197608467-8-22-2023-31-AS-NMAN-CV73ME-20230829182213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608467
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:15:37 PM

Unsubstantiated

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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2022 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20220307153524

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: 84	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	01:46 PM
MET WITH:	Janelle Topete		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident tested for drugs he is not taking.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted a subsequent complaint visit for the above allegation on 08/22/2023 at 11:04am to deliver investigative findings. LPA met with Administrator Janelle Topete and explained the purpose of the visit.

It is alleged that resident #1 (R1) toxicology was positive for TCA’s (antidepressants). To investigate the above allegation, LPA requested and obtained copies of facility files and documents including but not limited to the staff and resident rosters, physician report, and medication administration record on 03/09/2022 at 11:32am. LPA interviewed staff and residents at approximately 11:52am between 2:26pm. Interviews with six (06) out of eight (08) resident confirm that medication is kept in the med room and only staff give them medications. Six (06) out of (08) residents affirm no residents have given them any medications and they do not share their medications with other residents. At the time of the inspection, LPA observed the medication room locked and inaccessible to residents.
Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 31-AS-20220307153524

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE HOLLYWOOD	FACILITY NUMBER: 197608467
	VISIT DATE: 08/22/2023

NARRATIVE

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LPA observed resident’s medications in bubble packs rubbered banded together and separated by each resident. Residents with additional medications (gels, ointments and inhalers etc.) are maintained in a separate plastic bin for each resident. LPA observed prescribed narcotics inaccessible to residents stored in a locked cabinet cupboard in the nurse office. The assigned LVN on shift was observed to be in position of the key to the narcotics medication. During the course of the investigation LPA reviewed medical records on 05/22/2023 at approximately 2:55pm, which identified R1 toxicology report positive for Tricyclic Antidepressants (TCAs) and noted concerns for either human error or lab error and suggested repeat test. Hospital staff spoke with facility staff, but no noted follow-up requested. Although the toxicology results were positive hospital staff did not perform or request follow-up testing for R1. Based on interviews, observations and record review, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards are noted during this visit.

No deficiencies cited. Exit interview conducted and copy of report and appeal rights issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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