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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608291
Report Date: 03/27/2024
Date Signed: 03/27/2024 02:41:02 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
03/18/2024 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240318110224
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: 56DATE:
03/27/2024
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Chris Schroeder-Executive DirectorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility staff did not assist resident with wearing clean clothing
Facility staff did not assist resident with incontinence care
Facility staff did not assist resident with showering
Facility staff did not meet resident's dietary needs
Facility staff did not assist resident with using hearing aids
INVESTIGATION FINDINGS:
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Investigation Consisted of: Interview with Administrator(A#1), Facility Staff (S#1-S#5), Residents (R#1-R#6) and Reporting Party (RP).
LPA Iniguez reviewed the following records: Staff Roster, Residents Roster, (R#1-R#5) Physicians Report for Residential Care Facilities for the Elderly or LIC 602, (R#1-R#5) Admissions Agreement, (R#1-R#5) Identification and Emergency Information LIC 625, (R#1-R#5) Appraisal/Needs Service Plan LIC 625, (R#1-R#5) Medication Administration Record (MARS) for the month of March 2024, copies of facility communication faxes to (R#1) primary physician dated: 11/18/23, 10/20/23 and 9/18/23, copies of facility menu and copies of facility brochure meals services.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
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 9
Control Number 11-AS-20240318110224
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: 03/27/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation: Facility staff did not assist resident with wearing clean clothing.

The details of the complaint alleged that facility staff are not assisting residents with wearing clean clothes.



During the records review, LPA Iniguez examined the Service Plan Descriptions of (R#1), which had been set up by the resident and family upon admission. The facility staff conducted an assessment of the resident and suggested the appropriate services for their care. In (R#1)’s Service Plan Description, it was noted that they were enrolled in the Circle of Friends Service Plan (Assisted Living Area), which included weekly laundering of bed and linens and bath towels, daily bed making, and basic personal care. This service plan also included dressing and grooming assistance, standby assistance with showering as needed, or hands-on assistance with showering up to three times per week, and escort assistance to meals and activities while walking or by wheelchair. Additionally, LPA reviewed (R#1)’s Physician’s Report for the Residential Care Facilities for the Elderly (RCFE) LIC 602A, which indicated that (R#1) was able to bathe, dress, groom, feed themselves, and take care of their own toileting needs.
During an interview with the Administrator (A#1), he mentioned that (R#1) communicates their needs and requirements effectively. (R#1) needs minimal assistance with grooming and changing; their clothes are washed every week and as needed. Regarding showering and continence, (R#1) needs hands-on assistance and some prompting from facility staff. Additionally, (A#1) stated that they prefer to encourage (R#1) rather than directly ask them, as it results in a more positive response.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 11-AS-20240318110224
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: 03/27/2024
NARRATIVE
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During an interview with resident 1 (R#1), they stated that they change their clothes independently and do not require any assistance. Moreover, (R#1) mentioned that their clothes are clean when they change them. (R#1) said, “My clothes get clean here. I just put them in a laundry bag; my clothes are never soiled.”

During interviews with residents (R#2-R#6), (5) out of (5) residents stated that they do not need any assistance in changing their clothes, and they can do it by themselves. Additionally, (4) out of (5) residents stated that they wash their clothes independently, and only one resident mentioned that the facility washes their clothes for them.

During interviews with staff (S#1-S#3), (3) out of (3) staff members stated that every morning, caregivers encourage (R#1) to change and take a shower, rather than directly asking them if they want to. They have observed that using encouragement rather than direct questioning results in a more positive response from (R#1). The facility tries to assign caregivers that (R#1) is comfortable with, and if (R#1) refuses to shower during the morning shift (6:30 AM to 2:45 PM), the second shift (2:45 PM 11:00 PM) will encourage them to shower and change. If (R#1) still refuses to change, the caregivers will document their refusal and inform their physician and family. When it comes to washing (R#1)’s clothes, they are washed every week, and for other residents, clothes are washed every week or as needed, depending on the residents' requests.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 11-AS-20240318110224
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: 03/27/2024
NARRATIVE
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Allegation: Facility staff did not assist resident with incontinence care.

The details of the complaint alleged that facility staff are not assisting resident with their continence needs.


During the records review, LPA Iniguez reviewed the Service Plan Descriptions of resident (R#1). The resident and family created this plan upon admission, and the facility staff assessed the resident and recommended the services that they thought would fit their care. In the case of (R#1)’s Service Plan Description under the Circle of Friends Service Plan (Assisted Living Area), the plan includes daily bed-making and toileting reminders and assistance. Moreover, LPA also reviewed (R#1)’s Physician’s Report for the Residential Care Facilities for the Elderly (RCFE) LIC 602A. The report indicates that (R#1) does not suffer from bladder or bowel impediment.

During an interview with the Administrator (A#1), he stated that the facility is assisting (R#1) with their continence needs. In addition, (A#1) stated that (R#1)’s Residence and Service Agreement states that they receive essential services, including toilet reminders and daily bed making.

During an interview with resident 1 (R#1), they stated that they do not need assistance with their continence needs.

During interviews with residents (R#2-R#6), (5) out of (5) stated that they do not need assistance with their continence needs.

During interviews with staff (S#1-S#3), (3) out of (3) stated that they are assisting (R#1) with their continence needs. In addition, (S#3) said that they go there every day to ensure (R#1)’s continence needs are met. If (R#1) refuses to get a continence change, they wait for 20 minutes, and then ask again if they want to get a change. If (R#1) refuses again, they wait and ask again. If (R#1) gets upset, they stop asking, respect their decision, and document their refusal. However, overall, (R#1) changes regularly.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 11-AS-20240318110224
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: 03/27/2024
NARRATIVE
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Allegation: Facility staff did not assist resident with showering

The details of the complaint alleged that facility staff did not assist resident with showering.



