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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608467
Report Date: 06/27/2022
Date Signed: 06/27/2022 03:31:21 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2020 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 31-AS-20200117130958
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: 80DATE:
06/27/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Allyson YoungTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Facility staff sexually abused Resident #1 (R1)
Uncleared adult working in the facility
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation to deliver the findings for the above noted allegations. The initial visit was conducted 01/17/2020 by LPA Brian Balisi. Today, the LPA met with Allyson Young and explained the reason for the visit.

On 01/17/2020, the Department received a complaint in which it was alleged that Resident #1 (R1) was sexually abused by Staff #1 (S1). At 3:00 p.m. that day, LPA Brian Balisi conducted the initial complaint visit and toured the facility with Building Engineer, Deborah Kroeplin. Between 3:00p.m. – 4:30p.m., the LPA interviewed facility staff and reviewed and obtained copies of pertinent documents relevant to the investigation.

A subsequent visit was conducted by LPA Balisi on 01/21/2020. Between 12:23p.m. – 3:30p.m., the LPA conducted additional interviews with facility staff, and reviewed and obtained documents relevant to the investigation. On 3/16/2022 between 8:30a.m. – 2:00p.m.,
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 31-AS-20200117130958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BELMONT VILLAGE HOLLYWOOD
FACILITY NUMBER: 197608467
VISIT DATE: 06/27/2022
NARRATIVE
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Continued from 9099
LPA conducted a second subsequent visit; at which time, LPA conducted interviews with additional staff, former staff and a family member of R1. LPA also reviewed and obtained copies of additional documents pertinent to the investigation.

On 03/23/2022, the case was referred to Community Care Licensing Divisions Investigations Branch (IB) to obtain the forensic exam results and police report pertaining to R1. On 04/08/2022, IB Investigator Sonia Sandoval received and reviewed forensic exam records from the Rape Treatment Center. Moreover, on 05/03/2022, IB Investigator Sonia Sandoval received and reviewed police report from Los Angeles Police Department (LAPD). After numerous attempts 1/21/2020 at 2:30pm , 3/16/2022 at 1:30pm, 4/21/2022 at 4:30pm, 4/23/2022 at 3pm,to contact S1, on 05/27/2022, between 2:30p.m. and 4:00p.m., LPA interviewed S1.


Information gathered during the course of the investigation revealed that no current or former staff has ever witnessed S1 sexually abuse R1. The IB investigator’s review of the forensic exam records from the Rape Treatment Center revealed that on 04/05/2019, a forensic exam was conducted on R1, which resulted in no positive findings that a rape had occurred. Interview with a family member of R1 revealed that R1 was admitted into the hospital on approximately 04/05/2019, for an infection in their private area. The family member stated that hospital staff informed them that there was no physical evidence, such as abrasions or tissue damage on R1, to indicate that sexual abuse had occurred. Furthermore, hospital discharge records revealed there was not enough evidence to confirm that sexual abuse had occurred.
Belmont Village Hollywood management, which included Executive Director and Human Resources conducted an internal investigation, which included interviewing sixteen (16) staff members who had worked with S1 and R1. Per records reviewed, facility internal investigation concluded on 04/19/2019. Additionally, a review of the internal investigation revealed that S1 denied all allegations of sexual abuse against R1. Based on all information gathered during the internal investigation facility was unable to substantiate the allegation.
Furthermore, the IB Investigator’s review of LAPD police report revealed that R1 was unresponsive to LAPD officer’s questions during their investigation. The LAPD officer was informed by R1’s family member that due to R1’s diagnosis, R1 did not respond to anyone. The family member further revealed to the officer that R1 was admitted to the hospital due to an unusual discharge from R1’s private area. The report also indicated that approximately four (4) months ago, R1 was experiencing the same unusual discharge and treated for an infection.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 31-AS-20200117130958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BELMONT VILLAGE HOLLYWOOD
FACILITY NUMBER: 197608467
VISIT DATE: 06/27/2022
NARRATIVE
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Continued from 9099-C
S1 denied any sexual abuse had occurred with R1 while S1 was employed at this facility. Furthermore, S1 denied ever assisting R1 with the lights turned off in R1s room, and also denied ever being witnessed by any staff member, assisting R1 with the lights turned off in R1s room. Additionally, S1 provided a signed declaration denying any wrongdoing or sexual abuse against R1. Based on the information gathered during the course of the investigation, the Department does not have sufficient evidence to support the allegation that R1 was sexually abused by S1. Therefore, the above allegation has been deemed UNSUBSTANTIATED at this time.

