197609518-10-24-2024-29-AS-KBUY-DAJQKA-20241030121401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 10/24/2024
Date Signed: 10/24/2024 04:30:00 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
03/25/2024 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20240325102029

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: 133	DATE:	10/24/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Nancy Nelson		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Facility illegally evicted a resident in care.
Facility did not issue a refund to a resident in care.

INVESTIGATION FINDINGS:

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On 10/24/2024, Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation visit to deliver final findings for the above allegations. During this visit, LPA met with Executive Director (ED) Nancy Nelson and explained the reason for the visit.

On the allegation: Facility illegally evicted a resident in care. It is alleged that after Resident #1 (R1) was physically combative with staff due to R1’s cognitive decline, they were taken to a Psychiatric hospital beginning 01/28/2024. After being at the psychiatric hospital for a few days, R1’s responsible party was contacted by the facility who stated that after evaluation/reappraisal of R1, they could not return to the facility. R1’s responsible party moved their belongings out of the facility on 02/25/2024 and notified the ED. According to the allegation, the facility never provided an eviction notice to R1 and/or their responsible party.

Report 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: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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 4

Control Number 29-AS-20240325102029

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: 10/24/2024

NARRATIVE

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On 04/03/2024, LPA Chochian conducted a complaint investigation visit to the facility above from 10:00am to 11:00am. During this visit, LPA requested and received relevant documentation pertinent to the complaint allegation for record review. LPA Brian Phillips reviewed the documentation. R1’s physician report states that R1 has a primary diagnosis of Alzheimer’s dementia including the loss of cognitive functions. The documented secondary diagnosis for R1 is atypical depressive disorder with negative mood changes due to changing environments. Medical admission assessments by the facility documented that R1 was forgetful/confused with mood/personality changes. The facility admission agreement was signed and dated by the responsible party of R1 on 07/29/2022 prior to R1’s move in date of 07/31/2022. This admission agreement states that the facility can terminate the agreement upon thirty (30) days written and verbal notice to the resident/responsible party if it is determined that the resident has a need not previously identified and a reappraisal has been conducted with the determination that the facility is no longer appropriate. The admission agreement states that the facility is not designed or licensed to provide higher levels of care for serious mental or emotional disorders. If it is determined a resident is a danger to themselves or others and it is inappropriate for a resident remain in their apartment, then they will be asked to leave the facility and the admission agreement will terminate. The facility may discharge a resident if they present an immediate physical threat or danger to themselves or others. A resident may also be discharged if their dementia/mental disorder results in ongoing behavior that requires care and supervision greater than the facility can provide. Interview and documentation provided by Executive Director revealed that on 01/25/2024 the facility held a meeting with R1’s family to discuss R1’s changes in behaviors and possible evaluation for R1’s changing medical condition. R1’s doctor then ordered R1 to be admitted to a psychiatric hospital for further evaluation. On 01/28/2024, R1’s family, who had been in communication with R1’s doctors, indicated a bed was open in the hospital unit and R1’s family took R1 to the psychiatric hospital for a 14-day time period. All licensing agency interviews with facility staff and the responsible party of R1 indicated that the resident would not be returning to the facility after R1 was evaluated/reappraised while in the psychiatric hospital. Although Reporting Party indicated it was the facility that did not allow the resident to return, the Executive Director provided documentation and notes indicating the hospital social worker suggested to R1’s family discharging R1 to a Skilled Nursing Facility (SNF) for further medication adjustments with a doctor onsite. On February 10, 2024, R1’s family member verbally told the facility R1 would likely not be returning to the facility. R1’s family member then began removing R1’s personal belongings from the facility on 02/20/2024. R1’s family member reported to the facility on 02/23/2024 that R1 was discharged to a SNF. On 02/29/2024, R1’s family
Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240325102029

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: 10/24/2024

NARRATIVE

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member confirmed R1’s room at the facility was fully vacated, thus terminating the residency contract. Although R1 did not return to the facility following a stay at the psychiatric hospital, it is unclear whether the facility refused the resident to return or if the family and/or hospital social worker made the decision for R1 not to return. R1 was discharged to a SNF, which is a level of care the facility cannot provide per Title 22 regulations.

Based on the information gathered, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “facility illegally evicted a resident in care” is deemed UNSUBSTANTIATED at this time.

On the allegation: Facility did not issue a refund to a resident in care. It is alleged that R1 had their personal belongings removed from the facility on 02/25/2024 after being in a psychiatric hospital beginning on 01/28/2024. The allegation requests a refund for the days R1 was out of the facility from 01/28/2024 to 02/25/2024, with the resident not returning to the facility.

LPA requested and received a copy of the documented facility residence and services agreement/admission agreement. The facility admission agreement was signed and dated by the responsible party of R1 on 07/29/2022. The facility admission agreement has a refund policy regarding the vacating of an apartment, and the refund of unused portion of monthly fee. The monthly fee is defined in the admission agreement as total combination fee of apartment fees and service plan fees. Supplemental support services/additional services are offered for an additional fee. According to the facility admission agreement signed/dated by the responsible party of R1, the facility fees did not include any additional/supplemental support services for R1 while in care. The monthly fee charged to R1 was the combined apartment fee and the service plan fee. If the admission agreement is terminated, the resident must vacate the apartment and remove all property from it. The resident or their responsible party will remain liable for the monthly fee until the effective termination date and all the resident’s property is removed from their apartment, whichever occurs later. The facility may also charge a resident a property storage fee if they fail to remove their personal belongings by the effective termination date. Following the termination of the admission agreement, the facility will pay the resident or their responsible party a refund equal to any amount owed, minus certain conditions including any expenses
incurred to store resident’s property that was not removed upon vacating the apartment. According to the
facility admission agreement, R1 is liable for the monthly facility fee until all R1’s property is removed from

Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240325102029

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: 10/24/2024

NARRATIVE

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their apartment, as that occurred later than the effective termination date. All licensing agency interviews with facility staff and the responsible party of R1 indicated that the resident would not be returning to the facility following R1's stay in a psychiatric hospital beginning on 01/28/2024, but R1’s property was not removed from the facility until 02/25/2024 by their responsible party, who then notified the facility on 02/29/2024 that all R1’s personal belongings were out of their apartment. Therefore, R1’s responsible party is liable for R1’s monthly fee until 02/29/2024 and the facility is not required to issue a refund for the days R1 was out of the facility from 01/28/2024 to the date R1's belongings were removed. However, LPA Dulek was informed during the subsequent complaint visit that the facility chose to issue a refund to R1's responsible party, which was issued sometime toward the end April or beginning of May 2024.

Based on the information gathered, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “facility did not issue a refund to a resident in care” is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. Copy of today's 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: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC9099 (FAS) - (06/04)

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