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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 04:39:02 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
10/28/2024 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20241028122537
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:
11:30 AM
MET WITH:Diana Alvarado, Director of Resident Care ServicesTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is charging resident for services not received.
Staff did not accord resident privacy.
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 visit was discussed.

On 10/28/2024, the Department received the above listed allegations. On 10/30/2024, Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit. From approximately 11am- 2pm, LPA conducted interview with ten (10) randomly selected residents including resident #1. From approximately 2pm-3pm, LPA reviewed R1’s records and conducted interview with staff.

Following is a summary of the allegations and finding: Regarding allegation - Facility is charging resident for services not received: Information was received that R1 was hospitalized in 9/2024; when R1 returned to the community it was suggested that R1 hire a private aide for temporary assistance which would be less expensive than what the facility would charge for additional services. (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-20241028122537
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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R1 paid approximately $280 a day for the private aide. It was reported that R1 also received a billed from the facility for two months rent which included charges for additional services. According to R1 the additional services facility was charging was provided by the private aides which was already paid.
It was confirmed through interviews and records review that R1 was charged/billed in error for additional services not rendered. R1 and ED confirmed that a credit was issued for the additional service charges.
Based on the information obtained through record review and interviews; the allegations “Facility is charging resident for services not received”, is deemed substantiated at this time.

Regarding allegation: Staff did not accord resident privacy:
Information was provided that while R1 was on an outing, facility staff entered R1's room and took all medications (OTC, prescribed, and vitamins). To investigate this allegation, LPA conducted interview with R1, staff and reviewed records. Interviews revealed that R1 was hospitalized temporarily in 9/2024 due to a medication error. Records reviewed revealed that R1 was able to store and handle own medications. Staff confirmed that they entered R1’s room when R1 was not home and removed all medications. Staff expressed that for safety reasons it was the only solution at the time as a result of R1 mismanaging medication.

Based on the information obtained through record review and interviews; the allegation “Staff did not accord resident privacy”, is deemed substantiated at this time.


Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies are cited (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were 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: 2 of 5
Control Number 29-AS-20241028122537
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)(1)
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Personal Rights of Residents in All Facilities:(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. 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 Personal Rights of Residents.
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Based on interviews conducted, licensee did not comply with above section cited.
Staff went into resident's room without prior permission and removed resident #1's medications.
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Type B
05/30/2025
Section Cited
CCR
87507(f)
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The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
This requirement is not met as evidence by:
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Executive Director shall provide evidence that the billing errors have been resolved. Also include a statement of future compliance plan.
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Based on records review and interviews, licensee did not comply with section cited above. R1 was billed for services not provided by facility staff.
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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
10/28/2024 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20241028122537

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:
11:30 AM
MET WITH:Diana Alvarado, Director of Resident Care ServicesTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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2
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Staff did not ensuring that resident is provided their medication(s) as prescribed.
Staff are not following resident's physician order.
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 Diana Alvarado, Director of Resident Care Services and explained the reason for the visit.

On 10/28/2024, the Department received the above listed allegations. On 10/30/2024, Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit. From approximately 11am- 2pm, LPA conducted interview with ten (10) randomly selected residents including resident #1. From approximately 2pm-3pm, LPA reviewed R1’s records and conducted interview with staff.

Following is a summary of the allegations and finding:

Regarding allegation - Staff did not ensuring that resident is provided their medication(s) as prescribed:
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-20241028122537
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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Information was received that on 10/27/2024 the facility ran out of R1's prescription for Percocet, which R1 had to take daily for pain. Apparently, staff had not re-ordered the medication on time and R1 had to go all day without pain medication because the pharmacy uses a system called "Guardian" and the medications are only delivered in the evening.

Interview with staff and records review confirmed that the medication in question was a narcotic and needed an order form the doctor for staff to send out for refill.

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 allegation “Staff did not ensure that resident is provided their medication(s) as prescribed” is deemed unsubstantiated at this time.

Regarding allegation: Staff are not following resident's physician order: Information was received that facility refused to follow order from R1’s primary care physician stating that R1 can store and administer OTC and vitamins. Staff interviewed stated that the physician order was received in the evening on 10/21/2024, however a new physician report was required therefore until that was completed and returned medication was held. Staff reported that the OTC and vitamins was returned to R1 when the physician report was completed by the primary doctor in 11/2024. Random residents interviewed reported no issues with facility medication management.

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 allegation “Staff are not following resident's physician order” is deemed unsubstantiated at this time.


Exit interview held. Copy of the 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