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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 01/02/2025
Date Signed: 01/02/2025 11:04:49 AM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2024 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20240301140339
FACILITY NAME:BELMONT VILLAGE CALABASASFACILITY NUMBER:
197609518
ADMINISTRATOR:NELSON, NANCYFACILITY TYPE:
740
ADDRESS:24141 VENTURA BLVDTELEPHONE:
(818) 222-2600
CITY:CALABASASSTATE: CAZIP CODE:
91302
CAPACITY:165CENSUS: 128DATE:
01/02/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Diana AlvaradoTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not meet a resident's laundry needs.
Staff falsified a resident's care documents.
Staff did not ensure that a resident's room was free of trash.
Staff did not prevent residents' from playing in their feces.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 03/05/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Director of Resident Care Services, Diana Alvarado . Entrance interview.

During the initial visit on 03/05/2024, LPA Arroyo conducted a plant tour at 10:30AM, toured the Neighborhood (Memory Care) and observed five (5) random resident bedrooms starting at 10:33AM, conducted interviews with the ED, six (6) staff members, and three (3) residents between 9:55AM and 2:40PM, conducted a file review at 11:30AM, and obtained copies of pertinent documents.

Report Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
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 3
Control Number 29-AS-20240301140339
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE CALABASAS
FACILITY NUMBER: 197609518
VISIT DATE: 01/02/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff did not meet a resident’s laundry needs and staff did not ensure that a resident’s room was free of trash. It was reported that a resident was wearing wet clothes, blankets appeared wet, and the laundry hamper was full of soaking wet clothes. Additionally, the wastebasket in the resident’s room bathroom was full and had not been emptied. During a walkthrough on 03/05/2024, the LPA observed five (5) random resident rooms in the Neighborhood. The rooms appeared relatively clean, linens were not soiled, or wet, dirty laundry was observed in the hamper, and trash cans were not overflowing. Record review and interviews conducted revealed that housekeeping is scheduled at least once a week for each bedroom in memory care. Staff members stated that they are assigned a group of residents to care for daily, and some of their duties include cleaning and maintaining the residents' rooms and doing their laundry. Staff also mentioned that resident bedding is typically changed every few days but will be changed sooner if needed. Interviews further revealed that staff are responsible for taking out the trash; however, any shift can handle taking out the trash as it is included in their assignments. Additionally, interviews with residents corroborated staff statements, as residents confirmed that staff maintain their rooms clean. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “staff did not meet a resident’s laundry needs” and “staff did not ensure that a resident’s room was free of trash”. Therefore, these allegations are deemed Unsubstantiated at this time.

It was also alleged that staff falsified a resident’s care documents. It was reported that staff are signing off on completing tasks and caring for residents needs when in fact they have not. Interviews with staff revealed that each team member is assigned specific duties to complete while caring for the residents on a daily basis. Staff sign off after each task is completed to inform the next shift about what still needs to be taken care of. During shift changes, staff typically communicate with one another about tasks that are still pending for the day. Staff mentioned that during crossover, they inform the incoming team if any laundry or cleaning is still required for their assigned residents. Additionally, staff reported that there have been no issues with other shifts failing to complete the tasks assigned to them. Based on interviews conducted with staff, the Department has insufficient evidence to support the allegation of “staff falsified a resident’s care documents”. Therefore, this allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240301140339
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE CALABASAS
FACILITY NUMBER: 197609518
VISIT DATE: 01/02/2025
NARRATIVE
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Report Continued from LIC 9099C...

It was further alleged that staff did not prevent resident’s from playing in their feces. It was reported that due to lack of staff, residents were left unattended which resulted in residents playing in their feces. Interviews conducted with staff revealed that incontinent residents are typically changed every two (2) hours or sooner if needed. Staff stated that they have never witnessed or encountered any residents playing with their feces. However, there have been occasions when a resident has placed their hand in their pants, resulting in their hand being covered in feces. Despite this, staff have never observed the resident playing with or smearing the feces. Staff reported that they wash the resident's hands and change them, unless the situation is more severe, in which case they will give the resident a shower to ensure they are thoroughly cleaned. Based on interviews conducted, the Department has insufficient evidence to support the allegation of “staff did not prevent resident’s from playing in their feces”. Therefore, this allegation is deemed Unsubstantiated at this time.

No citations issued. Exit interview conducted. Report was reviewed and copy issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3