197608467-8-22-2023-31-AS-NMAN-CV739S-20230829180336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608467
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:27:24 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
03/10/2022 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20220310132329

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:	11:25 AM
MET WITH:	Janelle Topete		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

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Resident was diagnosed at the hospital for a drug overdose.

Staff sometimes administer medications directly into the residents mouth.

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 conduct additional interviews and deliver investigative findings. LPA met with Janelle Topete and explained the purpose of the visit.

#1. Resident was diagnosed at the hospital for a drug overdose.

It is alleged that resident #1 (R1) received an overdose of an unknown substance due to R1 was found with “pinpoint pupils, and in an alerted state. To investigate the above allegation, LPA requested documents relevant to the investigation including but not limited to staff and resident rosters, Physician Report and Resident Assessment and Service Plan at 2:05pm and began interviews with staff at approximately 2:16pm on 03/11/2022. Interviews with staff #1 (S1) revealed they were not aware that R1 was alleged to have been overdosed at the facility and was not informed by anyone that it had occurred.
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-20220310132329

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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R1 was sent to the hospital when they began experiencing shortness of breath and informed staff they could not breathe. During the investigation upon record review of R1s medical report R1 admitting diagnoses to the hospital on 02/25/2022 was Acute on chronic Hypercapnic and Hypoxemic Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD) Exacerbation, and Chronic Heart Failure with Preserved Ejection Fraction (HFPEF). At the time of the investigation LPA observed R1s physician report, their primary diagnoses are HRPEF and COPD. Based on interviews, observations, and record review there is not enough corroborating evidence to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED at the time of this investigation.

#2. Staff sometimes administer medications directly into the residents mouth.

It is alleged that staff stated that sometimes medication is placed directly into the resident’s mouth and sometimes they take it on their own. To investigate the above allegation, LPA began interviews with staff at approximately 2:16PM on 03/11/2022. Additional staff and resident interviews were conducted on 08/22/2023 at 11:33am between 1:10pm. Interviews with eight (08) out of (08) residents revealed they get their medication from the medication room or staff deliver it to their rooms. They receive their medication in a small cup or by a spoon which is placed in their hands, or they take it by spoon. They affirm they have not had their medication placed in their mouth by staff and have not witnessed staff place medication into another residents mouth. Interviews with S2 affirm they have never placed medication into a resident’s mouth, and they are aware residents have the right to refuse medication. S2 stated that R1 has tremors, and they would assist R1 with medication by placing their hand under R1 hand to prevent shaking. At the time of the investigation, LPA observed medication being distributed to residents in a cup then into their hand and the resident places their medication in their mouth. Upon record review of R1 physician report R1 is not able to administer their own prescription medication, and Cedar Sinai discharge summary R1 has tremors of the jaw and hands. Based on interviews, observations, and record review there is not enough corroborating evidence to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED at the time of this investigation. 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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