It was also alleged that there were two (2) staff who lacked a criminal record clearance and association to the facility that were working in the facility. The LPA’s record review of the employee files for S1 and Staff #2 (S2), revealed that both employees were cleared and associated to work at the facility, at the time of the investigation. The LPA record review of the Facility Personnel Report revealed that personal identifying information such as Date of Birth, Driver’s License and Social Security number for S1 and S2 matched what facility had on file for each employee. The LPA’s interviews with current and former staff revealed that S1 was the only employee with the name mentioned as an uncleared adult. Based on the interviews and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegation that there are ‘Uncleared Adult(s) working in the facility’. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2020 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 31-AS-20200117130958

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: 80DATE:
06/27/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Allyson Young TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Facility staff failed to meet reporting requirements
Facility staff failed to seek resident timely medical attention
Facility failed to protect resident from harm
INVESTIGATION FINDINGS:
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3
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5
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7
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10
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13
Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint investigation to deliver findings for the above allegations. The initial visit was conducted 01/17/2020 by LPA Brian Balisi. Today LPA met with Allyson Young and explained the reason for the visit.
On 01/17/2020, the Department received a complaint which alleged that facility failed to meet reporting requirements. It was reported that facility failed to report a suspected sexual abuse/inappropriate behavior by Staff #1 (S1) to Resident #1 (R1). At 3:00 p.m. that day, LPA Brian Balisi conducted the initial complaint visit and toured the facility with Building Engineer, Deborah Kroeplin. Between 3:00pm – 4:30pm, the LPA interviewed facility staff and reviewed and obtained copies of pertinent documents relevant to the investigation.

A subsequent visit was conducted by LPA Balisi on 01/21/2020. Between 12:23p.m. – 3:30p.m., the LPA conducted additional interviews with facility staff, and reviewed and obtained documents relevant to the investigation. On 3/16/2022 between 8:30a.m. – 2:00p.m.,
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 31-AS-20200117130958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BELMONT VILLAGE HOLLYWOOD
FACILITY NUMBER: 197608467
VISIT DATE: 06/27/2022
NARRATIVE
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Continued from 9099
LPA conducted a second subsequent visit; at which time, LPA conducted interviews with additional staff, former staff and a family member of R1. LPA also reviewed and obtained copies of additional documents pertinent to the investigation.

Information gathered during the course of the investigation revealed that the first suspected sexual abuse/inappropriate behavior by Staff #1 (S1) was reported to the facility management on 06/29/2018. Additionally, a second allegation of sexual abuse/inappropriate behavior was reported on 10/04/2018. Records reviewed and interviews conducted revealed that the facility conducted an internal investigation regarding the alleged incidents between 06/29/2018 and 07/03/2018. However, facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) or Suspected Dependent Adult/Elder Abuse form (SOC341) to the all appropriate agencies for either of the above incidents. Based on all information gathered, the above allegation, “facility failed to meet reporting requirements” is deemed SUBSTANTIATED at this time.

It was further alleged that facility staff failed to seek resident timely medical attention. It was reported that facility failed to obtain appropriate medical attention after the initial suspected sexual abuse allegation. Interviews conducted and records reviewed did not reveal any evidence that R1 was evaluated by any medical professional after the suspicions that R1 may have been sexually abused. Based on interviews and documentation obtained and reviewed, the Department has sufficient evidence to support the above allegation. Therefore, the above allegation that, ‘Facility staff failed to seek resident timely medical attention’ has been deemed SUBSTANTIATED at this time.