During the records review, LPA Iniguez reviewed the Service Plan Descriptions of resident (R#1). The plan was set up by the resident and their family upon admission, and facility staff assessed the resident and recommended the services that they thought fit their care. In the case of (R#1)’s Service Plan Description under the Circle of Friends Service Plan (Assisted Living Area), the plan includes standby assistance with showering as needed or hands-on assistance with showering up to three times per week. Additionally, LPA reviewed (R#1)’s Physician’s Report for the Residential Care Facilities for the Elderly (RCFE) LIC 602A, which indicated that the resident could bathe themselves.

During an interview with the Administrator (A#1), he stated that the staff generally help (R#1) at least three times per week or more if requested. The Administrator also confirmed that (R#1) has not refused to shower for more than three days. However, if (R#1) does refuse, the facility will contact their physician and representative.

During an interview with resident 1 (R#1), they stated that they do not need assistance with showering and can do it themselves without staff assistance.

During interviews with residents (R#2-R#6), (3) out of (5) stated that they can shower themselves without any assistance. Additionally, two out of five stated that they can shower themselves, but a caregiver is on standby just in case.

During interviews with staff (S#1-S#3), (3) out of (3) staff members stated that they encourage (R#1) to shower at least three times per week or as needed. However, if they observe that (R#1) is getting upset or refusing, they will stop asking and document the refusal.

Evaluation Report continues LIC 9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 11-AS-20240318110224
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: 03/27/2024
NARRATIVE
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Allegation: Facility staff did not meet resident's dietary needs

The details of the complaint alleged that facility staff are not meeting residents’ dietary needs.



During a tour to the facility, LPA observed how the facility takes food orders for its residents. The system is similar to that of a restaurant, where residents order food from the caregiver who fills out breakfast, lunch, and dinner forms. In the form, there is a checkbox to mark dine-in or room service. They then place the form in a container, which the kitchen staff retrieves and types into the system. Once the order is submitted, it prints a receipt in the kitchen, showing who requested the meal.

During the records review, LPA Iniguez examined (R#1)'s Service Plan Descriptions. The resident and their family set up this plan upon admission, and the facility staff assessed the resident to recommend the services that they think would fit their care. In the case of (R#1)'s Service Plan Description under the Circle of Friends Service Plan (Assisted Living Area), the service plan includes three meals daily, and snacks are available in the bistro between meals. Additionally, LPA reviewed (R#1)'s Physician's Report for the Residential Care Facilities for the Elderly (RCFE) LIC 602A. It is marked by (R#1)'s physician that they can feed themselves. Moreover, LPA reviewed a copy of the facility brochure on meal service, which states that the facility serves three meals per day and snacks between meals.

Evaluation Report continues LIC 9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 11-AS-20240318110224
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: 03/27/2024
NARRATIVE
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During an interview with the Administrator (A#1), he explained that generally, (R#1) comes to the dining room to eat their meals. The facility has both a dining room and a bistro area. If (R#1) wants to avoid coming down to eat their meals, they can order food from the staff, who then give the order to the kitchen staff. Once the order is in the kitchen, it prints a ticket order in the system with (R#1)'s order. Once the order is complete, the meal has the ticket information of what resident belongs to. In this case, it would be (R#1).

During an interview with resident 1 (R#1), they mentioned that they eat two meals per day, breakfast and dinner. When asked if they get hungry at other times, they said no. Additionally, (R#1) stated that they have not lost weight in the past few months. The facility provides meals to (R#1) when needed.

During interviews with residents (R#2-R#6), (5) out of (5) stated that they eat three meals per day, and there is always food available for them. Also, all (5) of them said that they have not lost weight because the facility staff provides them with meals regularly.

During interviews with staff (S#1-S#3), (3) out of (3) stated that (R#1) likes to eat two meals per day and wants to have breakfast in their room. Additionally, (S#1) stated that they have not noticed any significant weight loss in (R#1). However, if they notice any weight loss, they will immediately notify (R#1)'s physician and family about it.

Evaluation Report continues LIC 9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 11-AS-20240318110224
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: 03/27/2024
NARRATIVE
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Allegation: Facility staff did not assist resident with using hearing aids

The details of the complaint alleged that facility staff are not assisting residents with using their hearing aids.



During a facility tour, LPA observed two wellness centers located on the 3rd and 5th floors. Inside these centers, the residents are charged for hearing aids if they choose to use them. On the other hand, some residents charge their hearing aids in their rooms.

During an interview with the Administrator (A#1), he stated that the facility provides assistance to residents (R#1) with their hearing aids in two ways. Firstly, residents can keep their hearing aids in the wellness center, where the staff ensures that the hearing aids are charged during the nighttime. Then, the next day, the staff distributes the hearing aids to the residents. Secondly, if the residents want to keep their hearing aids with them, the facility staff assists those residents in charging the hearing aids for next-day use. In the case of (R#1), they choose to charge their hearing aids themselves, and the staff ensures that they do it correctly.

During an interview with resident 1 (R#1), they said they keep their hearing aids in their room, and the facility staff ensures that (R#1)'s hearing aids are connected correctly.

During interviews with residents (R#2-R#6), (5) out of (5) residents stated that they do not use hearing aids.

During interviews with staff (S#1-S#3), (3) out of (3) stated that (R#1) keeps their hearing aids in their room and refuses to give them to the caregivers. However, the caregivers make sure that the hearing aids are charged correctly for the next day.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 11-AS-20240318110224
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: 03/27/2024
NARRATIVE
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During this investigation, LPA found did not find sufficient evidence to support the above-mentioned allegations.

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, therefore the allegations are unsubstantiated.


California Code of Regulations (Title 22, Division 6, Chapter 8).

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

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9