197608467-8-22-2023-31-AS-NMAN-CV8PLY-20230831112532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608467
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:36:30 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
04/25/2023 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20230425084540

FACILITY NAME:	BELMONT VILLAGE HOLLYWOOD		FACILITY NUMBER:	197608467
ADMINISTRATOR:	MARY JANE RODRIGUEZ		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:	01:54 PM
MET WITH:	Janelle Topete		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Staff do not assist resident with toileting needs.

Staff do no do ensure resident's showering needs are met.

Facility has lack of water supply.

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.

#1. Staff do not assist resident with toileting needs.

It is alleged that R1 was told by staff to urinate and defecate on themself. To investigate the above allegation LPA requested and obtained copies of facility files and documents including but not limited to staff and resident rosters, physician reports and PAL Approach Chart and Service Plan at 12:32pm. LPA interviewed the ED at 12:37pm, additional interviews with staff and residents were conducted at approximately 2:10pm. Interviews with seven (07) out of eight (08) incontinent residents confirm they have not been told to urinate or defecate on themselves. They confirm staff assist them with their toileting needs and they are checked on
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-20230425084540

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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often to see if they need assistance with toileting. Interveiws with staff revealed that R1 has a catheter, and they affirm that incontinent residents are checked on every two (02) hours and have not told any residents to defecate or urinate on themself. During the time of the investigation upon record review, LPA observed the April 2023 PAL Approach Chart and Service Plan, R1 received assistance for incontinent care every (02) hours or as needed for toileting and catheter continence each shift. Based on interviews, observations, and record review there is not enough corroborating evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

#2. Staff do not ensure resident's showering needs are met.

It is alleged that resident #1 (R1) hasn't bathed in 2 years. LPA conducted an interview with R1 at 2:47pm when asked if they refused showers? R1 stated “I don’t remember”. LPA asked if S2 gave them a sponge bath this morning? R1 replied “they probably did, but I don’t know”. At the time of the investigation seven (07) out of eight (08) residents confirm “they receive 3 showers per week”. Interviews with staff revealed that R1 refuses showers. S2 confirm that they give R1 a sponge bath in the mornings because they refuse showers when asked by staff. During the investigation LPA observed the April 2023 PAL Approach Chart and Service Plan, R1 receives a sponge bath during the first shift, but refuses a shower during second shift. Based on interviews, observations, and record review there is not enough corroborating evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

#3. Facility has lack of water supply.

It is alleged that the facility is lacking water supply. To investigate the above allegation, LPA interviewed seven (07) out of eight (08) residents confirm they have not had any issues or disruptions with the water supply. Interviews with staff confirm they have not had any issues or disruptions with the water supply.

Continued on LIC9099C.

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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Control Number 31-AS-20230425084540

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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At the time of the investigation LPA observed (08) random bathrooms all to have a working water supply. LPA tested toilets, sinks and bathtubs all observed to be operating and functioning properly. Based on interviews, and observations there is not enough corroborating 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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