197609518-3-12-2025-29-AS-KLOZ-DF3TJN-20250324144639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 03/12/2025
Date Signed: 03/12/2025 05:25:05 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, 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
03/04/2024 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20240304152506

FACILITY NAME:	BELMONT VILLAGE CALABASAS		FACILITY NUMBER:	197609518
ADMINISTRATOR:	NELSON, NANCY		FACILITY TYPE:	740
ADDRESS:	24141 VENTURA BLVD		TELEPHONE:	(818) 222-2600
CITY:	CALABASAS	STATE: CA	ZIP CODE:	91302
CAPACITY:	165	CENSUS: 122	DATE:	03/12/2025
		UNANNOUNCED	TIME BEGAN:	04:03 PM
MET WITH:	Nancy Nelson		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility failed to seek timely medical attention for resident resulting in a questionable death.
Staff inappropriately handled the residents resulting in bruising.
Staff did not provide a resident care service as agreed.
Residents sustained pressure injuries due to neglect.
Resident fell due to staff neglect.
Staff did not respond to a resident's calls for assistance.
Staff violated residents’ personal rights.
Facility retained a resident requiring a higher level of care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced subsequent complaint visit to this facility today to deliver investigation finding. LPA met with Executive Director (ED) Nancy Nelson and explained the reason for the visit.

On 03/04/2024, the Department received the above listed allegations with lack of pertinent information. On 03/07/2024, at approximately 8:30 a.m., LPA Chochian left voicemail message for the reporting party, however no return call was received. An email was also sent on 03/07/2024 to the reporting party and no response was received.

Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit on 03/07/2024 and met with the ED. Allegations were briefly discussed with ED. A toured of the facility was conducted at approximately 3:30pm to ensure there are no immediate health and safety concerns. Residents in “The Neighborhood” were unable to be interviewed due to lack of capacity. (Continue to LIC9099c)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

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 29-AS-20240304152506

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: 03/12/2025

NARRATIVE

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Staff was interviewed at approximately 4pm and facility records were reviewed. Additional attempts were made to reach the reporting party on 05/10/2024; 08/15/2024; 11/19/2024; and on 01/14/2025 but was unsuccessful.

A subsequent visit was conducted on 02/19/2025, and interviews were conducted with six (6) staff from approximately 11:30am-3:00pm; additional records pertaining to former resident (R1) were requested and reviewed; interview conducted with potential witnesses.

Following is a summary of the allegations and investigation finding:

Regarding Allegation: Facility failed to seek timely medical attention for resident resulting in a questionable death. Information was provided that resident #1 (R1) was observed showing signs of a stroke on 01/09/2024 and facility did not seek timely medical attention for R1; resident passed away within 48 hours. No additional information was provided about the resident’s questionable death identifiers. Several attempts were made to reach the reporting party to obtain additional information however no response was received.

To investigate the allegation, the LPA reviewed the Department’s database for Death Reports (LIC624 A). The LIC 624A report received in our office on 01/12/2024, indicate the manner of death to be of natural causes due to conditions contributing to death. Facility staff interviewed reported that R1 was not observed showing any signs of a stroke prior to death. R1 was admitted to Affinity Healthcare Resources on 12/30/2023. The hospice notes reflect that due to R1’s poor prognosis and declining condition, family wished to decrease hospitalization and treatment and opted for hospice care for palliative measures and symptom management. R1 was seen by the hospice nurse for routine skilled nursing and support services. Resident was placed on comfort care level of care for respiratory distress and pain; discharge summary obtained from Affinity Healthcare Resource noted resident #1’s terminal diagnosis of Athscl Heart disease of native coronary artery. On 01/11/2024, resident expired peacefully with hospice nurse and family at bedside; immediate cause of death documented as “cardiopulmonary arrest”.

Based on the information obtained through record review and interviews; the allegations “Facility failed to seek timely medical attention for resident resulting in a questionable death”, is deemed Unsubstantiated at this time. (Continue to LIC9099c)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240304152506

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: 03/12/2025

NARRATIVE

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Regarding allegations: 1) Staff inappropriately handled the residents resulting in bruising; 2) Staff did not provide a resident care service as agreed; 3) Residents sustained pressure injuries due to neglect; 4) Resident fell due to staff neglect; 5) Staff did not respond to a resident's calls for assistance; 6) Staff violated residents’ personal rights; 7) Facility retained a resident requiring a higher level of care. Reporting party was contacted several times to gather supporting information for these allegations and no response was received; no resident names or dates of alleged incidents was provided.

To investigate these allegations LPA conducted interview with facility ED and staff; toured the memory care unit and assisted living side. Residents of the “Neighborhood” were unable to be interviewed due to lack of capacity. Random interviews were conducted with residents residing in the assisted living side and other potential witnesses; no mistreatment or neglect was reported. LPA also reviewed facility incident and death reports from 11/2023 – 1/2024; no discrepancies found. ED and Director of Resident Care Services stated that facility did not retain any resident requiring higher level of care; no resident retained with pressure injury greater than stage 2.

Based on the information obtained through facility record review and interviews conducted allegations listed above are deemed Unsubstantiated at this time.

Exit interview conducted and copy of report provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC9099 (FAS) - (06/04)

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