197608467-10-19-2023-31-AS-MVAO-D5WTNJ-20240604145249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608467
Report Date: 10/19/2023
Date Signed: 10/19/2023 02:15:25 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
10/17/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20231017141047

FACILITY NAME:	BELMONT VILLAGE HOLLYWOOD		FACILITY NUMBER:	197608467
ADMINISTRATOR:	JANELLE TOPETE		FACILITY TYPE:	740
ADDRESS:	2051 N HIGHLAND AVE		TELEPHONE:	(323) 874-7711
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90068
CAPACITY:	150	CENSUS: 86	DATE:	10/19/2023
		UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Janelle Topete - Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff are providing resident services without the resident's consent

INVESTIGATION FINDINGS:

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

LPA conducted a physical plant tour at 10:05 AM, requested copies of facility documents relevant to the investigation at 10:40 AM, interviewed staff and residents between 11:00 AM to 12:30 PM and reviewed records between 12:30 PM to 2:00 PM. It was alleged that Resident #1 (R1) has not agreed for staff to assist R1 with managing own medication and staff took all of R1's medication. LPA's record review today revealed R1 was hospitalized on 08/29/23 and was discharged to a skilled nursing facility (SNF) for rehabilitation and came back to the facility on 09/22/23. Upon re admission, R1 was assessed by the SNF physician and stated that R1 was unable to manage own medication on R1's medical assessment form (LIC 602). (continued on LIC 9099-C)

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: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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-20231017141047

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: 10/19/2023

NARRATIVE

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(continued from LIC 9099)

Further review of facility medication management assessment done also on 09/22/23, confirmed that R1 was not able to manage own medication. R1 was informed about the new assessment and the charges that went with it effective 09/22/23 and again on 10/19/23.

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC9099 (FAS) - (06/04)

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