197609518-8-27-2024-29-AS-KHEN-D8MW2C-20240830165404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 08/27/2024
Date Signed: 08/27/2024 03:20:29 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
01/23/2024 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20240123152644

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: 139	DATE:	08/27/2024
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Nancy Nelson		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Resident sustained unexplained bruises

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegation listed above. LPA arrived at the facility at 02:05PM and was greeted by the concierge. LPA met with Executive Director (ED) Nancy Nelson at 02:13PM. Entrance interview conducted.

During today's visit, LPA interviewed staff between 02:22PM and 03:00PM. During an initial complaint visit which took place on 01/30/2024, LPA interviewed facility management at 09:26AM, toured the facility with Executive Director and Director of Resident Care Services at 11:42AM. No immediate health and safety hazards were observed during facility tour. LPA obtained copies of documents pertinent to the investigation. During an unrelated complaint investigation on 02/08/2024, LPA conducted resident interviews and discussed Resident #1 (R1) who is named in the complaint with the ED and Director of Resident Care Services. Throughout the course of the investigation, LPA reviewed pertinent documents. The following was then determined:
Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

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-20240123152644

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: 08/27/2024

NARRATIVE

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The complaint alleges that R1 sustained unexplained bruising while at the facility. Record review revealed that R1 had a diagnosis of dementia and resided in the facility's memory care unit. While residing at the facility, staff indicated that R1's dementia progressed and that R1's behaviors escalated. R1 became difficult to care for, as R1 became more aggressive with staff and refused care. Nurse's notes reviewed indicated R1 had an unwitnessed fall on 01/12/2024, which resulted in staff calling 9-1-1 and obtaining outside medical treatment for R1. Staff interviewed indicated that R1 was aggressive when EMTs arrived to take R1 to the hospital. R1 was large in stature and that 4 EMTs were observed holding R1 to the gurney while taking R1 out of the facility. Resident returned from the hospital the same day with no known injuries noted. On 01/16/2024 and 01/17/2024, bruising was noted on R1's forehead, nose and under eye. Staff notes indicate family was informed of the noted bruising. On 01/19/2024, additional bruising was noted on R1's arms, hip and back and R1 was taken to urgent care for observation of the bruising. Text messages between facility and PCP were provided to LPA indicating the bruising and request for outside medical treatment. Staff interviewed indicated that at the time of the allegation, R1 had increasing paranoia and possible hallucinations. R1 reported not trusting care staff and refused full body showering. Therefore, staff was unable to clearly observe R1 for physical changes or bruising timely, as R1 refused observation. As R1 refused observation and a full body check for injuries, it is difficult to ascertain when the bruising occurred and whether the resident was present at the facility during the time of the alleged bruising. Additionally, as the bruising was noted but of unknown origin, there is no way of knowing how the bruising occurred and whether it was a result of a lack of care and supervision at the facility. Both residents and staff interviewed indicated they have never heard of or observed any staff being rough with the residents and residents feel safe at the facility. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "resident sustained unexplained bruising" is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview was conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC9099 (FAS) - (06/04)

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