It was further alleged that the facility failed to protect resident from harm. It was reported that after the suspected concerns regarding inappropriate behaviors was reported, management continued to let S1 assist R1. Information gathered during the course of the investigation revealed that concerns of possible sexual abuse/inappropriate behaviors was initially reported on 06/29/2018.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 31-AS-20200117130958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BELMONT VILLAGE HOLLYWOOD
FACILITY NUMBER: 197608467
VISIT DATE: 06/27/2022
NARRATIVE
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Continued from 9099-C

Records reviewed and interviews conducted revealed that the facility conducted an internal investigation regarding the alleged incidents between 06/29/2018 and 07/03/2018. The internal investigation conducted reflected that there was no indication that S1 was spending inappropriate time with any resident. However, management was to continue monitoring S1.

A second allegation of sexual abuse/inappropriate behavior towards R1 by S1 was reported to management on 10/04/2018. Information gathered during the course of the investigation revealed that S1 was never reassigned to a different department, even though there was an allegation of sexual abuse/inappropriate behavior towards R1 by S1 on two different occasions. Furthermore, review of the employee file for S1 revealed that S1’s last day of onsite was 03/31/2019. Facility “Daily Check-in” logs further revealed that S1 was providing care and supervision to R1 up to 03/31/2019, which was nine months after the initial allegations. LPA interview with Executive Director revealed S1 was suspended on 4/5/2019, as the facility conducted an internal investigation for the sexual abuse allegation. Interview further revealed that S1 did not return to work for this facility at the conclusion of their investigation. Based on the information gathered, the Department does have sufficient evidence to support the above allegations. Therefore, the allegations that “facility failed to protect resident from harm” has been deemed SUBSTANTIATED at this time.

Citations issued (please see 9099-D), appeal rights given, exit interview conducted. Report issued and sent via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 31-AS-20200117130958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BELMONT VILLAGE HOLLYWOOD
FACILITY NUMBER: 197608467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2022
Section Cited
CCR
87211(c)
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87211(c) Reporting Requirements. Any suspected physical abuse that does not result in serious bodily injury... shall be reported...within twenty-four (24) hours.

This requirement is not met as evidenced by:
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Licensee will review 87211 Reporting Requirements. Submit memo of understanding regarding reporting requirements, including Mandated Reporting, to CCL via email by COB 06/28/2022.
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Based on record review, the licensee did not comply with the section cited above, as staff did not fulfill reporting requirements to appropriate parties, including Mandated Reporter requirements by reporting suspected abuse, which poses an immediate health and safety risk to residents in care.
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Type B
07/01/2022
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care. The Licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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Licensee will review 87465(a)(1) Incidental Medical and Dental Care. Submit memo of understanding regarding reporting requirements to CCL via email by COB 07/01/2022.
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Based on interviews and record review, the licensee did not comply with the section cited above as Licensee did not arrange or assist in arranging for R1 to receive a medical examination after there were suspicions of sexual abuse, which poses as a potential health and safety risk 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 31-AS-20200117130958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BELMONT VILLAGE HOLLYWOOD
FACILITY NUMBER: 197608467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2022
Section Cited
CCR
87468.1(3)
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87468.1(3) Personal Rights of Residents in All Facilities. To be free from punishment, humiliation...interfering with daily living functions such as eating, sleeping, or elimination.
This requirement is not met as evidenced by:
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Licensee will review 87468.1(3) Personal Rights of Residents in All Facilities. Submit memo of understanding regarding reporting requirements to CCL via email by COB 07/01/2022.
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Based on interviews and record review, the licensee did not comply with the section cited above, as R1 was suspected to have been the victim of sexual abuse / inappropriate behaviors by S1 in 06/29/2018 , but S1 was still allowed to provide care and supervision towards R1 up until termination on 03/31/2019, which poses a potential health and safety risk 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8