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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 04/09/2025
Date Signed: 04/09/2025 02:25:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
03/19/2024 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20240319090812
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: 122DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Nancy Nelson, Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff do not administer resident's medications as prescribed.

INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Emily Peraldi and Quoc Huynh conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 10:22 a.m., the LPAs met with staff and explained the reason for the visit. At 10:35 a.m., Executive Director (ED) Nancy Nelson met with the LPAs.

During the initial visit conducted on 3/20/2024 between 9:50 a.m. and 5:10 p.m., LPA Peraldi and LPM Heffernan conducted a physical plant tour and conducted a review of medication, medication records, policy and procedures with medication technician. During today’s visit, the LPAs conducted a physical plant tour and conducted interviews with the ED, two (2) staff and four (4) residents. Between 12:50 p.m. and 1:22 p.m., the LPAs conducted a review of medication and medication documentation with medication technician for four (4) residents. The LPAs also obtained copies of pertinent documents on both visits. Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
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-20240319090812
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE CALABASAS
FACILITY NUMBER: 197609518
VISIT DATE: 04/09/2025
NARRATIVE
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Regarding the allegation: Staff do not administer resident's medications as prescribed. On 03/19/2024, the Department received a complaint alleging staff not dispensing medications as prescribed to Resident #1 (R1). During the initial visit on 03/20/2024, starting at 2:16 p.m., LPA Peraldi conducted a review of medication and medication documentation with staff for four (4) residents and observed the following: Resident #1’s medications, Amlodipoine 5MG tab quantity 90 (1 tablet by mouth once daily) and Oxybutynin ER 5MG tab quantity 88 (1 tablet by mouth once daily) both had the fill date of 12/14/2023 and were observed to have multiple tablets remaining. During the medication review, staff could not provide a start date. However, regardless of start date and based off the date filled, if staff assisted R1 with R1’s medication as prescribed, the medication should have been finished and new bottles ordered or filled. During today’s visit, the LPAs conducted a review of medication and medication documentation with medication technicians for four (4) residents and observed no errors. Based on medication review, observation and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff do not administer resident's medications as prescribed” is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240319090812
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS
FACILITY NUMBER: 197609518
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2025
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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The ED will submit a statement of understanding of the regulation and how they will continue follow their their medication procedures.
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Based on record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R1’s self-administered medications per physician’s order which poses an immediate 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3