197608466-6-22-2021-29-AS-JAPL-C8M2XB-20211109164651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608466
Report Date: 06/22/2021
Date Signed: 06/22/2021 12:26:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2021 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20210129163655

FACILITY NAME:	BELMONT VILLAGE ENCINO		FACILITY NUMBER:	197608466
ADMINISTRATOR:	DRACHENBERG, CYNTIA		FACILITY TYPE:	740
ADDRESS:	15451 VENTURA BLVD		TELEPHONE:	(818) 788-8870
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY:	150	CENSUS: 107	DATE:	06/22/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Cyntia Drachenberg		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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1. Failure to provide resident(s) with a reasonable level of privacy (room door was removed).
2. Failure to keep resident(s) free from punishment, humiliation, intimidation, or abuse (getting hit on her right side every Friday).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena arrived at 8:30 am for an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Administrator Cyntia Drachenberg at 9:00 am and informed her for the reason of the visit. During today’s visit, LPA interviewed staff, Resident #1(R1), and conducted additional observations.

On 02/03/2021, LPA Eva Miller initiated a virtual visit and conducted an interview with Administrator and requested records, which were received by RO on 02/05/2021.

Interviews: Interviews of residents, staff and administrator yielded the following information:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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 3

Control Number 29-AS-20210129163655

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 06/22/2021

NARRATIVE

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Interviews: Interviews of residents, staff and administrator yielded the following information:

Regarding the allegation: Failure to provide resident(s) with a reasonable level of privacy (room door was removed). It was alleged that R1 door was removed depriving R1 of privacy.

LPA met with Administrator at 9:00am for an initial interview. During the interview with the Administrator, it was learned that the door leading from the bedroom to the living room area had some screws off, therefore the door was not fully off the hinges, just tilted to the side. According to the facility report presented by Administrator, the door was placed back on its hinges and fixed on 1/18/2021. The repair took longer than expected (about a week) due to facility repair worker out with COVID-19. In the matter of following up with R1's physician about the concerns of R1 hallucinations, confusion and paranoia, Administrator stated that doctor did not reply to those concerns. In the matter of R1 receiving Home Health physical therapy for the right rib pain, it was stated that R1 received evaluation on 01/31/2021, and therapy on 2/24/21, 3/4/21, 3/10/21, 3/17/21, 5/19/21, 6/01/21.

During today’s visit, LPA visited R1 in room #345, the interview started at 9:15am. LPA observed at this time that the door was fully attached to door frame. The following statements were taken from R1, when asked regarding bedroom door being removed. R1 stated, “Door was not completely off the hinges, some screws came off and the door was leaning to the side”. I don’t know how that happened. It took them about a week to get it fixed”. This allegation is Unsubstantiated at this time.

Regarding the allegation: Failure to keep resident(s) free from punishment, humiliation, intimidation, or abuse. It was alleged that R1 gets hit on the right side every Friday.

LPA interviewed R1 at 9:30 am. The following statements were made by R1 regarding this allegation. LPA asked, “How are you feeling today? Do you have any pain?” R1: “No, I feel fine. LPA-"Any pain on your right side?" R1, "No, no pain". LPA, "What caused your pain on your right side?". R1, “Someone comes in at night and pushes the chair into my rib”. R1 pointed to the right side, below the armpit. LPA, “What do this person(s) look like, the ones pushing the chair on your right side?”. R1, “I don’t know I don’t see them, when they do it, I don’t feel it, but I feel pain when I wake up”. LPA, “Do you know if it is a woman or a man?” R1, “No, I don’t see, I don’t know who they are, they could be aliens from Mars, could be anybody, I don’t see them”.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210129163655

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 06/22/2021

NARRATIVE

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LPA- “Have you shared with your family about someone hurting you?” R1, “No, I don’t want to worry them”. LPA, “Have you gone to the doctor for this pain on your right side?”. R1, “No its not that important”. LPA, “When was the last time someone pushed the chair on your right side?”. R1, “About a month ago”. LPA, “Are you happy here?”. R1, “I am very, very happy here, everyone is so nice to me”.

LPA reviewed Physicians’ report dated 2/4/2021. R1 was seen by physician for the complaint of the pain on her right side. The report indicated the following. After-Visit Summary: X-rays of the right side did not show any evidence of obvious fractures, or bruises. Doctor ordered home health work for R1 at Belmont to help with the pain. Belmont has provided home health therapy for R1.

Caregiver Interview: At 9:45am LPA interview Caregiver for Residents on the third floor. Caregiver assists R1 with dressing, bathing and wheelchair to take R1 to eat and bring back to room, but only when R1 needs assistance, and when R1 returned from the hospital, R1 is very independent. Sometimes R1 complaints things are stolen from the room. This allegation is Unsubstantiated at this time

No deficiencies cited. Exit interview conducted. Signatures obtained. A copy of report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC9099 (FAS) - (06/04)

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