197608466-3-22-2022-29-AS-JAPL-CCSQWW-20220323123233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608466
Report Date: 03/22/2022
Date Signed: 03/22/2022 04:31:41 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
11/09/2021 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20211109161446

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: 110	DATE:	03/22/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Mary Jane Rodriguez		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Memory care residents are being video-recorded with the Safely-U Monitoring system without their consent.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced for a subsequent complaint visit to deliver the findings regarding the allegation above. The LPA met with Mary Jane Rodriguez, Operations Specialist, and explained the reason for the visit.

During the initial visit conducted on 11/18/2021, Licensing Program Analyst (LPA) Sandra Urena arrived unannounced for an initial 10-day complaint visit. The LPA met with Administrator Cyntia Drachenberg, and explained the reason for the visit. LPA Urena and Executive Director conducted a physical plant tour at 9:40 a.m., and interviewed staff from 10:00 a.m. to 10:20 a.m. Records were requested for review.

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: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

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 3

Control Number 29-AS-20211109161446

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: 03/22/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the above allegation, it was alleged that memory care residents were being recorded without their consent. Interviews and records review revealed that this facility utilizes the SafelyYou system, which is a fall detection program that detects when a fall takes place in a resident’s room. Research and staff interviews revealed that the video surveillance is not monitored by staff but is monitored by artificial intelligence. When the SafelyYou’s artificial intelligence detects a body on the ground, the program sends a ‘fall’ video to the SafelyYou system, which is only accessible by management and the nurse on duty. The clip captures the fall approximately ten minutes prior to the event, and approximately ten minutes following the perceived fall.

The staff do not have access to any other video clips other than what is provided by the software. As many residents in the memory care unit have cognitive impairment, oftentimes they are unable to communicate how or what caused a fall. The clip allows staff to assess the action that precedes the fall, the severity of the fall (ie. if a resident hit their head) and can determine whether there are other fall prevention measures needed in the room. Furthermore, it allows the staff to assess if an actual fall occurred; for example, a resident could be picking up something from the floor. Staff stated that the usage of the system has drastically reduced the usage of emergency personnel. Lastly, there isn’t any live video streaming, no audio recording, and the non-fall video surveillance is deleted from the system. Simultaneously, facility staff are alerted that a fall has taken place in a resident’s room, and staff are able to respond to a perceived fall in a timely fashion.

Prior to the implementation of the SafelyYou system, the facility held conference calls and video conferences with families, explaining the use of the system. All informed parties were given the option to opt in or opt out of the SafelyYou system. The physical plant tour revealed that the SafelyYou cameras are installed in all memory care rooms; however, if consent is not provided, the camera is not activated in the resident’s room. However, it was reiterated that consent can be rescinded at any time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20211109161446

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: 03/22/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

After further review, the Department applies the following definition of “informed consent”, which is: “A person’s agreement (or that of their legally authorized representative’ to allow something to happen, made with full knowledge of the risks involved and the alternatives,” (Source: Garner, Bryan, editor. Black’s Law Dictionary, 4th Pocket Ed. West Group Publishing, St. Paul, Minn, 2011, p. 149). Per the interviews and record review, the facility does their due diligence to ensure that consent was received from the resident’s responsible party. Although facility residents may be informed of the SafelyYou system, due to their cognitive impairment, the resident may not retain this knowledge at a later time or date. Should a resident display concern regarding the system, further discussion would be had with the resident's responsible party. The facility provided the signed copies of the consent forms, verifying that the resident’s responsible party agreed to the usage of the SafelyYou monitoring system in the resident's room.

Based on the investigation, there is insufficient evidence to support the claim that memory care residents are being video-recorded with the Safely-U Monitoring system without their consent. The consent is provided by the resident’s legally authorized representative. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the 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: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3