197608291-6-4-2025-11-AS-SCIS-DKCUN9-20250808154334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608291
Report Date: 06/04/2025
Date Signed: 06/04/2025 02:07:43 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
05/28/2025 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20250528120946

FACILITY NAME:	BELMONT VILLAGE WESTWOOD		FACILITY NUMBER:	197608291
ADMINISTRATOR:	SCHROEDER, CHRIS		FACILITY TYPE:	740
ADDRESS:	10475 WILSHIRE BLVD		TELEPHONE:	(310) 475-7501
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90024
CAPACITY:	240	CENSUS: 176	DATE:	06/04/2025
		UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Daisy Ceballos, Director of Resident Care		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff mishandle the residents medications

INVESTIGATION FINDINGS:

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On 6/4/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Felisa Shirley arrived and spoke to the Director of Resident Care, Daisy Ceballos and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following:
On 6/4/25 LPA requested and reviewed copies of the following records: Resident file, Resident Roster, Staff roster, MAR for May 2025, Physicians Report, 4/1/25 and Identification and Emergency Information, 5/8/21. LPA Felisa Shirley conducted a tour of the facility and to the 3rd floor Medication Room. LPA Shirley interviewed Staff 1 – Staff-11(S1 – S11) and Resident 1 – Resident 10(R1 – R10).

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250528120946

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: 06/04/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff mishandle the resident’s medications

On 6/4/25, LPA Shirley reviewed R1’s Medication Administration Record, (MAR) for May 2025. LPA Shirley observed that every medication listed was administered during the correct time frame. LPA Shirley reviewed list of medications for frequency and did not observe any specific times for medications listed. During the tour to the Medication room, LPA read every medication for instructions and did not observe any specific time for administration. Per review of R1’s file and interview with the Director of Resident Care, there were no orders nor request for medications to be given at a specific time.

LPA Shirley interviewed staff 1 – staff 11 (S-1 – S-11). LPA asked, does staff mishandle resident’s medications. Of those interviewed 11 out of 11 stated no. LPA interviewed resident 1 – resident 10 (R-1 – R10). LPA asked, does staff mishandle your medications. Of those interviewed, 9 out of 10 answered, no and 1 answered yes.

Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. 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 is Unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Director of Resident Care, Daisy Ceballos.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC9099 (FAS) - (06/04)

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