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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608468
Report Date: 10/25/2023
Date Signed: 10/25/2023 02:00:15 PM

Substantiated


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
10/16/2023 and conducted by Evaluator Antonia Alvizar
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20231016145549
FACILITY NAME:BELMONT VILLAGE BURBANKFACILITY NUMBER:
197608468
ADMINISTRATOR:RODRIGUEZ, MARY JANEFACILITY TYPE:
740
ADDRESS:455 E ANGELENO AVETELEPHONE:
(818) 972-2405
CITY:BURBANKSTATE: CAZIP CODE:
91501
CAPACITY:160CENSUS: 127DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Richard Pyo and Mary Jane RodriguezTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not prevent resident from eloping from the facility
Facility refused to provide resident's requested records to resident's responsible party
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Naira Margaryan and Licensing Program Analyst (LPA) Antonia Alvizar conducted an initial visit to the facility to conduct an investigation of the above noted allegations. LPM and LPA met with the Director of Resident Care Services (DRCS) Richard Pyo and explained the purpose of this visit. At 9:34 a.m. Senior Executive Director (SED), Mary Jane Rodriguez arrived and assisted during this visit.

At 9:25a.m. LPA requested copies of the facility documents. The documents included, but not limited to staff roster with contact information, work schedule, resident roster, resident #1 (R1’s) physician report, needs and service plan, reassessment, copies of unsual incident reports involving R1 and pertinent documents relevant to the investigation. At the time of visit between 9:00 a.m. – 10:00 a.m., LPM Margaryan and LPA Alvizar spoke with SED and DRCS. At 10:12a.m. LPA, LPM, DRCS and SED toured the physical plant to ensure that all exit doors were equipped with the alarm system.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
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 4
Control Number 31-AS-20231016145549
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 BURBANK
FACILITY NUMBER: 197608468
VISIT DATE: 10/25/2023
NARRATIVE
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Upon inspection, It was observed that the alarms on exit door were operational. The alarm on main entrance door was disabled between 8:00am to 8:00pm due to main entrance being monitored by the staff working at the front desk.

Staff did not prevent resident from eloping from the facility.

It is alleged that on 10/11/2023 resident #1(R1) wandered away from the facility and staff had no knowledge of R1’s elopement. The Law Enforcement found R1 on 01/12/2023 on or around 12:50am a mile and a half away from the facility. LPA, LPM and RD conducted a physical plant tour and observed that a back door leading to outside the facility was not connected to the staff.

Upon inspection, it was observed that the alarms on exit doors were operational and connected to individual monitoring device assigned to each staff. The alarm on main entrance door is disabled between 8:00am to 8:00pm due to main entrance being monitored by the staff working at the front desk. Alarm on main entrance is turned on at 8:00pm. Information received revealed that after 9:00pm, no staff is available to monitor front desk and main entrance is monitored by night shift staff through the monitoring devices.

Interviews reveal that R1 was last checked by the staff on or around 9:00pm. On or around 10:30am, more than one facility staff received a signal on their devices. However, since the main entrance is being used not only by the residents, but also by the facility staff, everyone working at night shift assumed that the alarm sound because the staff came in or left the facility. The staff on the shift were busy with other duties/tasks. By the time Night shift supervisor came down from the 3rd floor to check the door, they observed no one at the door. At 12:50am, R1’s family member called the facility to check if R1 is in the community and R1 was not present. R1 was found by the Officers from Glendale Police Department.


A review of R1’s records conducted at 10:25am revealed that R1 cannot leave facility unassisted.
Based on inspection, observation, interviews, and record review there is a sufficient information to verify the allegation. Therefore, the allegation is Substantiated at this time.

Facility refused to provide resident's requested records to resident's responsible party.

It is alleged that R1 POA requested the R1’s records, and the facility refused to provide them in timely manner.

Continue LIC9099c

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20231016145549
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 BURBANK
FACILITY NUMBER: 197608468
VISIT DATE: 10/25/2023
NARRATIVE
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At the time of visit between 9:00 a.m. – 10:00 a.m., LPM Margaryan and LPA Alvizar spoke with SDE and DRCS. Interviews reveal that on 10/12/2023 on or around 2:30pm, R1’s responsible person requested residents records and were not provided to them. The first contact from the facility related to R1’s record was made on 10/19/2023 by DRCS via email.

Information revealed during this investigation verifies that R1’s records were not provided to their responsible party in timely manner. Therefore, the allegation is Substantiated at this time.


Under Title 22, Division 6, Chapter 8, following citations were issued and recorded on LIC9099D.

No other health and safety hazard is noted during this visit.
Exit interview is conducted and a copy of report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20231016145549
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 BURBANK
FACILITY NUMBER: 197608468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
87705(k)(8)
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87705 Care of Persons with Dementia, (k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates: (8) Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care
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Within 24 hours the Licensee will provide a written plan of action explaining the steps they will follow providing health and safety measures of dementia residents. Including the measures taken to ensure that Dementia resident can not leave the facility unassisted
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& supervision... of all residents who leave the facility. This requirement is not met as evidenced by. The Licensee did not ensure to provide required assistance to R1 who was not able to leave facility unassisted. This poses an immediate health and safety risk to residents in care.
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Type B
11/01/2023
Section Cited
CCR
87468.2(a)(19)(2)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities.
(a) In addition to the rights listed in Section 87468.1,Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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The Licensee will provide a written plan of action explaining the steps they will follow
to provide residents records in a timely manner.
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(19)To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.
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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: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4