197608468-10-13-2022-28-AS-MVAO-CLMRTF-20221129121817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608468
Report Date: 10/13/2022
Date Signed: 10/13/2022 04:05:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2022 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20220921094616

FACILITY NAME:	BELMONT VILLAGE BURBANK		FACILITY NUMBER:	197608468
ADMINISTRATOR:	RODRIGUEZ, MARY JANE		FACILITY TYPE:	740
ADDRESS:	455 E ANGELENO AVE		TELEPHONE:	(818) 972-2405
CITY:	BURBANK	STATE: CA	ZIP CODE:	91501
CAPACITY:	160	CENSUS: 131	DATE:	10/13/2022
		UNANNOUNCED	TIME BEGAN:	01:44 PM
MET WITH:	Mary Jane Rodriguez		TIME COMPLETED:	04:27 PM

ALLEGATION(S):

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Facility providing spoiled food to resident(s).

INVESTIGATION FINDINGS:

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LPA Lopez made subseqent visit and met with Administrator Mary Jane Rodriguez and discussed the purpose of the visit. Initial visit was conducted on 09/22/22.

The investigation consisted of asking for and obtaining copies of resident rooster, staff roster, and food menu, LPA interview 13 residents R1-R13 and 6 staff S1-S6 LPA toured the dining room at around 12:39PM on 9/22/22 and inspected the food freezers, refrigerators, and non-perishable food storage area with Chef Manager.

Regarding the Allegation: Facility providing spoiled food to resident(s). It is alledged that facility serves spoiled food to residents and expired milk to one resident. LPA observed the served meals and drinks at lunchtime during visit of 9/22/22 and it looked healthy and nutritious. LPA interviewed 6 staff including Chef Manager, servers, and cooks and 6/6 staff denied the allegations. LPA interviewed 13 residents and 12/13 could not collaborate the allegations. (continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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 28-AS-20220921094616

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE BURBANK	FACILITY NUMBER: 197608468
	VISIT DATE: 10/13/2022

NARRATIVE

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The alleged person who was allegedly served the expired milk does not live at facility and is not on facility rooster according to Administrator.

During inspection of the food storage area, many food items were found to be expired, but no evidence that it was ever served to residents. This is addressed in CM report. See 809 dated 10/13/2022

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of this report will be emailed due to the Executive Director/Administrator due to printer issues.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC9099 (FAS) - (06/04)

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