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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 05/18/2025
Date Signed: 05/27/2025 04:34:49 PM

Substantiated


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
01/17/2025 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20250117145754
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: 114DATE:
05/18/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Diana Alvarado, Director of Resident Care ServicesTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not ensure resident had their oxygen when out of room
Staff did not safeguard resident's personal belongings
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 the Director of Resident Care services Diana Alvarado and reason for the visit was discussed.

On 01/17/2025, the Department received the above listed allegations. On 01/24/2025, Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit. From approximately 11am- 1:45pm LPA and Mrs. Alvarado toured the facility common areas and resident rooms. Interviews were conducted during the tour with 6 (six) randomly selected residents and 2 (two) other potential witnesses. On 02/19/2025, during a subsequent complaint visit for another complaint, LPA Chochian reviewed resident records and interviewed six (6) staff members.

Following is a summary of the allegations and finding:
(Continue to LIC9099c)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025
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 5
Control Number 29-AS-20250117145754
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: 05/18/2025
NARRATIVE
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Regarding allegations - Staff did not ensure resident had their oxygen when out of room and Staff did not safeguard resident's personal belongings: Information was received that Resident #1 (R1) was not on continuous oxygen from approximately 01/09/2025 – 01/17/2025. According to the reporting party the facility evacuated on 01/09/2025 due to the Kenneth fire and R1’s portable oxygen was lost. Staff did not ensure R1 was on continuous oxygen. R1 went to a hair appointment without a supply of oxygen.

It was confirmed through interviews and records review that there is an order on file from R1’s physician that R1 requires continues (24 hours) oxygen use. Staff interviewed confirmed that R1’s portable oxygen cord was lost during the evacuation period. Staff stated that R1 was provide with a concentrator which was used in room and when R1 would go down for meals. R1’s facility records reviewed with staff revealed that R1’s assessments/care plan did not indicate that R1 is required 24-hour oxygen use. Staff could not confirm that R1 was monitored and ensured that when R1 left the room or went out of the facility was with oxygen.

Based on the information obtained through record review and interviews; the allegations “Staff did not ensure resident had their oxygen when out of room and Staff did not safeguard resident's personal belongings”, is deemed substantiated at this time.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20250117145754
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2025
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Executive Director shall provide a plan of correction on how they will maintain future compliance with Personal Rights of Residents.
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Based on records review and interviews conducted, the licensee did not comply with the section cited above. R1 is to be on continous oxygen use. Staff did not ensure R1 was with oxygen when out the room from approximately 1/9/2025 to 1/17/2025.
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Type B
05/30/2025
Section Cited
CCR
87217(b)
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(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.
This requirement is not met as evidence by:
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Executive Director shall provide a plan of correction on how they will maintain future compliance with regards to safeguarding residents' personal property.
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Based on interviews conducted, the licensee did not comply with the section cited above. R1's portable oxygen charging cord was missing/lost.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/17/2025 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20250117145754

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: 114DATE:
05/18/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Diana Alvarado, Director of Resident Care ServicesTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
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9
Staff are not checking on resident
Staff are mismanaging resident’s medication
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 the Director of Resident Care services Diana Alvarado and reason for the visit was discussed.

On 01/17/2025, the Department received the above listed allegations. Information was received that resident is left in bed and not checked on for several hours. Information was received that resident #1 was left in bed (date unknown) until 3pm and was not checked on by staff. It was also reported that a cup of pills which did not belong to resident #1 was found in the room on or about 01/16/2025.

On 01/24/2025, Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit. From approximately 11am- 1:45pm LPA and Mrs. Alvardo toured the facility common areas and resident rooms. Interviews were conducted during the tour with 6 (six) randomly selected residents and 2 (two) other potential witnesses. (Continue to LIC9099c)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250117145754
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: 05/18/2025
NARRATIVE
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On 02/19/2025, during a subsequent complaint visit for another complaint, LPA Chochian reviewed medication records and interviewed additional staff.

Following is summary of the investigation:

On 01/24/2025, From approximately 11am- 1:45pm LPA and Mrs. Alvarado toured the facility common areas and resident rooms. Interviews were conducted during the tour with 6 (six) randomly selected residents and 2 (two) other potential witnesses. Also during the tour LPA visited the medication room and reviewed random sample centrally stored medication records with staff.

Residents interviewed reported no issues or concerns with receiving care services from staff. Resident expressed being satisfied with staff providing care and medication service. Resident #1 was out of the building during LPA’s visit therefore was unable to be interviewed at that time. LPA was able to communicate with resident #1 on 05/09/2025 however resident was not able to provide much information due to decline in health. Resident did express being satisfied with the staff at the facility. Resident was unable to recall the alleged incident related to medications being left in resident’s room. LPA conducted a sample review of the centrally stored medication records for the month of January 2025 and found no discrepancies at the time.

Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff are not checking on resident” and “Staff are mismanaging resident’s medication” is deemed unsubstantiated at this time.

Exit interview held and copy of report provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5