197609518-12-20-2021-29-AS-JAPL-C9YVTF-20211223154305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 12/20/2021
Date Signed: 12/20/2021 04:30:33 PM

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
12/14/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20211214101638

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: 123	DATE:	12/20/2021
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Kelly Adair		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility is poisoning the resident
Facility is financially abusing the resident

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos arrived unannounced to conduct an initial complaint visit. The LPAs met with Kelly Adair, Director of Resident Care Services, and explained the reason for the visit. Executive Director Nancy Nelson was unavailable.

To investigate, the LPAs interviewed staff at 12:01 p.m., 12:12 p.m., 12:33 p.m., and 12:47 p.m. In addition, the LPAs reviewed pertinent documents, interviewed Resident #1 (R1) at 1:43 p.m., and interviewed R1’s conservator at 3:10 p.m.

Regarding the allegation: Facility is poisoning the resident
It was alleged that Resident #1 (R1) was being poisoned. Information obtained from an interview with R1 could not support claims that R1 was poisoned. R1 claimed that they made an off-handed comment regarding the dining options at this facility and stated that due to the level of seasoning and options, made a joke claiming that someone was trying to poison them.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211214101638

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: 12/20/2021

NARRATIVE

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Staff whom assisted R1 with dining and food service corroborated claims that R1 mentioned being 'poisoned' as a result of food choices. Yet, R1 that they received appropriate care in this facility. Staff interviews supported claims that R1 has made mentioned of being poisoned, yet R1 does not provide details as to whom is poisoning them. Records review and interviews revealed that R1 had experienced an altered mental status and was recommended for an evaluation by a neurologist.

Based on the information obtained, there is insufficient evidence to support the claim that R1 was being poisoned. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility is financially abusing the resident
It was alleged that R1 was being financially abused while in care. At the time of the complaint, no additional information was provided. Per the interview conducted with R1, R1 denied claims that they were being financially abused by any person residing at this facility. R1 claimed that they were conserved and that their conservator made monthly payments to the facility. Per the interview with R1, any concerns that R1 had regarding finances did not pertain to persons at this facility. An interview with R1’s conservator confirmed that they do not believe R1 is being financially abused by anyone at this facility. A review of monthly invoices confirmed that timely payments were made with no discrepancies. Staff interviews revealed that R1 had mentioned that they were being financially abused, but R1 had not provided any specifications and did not direct the claim to anyone at this facility.

Based on the information obtained, there is insufficient evidence to support the claim that R1 was being financially abused while in care. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

LIC9099 (FAS) - (06/04)

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