197609518-10-11-2024-29-AS-DPEA-DAAS92-20241022134002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 10/09/2024
Date Signed: 10/11/2024 08:40:30 PM

Unsubstantiated

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
02/20/2024 and conducted by Evaluator Valeria Conway

COMPLAINT CONTROL NUMBER: 29-AS-20240220152012

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: 132	DATE:	10/09/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Diana Alvarado		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not ensure resident was adequately fed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Valeria Conway made a subsequent complaint visit to facility to deliver complaint findings. Administrator was unavailable during today's visit, but authorized Diana Alvarado, Director of Resident Care Services to sign today's reports. LPA explained the purpose of the visit.
Entrance interview conducted.

It was alleged that the staff did not ensure resident was adequately fed, as it was reported that staff did not ensure meals were delivered to Resident #1 (R1) for several days following a physicians change in the residents dietary order.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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 2

Control Number 29-AS-20240220152012

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: 10/09/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 9099

On 02/27/2024, LPAs V. Conway and M. Arroyo conducted an initial 10-day visit. During today’s visit, the LPAs conducted a physical plant tour to ensure there are no immediate health and safety concerns at 10:58 a.m. At 11:10 a.m., the LPAs toured the Memory Care unit and observed random resident bedrooms.Between 10:20 a.m. and 2:15 p.m., the LPAs conducted interviews with the ED, three (3) staff, five (5) residents including R1, and two (2) private caregivers (PCG).

At 11:48 a.m., the LPAs also conducted a resident file review and obtained copies of pertinent documents relevant to the investigation. Additionally, on 08/28/2024, LPA Conway conducted additional interviews with random staff, and hospice agency staff that were providing services to R1.

Interviews conducted revealed that facility staff consistently deliver pureed food to R1. However, R1 has been refusing the meals. Interviews with hospice agency staff reflected that a new order for pureed food and nutritional drinks were sent over for R1 on 08/25/2023. On 08/26/2023, Hospice agency staff contacted the facility staff to ensure that the new dietary orders were been followed. Facility staff confirmed new orders and informed hospice staff that R1 also refused to eat the pureed food. On 08/29/2023, hospice nurse met with R1 who expressed that they did not want to eat the provided food. Hospice physician ordered nutritional drinks for R1 to ensure they receive an adequate source of nutrients during this time. This measure was intended to support R1’s nutritional needs as pat of their care plan.
Moreover, information gathered during the course of the investigation reflected that for those residents that are unable to go to the dining room, staff deliver their meals directly to the residents’ rooms three (3) times a day. Additionally, all employees have access to a board in the kitchen displaying a list of residents’ names, along with their special diets, food allergies and unit numbers. ED stated that as soon the facility receives a new physicians order for a special diet, management immediately communicate those changes to the chef, who promptly updates the meals served to the resident. Based on information gathered, the Department does not have sufficient evidence to determine that the R1 was not adequately fed.
Therefore, the above allegation “staff did not ensure resident was adequately fed" is deemed UNSUBSTANTIATED at this time.

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

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2