197609518-5-17-2022-29-AS-JAPL-CERP86-20220525110500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 05/17/2022
Date Signed: 05/17/2022 05:01:52 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
11/30/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20211130090111

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: 131	DATE:	05/17/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nancy Nelson		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility staff are not assisting with resident self-administration of medication as prescribed.
Insufficient staffing
Licensee does not assure that a resident is provided regular laundry service
Failure to monitor resident's nutritional intake

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Nancy Nelson and explained the reason for the visit.

During the initial visit conducted on 12/10/2021, LPA Smith along with LPA Elsie Campos reviewed documents, interviewed staff at 9:20 a.m. and 9:56 a.m., and toured the kitchen at 11:35 a.m. In addition, the LPA conducted a subsequent interview with nursing staff on 12/20/2021 at 12:25 p.m. and on 5/17/2021 at 1:57 p.m. On 5/02/2022, the LPA interviewed staff at 2:00 p.m., 2:11 p.m., 2:21 p.m., 2:53 p.m. and 3:04 p.m. and 3:34 p.m. On 05/06/2022, the LPA reviewed records and interviewed residents from 1:45 p.m. - 3:15 p.m.

Today, the LPA interviewed staff at 10:09 a.m., 11:47 a.m., 11:56 a.m., 12:06 p.m., 12:27 p.m., 12:47 p.m., 11:57 p.m., 4:01 p.m., and 4:07 p.m.; and, interviewed residents at 9:46 a.m., 9:50 a.m., 10:20 a.m., 10:28 a.m., 10:39 a.m., 10:48 a.m., 11:00 a.m., and 11:16 a.m. In addition, the LPA reviewed medical records.

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: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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-20211130090111

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: 05/17/2022

NARRATIVE

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Regarding the allegation: Facility staff are not assisting with resident with the self-administration of medication as prescribed.
It was alleged that Resident #1 (R1) did not receive their medications on 11/23/2021, 11/24/2021, and 11/25/2021 and that R1 was observed with ‘unknown’ pills in an envelope. Interviews and record review confirmed that at the time the complaint was received, R1 was receiving a thyroid medication (Synthroid 88mcg) once daily and had a pain medication what was administered as needed (Meloxicam). Interviews revealed that in October 2021, after discussion with R1’s responsible party, the facility requested to add R1’s thyroid medication on cycle with the facility’s preferred pharmacy, Ron’s Pharmacy. Staff claimed that they wanted to do this to avoid any concerns with medications not being delivered in a timely manner and felt that switching pharmacies would make for a smoother transition. Records review noted that on 10/24/2021, the facility placed an order with Ron’s Pharmacy for R1’s thyroid medication. Yet records review further noted that on 11/23/2021, nursing staff documented that Ron’s Pharmacy did not deliver R1’s thyroid medication to the facility, even though the facility requested that the medication to be added on cycle delivery in October 2021. At that time, staff claimed that R1 still had additional thyroid pills, as they placed an order on 10/24/2021. Staff stated that as of 11/23/2021, R1 had not completely ran out of thyroid medication. Staff claimed that prior to a resident running out of a medication, staff ensure that refills are ordered promptly, or they will reach out to a resident’s responsible party or physician to notify them that a medication is running low. After documenting that R1’s thyroid medication was running low, nursing staff confirmed that an emergency order for the medication was placed on 11/25/2021 with Ron’s Pharmacy.

The LPA reviewed the Medication Administration Record (MAR) for R1 and spoke to the nursing staff whom indicated that they assisted R1 with the self-administration of medication for 11/23/2021, 11/24/2021, and 11/25/2021. Interviews with nursing staff revealed that R1 received the last dosage of the thyroid medication the morning of 11/25/2021 and confirmed that they placed an emergency order for the medication on 11/25/2021. Staff claimed that R1 received the medication on 11/23/2021, 11/24/2021, and 11/25/2021 and it was notated in the MAR as administered. Lastly, staff confirmed that R1’s thyroid medication was delivered by Ron’s Pharmacy the evening of 11/25/2021. In addition, interviews and documentation confirmed that R1 was given pain medication (Meloxicam) in an envelope, in an event that R1 stayed with their family overnight. This is a known practice. Staff claimed that R1’s responsible party was aware that R1 had these medications in their possession for this purpose. However, it was revealed that R1 returned to the facility the evening of 11/25/2021 and R1 received their thyroid medication the morning of 11/26/2021.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20211130090111

