<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 08/04/2026
Date Signed: 08/04/2026 04:40:55 PM

Substantiated


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
07/31/2026 and conducted by Evaluator Angela Barutyan
COMPLAINT CONTROL NUMBER: 29-AS-20260731104916
FACILITY NAME:BELMONT VILLAGE CALABASASFACILITY NUMBER:
197609518
ADMINISTRATOR:CYNTHIA DRACHENBERGFACILITY TYPE:
740
ADDRESS:24141 VENTURA BLVDTELEPHONE:
(818) 222-2600
CITY:CALABASASSTATE: CAZIP CODE:
91302
CAPACITY:165CENSUS: 131DATE:
08/04/2026
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Cyntia DrachenbergTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff incorrectly administered medication to resident resulting in hospitalization
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 11:20AM. LPA was greeted by staff and met with Executive Director (ED) Cyntia Drachenberg. Entrance interview conducted.

During today's visit, LPA conducted interviews with three (3) staff members, one (1) visitor, and attempted an interview with one (1) resident between 11:29AM-01:10PM, conducted a brief physical plant tour between 12:49PM-01:15PM, and reviewed and obtained copies of pertinent documents.

REPORT CONTINUED ON LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
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 3
Control Number 29-AS-20260731104916
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: 08/04/2026
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
It was alleged that Resident #1 (R1) was accidentally administered incorrect medications by facility staff, resulting in hospitalization. The Department received an incident report on 07/28/2026 documenting that on 07/28/2026 around 10:15AM, R1 “was administered incorrect medication by medication technician. Resident remained vitally stable” and vomited around 10:50AM, after which paramedics were called. Resident was admitted to the hospital with a final diagnosis of acute hypoxia, accidental medication error, and bradycardia (slow heart rate). Interviews with (3) staff members confirmed that R1 was mistakenly administered all ten (10) morning medications prescribed to Resident #2 (R2) by Staff #1 (S1), instead of R1’s prescribed medications. The medications administered to R1 included alprazolam 0.25mg (Xanax), amlodipine 2.5mg, atorvastatin 20mg, escitalopram 20mg, gabapentin 400mg, lamotrigine 250mg, lamotrigine 50mg, memantine 28mg, omeprazole 20mg, ondansetron 8mg (Zofran). LPA reviewed R1’s medication log and did not observe any of these ten (10) medications prescribed to R1. All staff interviewed stated that the error was observed “immediately” after it was administered by S1 and paramedics were called within the hour. Staff stated that R1 was not at baseline and exhibiting increased drowsiness. LPA reviewed R1’s hospital discharge paperwork documenting diagnoses of accidental drug ingestion and bradycardia. ED Drachenberg stated that S1 redid their online trainings, got shadowed by the facility’s Licensed Vocational Nurse (LVN) for skill validation, and received a corrective action notice. ED stated that the facility’s medication administration system was updated to include new and accurate photographs of all residents to prevent administration errors due to residents looking similar to each other or different from their initial photograph taken upon admission. LPA reviewed a medication technician skills validation packet for S1 signed and dated by the facility’s LVN on 07/29/2026 confirming S1 was observed to be knowledgeable in medication management – med policy, medication management – basics, medication management – processes, medication management – pharmacy, and Accuflo (the facility’s medication administration record system). LPA also observed a one hour online training completed by S1 on 07/29/2026 with the course title, “Accuflo (eMAR: Assisted Living Medication Management Software). LPA attempted an interview with R1 and observed no immediate health and safety concerns. Based on interview and record review, the allegation “Staff incorrectly administered medication to resident resulting in hospitalization” is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties.



Exit interview conducted. Appeal rights and a copy of the report were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20260731104916
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2026
Section Cited
CCR
87465(h)(4)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:
(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated that S1 will complete 8 hours of additional medication training and submit proof to CCLD by the due date.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the section cited as R1 was administered another residents’ medications by S1 which posed an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3