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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608467
Report Date: 06/22/2021
Date Signed: 06/23/2021 08:49:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOLLYWOODFACILITY NUMBER:
197608467
ADMINISTRATOR:YOUNG, ALLYSON LFACILITY TYPE:
740
ADDRESS:2051 N HIGHLAND AVETELEPHONE:
(323) 874-7711
CITY:LOS ANGELESSTATE: CAZIP CODE:
90068
CAPACITY:150CENSUS: 74DATE:
06/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:17 PM
MET WITH:Adriana Sais - Resident Care DirectorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Gary Tan, LaQueena Lacy and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management follow up visit regarding the incident occurred 03/31/2021.

Woodland Hills South Adult and Senior Care Regional Office (WHASCRO) received an incident report involving the facility resident #1 (R1). As per Incident report on 03/31/2021, R1 fell and injured R1’s Right Shoulder. Subsequently R1 required hospitalization and had a surgery, as the fall resulted fractured clavicle and humerous.

On 04/09/2021 the incident was investigated by the case carrying LPA. LPA investigation included interviewing residents, staff, and other relevant parties, reviewing R1's facility file, medical records and other relevant documents. Investigation revealed that on 03/31/2021 on or after 5:30pm, facility staff #1 (S1) went to assist R1 and observed R1's hands and face covered with feces. Before transferring R1 from the wheelchair to bed to clean R1, S1 left R1 on the wheelchair, removed footrests and walked out from the room to ask for assistance. By the time S1 returned, R1 was on the floor laying on right shoulder parallel to the bed. S1 pulled R1 from the floor and assisted R1 back to bed by lifting and holding R1 under R1's arms. As per medical professionals interviewed during investigation, lifting and holding R1 under R1 arms could contribute to the injuries resulted from fall.

At the time of this visit at 3:30 PM, LPAs explained the findings to the Resident Care Services Director.


(continued on LIC 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/22/2021
NARRATIVE
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(continued from LIC 809)

Based on interviews, inspection, observation and record review, it was concluded that:

1. R1 fell due to being left untended on the wheelchair with no footrest, while staff went to ask for assistance.

2. R1 was not assessed for pain prior to moving them from the floor to bed.

3. R1 complained of pain after staff lifted R1 from the floor and assisted back to bed by pulling and holding R1 under R1's arms.

Details of investigation was documented on previous Licensing visit conducted on 04/09/2021 at which time, the Executive Director (ED) was informed that all noted deficiencies will be cited and immediate $500.00 civil penalty will be issued to the facility. In addition, ED was informed that upon further analysis conducted by the department, an additional civil penalty might be assessed, based on Health and Safety Code 1548.

Under Title 22, Division 6, Chapter 8, following deficiencies were cited and recorded on LIC 809 D

Exit interview conducted. A copy of the report was issued. Appeal rights provided.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2021
Section Cited

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A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing basic services specified below...
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This requirement is not met as evidenced by:

Based on interviews and record review
the Licensee did not ensure that the resident was supervised as required. R1 fail and sustained of injuries due to being left unattended. This poses an immediate health and safety hazard to residents in care.
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Type A
06/24/2021
Section Cited

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Basic services shall at a minimum include: (1) Care and supervision; as per H & S Code 1569.2(c). the facility assumes responsibility for or provides ongoing assistance with activities of daily living without which the resident’s … health, safety, or welfare would be endangered.
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This requirement is not met as evidenced by:

Based on interviews and record review the licensee did not provide required assistance to the resident after the fall. This poses an immediate health and safety hazard to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2021
LIC809 (FAS) - (06/04)
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