schedule, LPA Iniguez observed that the housekeeping cleaning schedule is once per week or as need it.

On March 6, 2025, at around 1:00 PM, LPA Iniguez and the Executive Director inspected a total of (15) residents and (5) public restrooms. LPA Iniguez noted that the residents’ rooms and public restrooms were clean.

On March 6, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), he stated that the facility is always clean, the housekeeping staff cleans the public restrooms once or twice a day, and the resident’s room every week or as needed.

On March 6, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#13), (13) out of (13) stated that the facility, including their rooms and the public restrooms, was clean.

On February 26, 2025, during interviews with witnesses (W#1-W#14) at approximately 9:00 AM, (13) out of (14) stated that the facility staff ensures the residents rooms and public restrooms are kept clean.

On March 6, 2025, at approximately 9:00 AM, during interviews with cleaning staff (C#1-C#5), (5) out of (5) stated that the facility is clean, including the resident's room and public restrooms. Also, they stated that the facility's public restrooms get cleaned up to two times per day or as needed, and the resident's rooms every week or as needed.


Evaluation Report continues LIC 9099-C...
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20250218153221
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE WESTWOOD
FACILITY NUMBER: 197608291
VISIT DATE: 03/06/2025
NARRATIVE
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During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.


An exit interview was conducted, and a copy of the Complaint Report was given to Chris Schroeder / Executive Director.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7