197608467-2-29-2024-31-AS-TAGD-D58NS3-20240513104228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608467
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:27:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
07/03/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230703122138

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: 87	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Janelle Topete - Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff mishandling residents medication

Staff do not ensure that resident has access to a toilet while in care.

Staff do not ensure that resident's showering needs are met while in care

Staff do not ensure that resident makes his appointments while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with Executive Director Janelle Topete and explained the reason for the visit.

LPA conducted physical plant tour at 10:02 AM, requested copy of facility documents relevant to the investigation at 10:45 AM, reviewed records from 11:00 AM to 12:00 PM and interviewed residents and staff between 12:00 PM to 1:45 PM. Regarding the allegation that Staff is mishandling resident’s medication, it was alleged that Resident #1 (R1) is not being administered medication as prescribed. LPA's record review today at 11:00 AM revealed that per the Reporting Party (RP), by R1's own admission, R1 was non-compliant with own medication. LPM Margaryan's record review on 09/14/23 of R1's medication administration record (MAR) for May and June of 2023 revealed that R1 was being administered medication as prescribed by R1's own physician. LPA's record review today between 11:00 AM to 12:00 PM also revealed that R1 was being administered medication as prescribed for the last two (2) months.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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-20230703122138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BELMONT VILLAGE HOLLYWOOD	FACILITY NUMBER: 197608467
	VISIT DATE: 02/29/2024

NARRATIVE

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(continued from LIC 9099)

LPA's interview with the Wellness Director today at 11:14 AM revealed that R1 never missed a medication but sometime refused but then turned around and took it later.

Regarding the allegation that Staff do not ensure that resident has access to a toilet while in care, it was alleged that R1 had no access to toilet. LPA's observation during physical plant tour today at 10:02 AM, revealed that R1's own apartment has its own bathroom located in own bedroom and about eight (8) to ten (10) feet away from R1's bed. LPA's interview with Executive Director today at around 11:30 AM revealed that R1 was on catheter and called on care staff to bring R1 to own bathroom to urinate without knowing that R1 had already urinated and when told about this by the staff, R1 gets agitated and yells at the staff.

Regarding the allegation that Staff do not ensure that resident's showering needs are met while in care, it was alleged that R1 does not get assistance to shower. LPM Margaryan's record review on 09/14/23 and LPA's record review today between 11:00 AM to 12:00 PM revealed that R1 is scheduled to shower three (3) times a week per care plan and admission agreement and being given showers per schedule regularly unless R1 refused. LPA's interview with staff today between 12:00 PM to 1:45 PM confirmed that R1 was being given shower regularly 3x a week but sometimes refused, depends on R1's mood.

Regarding the allegation that Staff do not ensure that resident makes his appointments while in care, it was alleged that coordination with appointments of R1 is not up to R1's standard. LPA's interview with Wellness director today at 11:14 AM, revealed that, all of R1's regular doctor's appointment is being coordinated by R1's Primary Care Physician (PCP) to the facility and the facility nurse coordinate with the facility driver to ensure that R1 make it to R1's appointment on time. LPA's record review today revealed that R1 did not miss any medical appointment as scheduled by R1's PCP.

Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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