197608467-4-9-2021-31-AS-NMAN-BZWUSN-20210409155038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608467
Report Date: 04/09/2021
Date Signed: 04/09/2021 03:51:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	BELMONT VILLAGE HOLLYWOOD		FACILITY NUMBER:	197608467
ADMINISTRATOR:	YOUNG, ALLYSON L		FACILITY TYPE:	740
ADDRESS:	2051 N HIGHLAND AVE		TELEPHONE:	(323) 874-7711
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90068
CAPACITY:	150	CENSUS: 74	DATE:	04/09/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Allyson Young		TIME COMPLETED:	04:00 PM

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	LPA Naira Margaryan conducted unannounced Case Management visit to facility. LPA met the Executive Director (ED) and explained that this visit was conducted to follow up and obtain more information regarding the fall incident involving facility resident #1 (R1). Woodland Hills South Adult and Senior Care Regional Office (WHSASCRO) received an incident report involving the facility resident #1 (R1). As per Incident report on 03/31/2021 during transfer assistance from the wheelchair to bed, R1 fell and injured their Right Shoulder. R1 was sent to the hospital and require surgery, as the fall resulted fractured clavicle and humerous. Upon review of incident report, it was noted that the description of incident is incomplete and required additional clarification. Therefore, LPA Margaryan visited the facility to obtain additional information. At the time of this visit at 9:00am, LPA spoke with the Executive Director (ED). Between 10:30am, and 11:30am, LPA had a phone interview with the staff #1 (S1) and with the medical professionals working at the facility. At 2:40pm LPA spoke with other facility staff assisting R1. Staff indicated that R1 required two (02) party assistance. Interviews revealed that one of the radios that S1 and other staff are using to communicate with each other and ask for help, was broken for about one month. At list one (01) out of three (03) caregivers working on each shift had no radio for communication. At 10:30am, with the assistance of ED, LPA inspected R1’s room to understand how the incident occurred. ED demonstrated the position of the wheelchair and position of the resident on the floor, based on explanation ED received from the S1, during internal investigation of the incident. A review of R1's records conducted prior to and at the time of this visit, revealed that R1 is at risk of fall but required one (01) persons assistance.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira Margaryan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BELMONT VILLAGE HOLLYWOOD	FACILITY NUMBER: 197608467
	VISIT DATE: 04/09/2021

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

Information received revealed that on 03/31/2021 on or after 5:30pm, S1 went to assist R1 and observed R1's hands and face covered with feces. Before transferring R1 from the wheelchair to bed to clean them up, S1 left R1 on the wheelchair, removed footrests and walked out from the room to ask for assistance. By the time S1 returned, R1 was on the floor laying on her right shoulder parallel to the bed. S1 pulled R1 from the floor and assisted them back to bed by lifting and holding R1 under their arms.

Based on interviews, inspection, observation and record review, the following was concluded; :
1. R1 fell due to being left untended on the wheelchair with no footrest, while staff went to ask for assistance.
2. R1 was not assessed for pain prior to moving them from the floor to bed.
3. Staff lifted R1 from the floor and assisted back to bed by lifting and holding R1 under their arms,
(This action could contributed to the injuries resulted from fall).

LPA Margaryan discussed this incident with ED and informed that due to time constrains, LPA Margaryan is unable to complete this visit.
All noted issues effecting resident's health, safety and well being will be addressed and citations and possible civil penalties will be issued at later time.

During this visit LPA and ED discussed gross bodily injuries that may result in enhanced civil penalties.
Exit interview was conducted and a copy of this report was issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Naira Margaryan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2