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: 05/17/2022

NARRATIVE

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Lastly, the LPA conducted interviews with nursing staff, residents, and medication technicians regarding the process for assisting residents with the self-administration of medication. Interviews revealed that R1 would go to the Wellness Center to retrieve their medications. Staff claimed that residents took their medications in front of the staff prior to leaving the center. When asked what happens if a resident does not go to the Wellness Center in a timely manner or if a resident needs a reminder to go to the Wellness Center, nursing staff stated that they will inform the caregivers that a resident is needed in the Wellness Center, or a nursing staff and/or a medication technician will go to the resident to assist with the self-administration of medication.

Based on the investigation, there is insufficient evidence to support the claim that staff are not assisting with resident with the self-administration of medication as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Insufficient staffing
It was alleged that the facility was understaffed. Interviews revealed that in general, staff and residents believed that the facility was sufficiently staffed. It was revealed that there have been periods of under-staffing due to the COVID-19 pandemic or holiday scheduling; however, the facility would utilize a staffing agency to fill in to ensure that staffing ratios were met. At this time, the facility is rarely using agency staff as they claim they are fully staffed with facility employees. Staff revealed that as there were some residents whom needed two persons for transfers or for care, staff denied claims that they improperly transferred a resident alone or without the assistance of another staff person. The majority of residents interviewed felt that their needs were met in a timely manner. A review of schedules and interviews revealed that there are at least six caregivers for the AM and the PM shift for the Assisted Living side, which did not include management staff, medication technicians, or nursing staff. Whereas staff claimed that residents may wait longer in the mornings due to assisting residents with getting ready in the morning, staff claimed that they helped one another out and did not feel that they needed additional staff in the facility. Lastly, staff communicated that when a pull cord or resident pendant is activated, they respond in a timely manner to ensure that the resident need is met.

Based on the investigation, there is insufficient evidence to support the claim of insufficient staffing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20211130090111

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: 05/17/2022

NARRATIVE

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Regarding the allegation: Licensee does not assure that a resident is provided regular laundry service
It was alleged that R1’s clothing, linens, and towels were not laundered regularly. To investigate, the LPA interviewed staff whom provided laundering services for R1. Staff commented that R1’s laundry was targeted for completion once a week, and specifically during the PM shift. In general, staff confirmed that they did launder R1’s clothing and linens, yet also indicated that R1 would oftentimes ‘refuse’ to have their laundry done. Staff claimed that in instances that R1 – or any resident – would refuse laundering services, they would attempt to come back another time or attempt to do the laundry during the time that R1 was not in the room. Staff claimed that there were times that R1 was ok with their laundry being done, and that staff were able to do it without concern. However, staff denied claims that staff failed to launder R’s clothing, linens, or towels. Staff stated that all residents had a schedule for laundry in their room, and the caregivers were notified of a resident’s laundry day on their assignment sheets prior to starting their shift.

In general, residents confirmed that laundering of their clothes and linens took place once a week. Residents noted that sometimes they would press their call button to ensure that staff would tend to their laundry, but also noted that they would come to the room and that the clothes would be gone, and it was assumed that they were doing the laundry. Residents did not communicate concerns of their clothes being soiled or uncleaned. Per the facility’s admission agreement, it is notated that laundering of bed linens, bath towels, and clothing was done once a week.

Based on the investigation, there is insufficient evidence to support the claim that the licensee does not assure that a resident is provided regular laundry service. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Failure to monitor resident's nutritional intake
It was alleged that the facility failed to ensure that R1’s nutritional intake was monitored. A review of the facility’s Admission Agreement noted that the facility offered the following special diets: no added salt diet, reduced carbohydrate diet, lower fat/low cholesterol diet, finger food diet, mechanical soft diet, pureed diet. However, it is also notated that the dining room allows for residents to self-select menu items to meet special dietary needs. A review of R1’s Physician’s Diet Order, which was initially filled out on 5/27/2021, indicated that R1 was on a regular diet.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20211130090111

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: 05/17/2022

NARRATIVE

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Staff claimed that dining staff were alerted to a resident’s dietary restrictions as they are posted in the kitchen and there is a detailed list of residents whom are on a special diet. The LPA reviewed the facility’s dietary restrictions list, printed 12/1/2021, and it was noted that R1 was on a regular diet, yet had a severe allergy to shrimp. Interviews with dining staff alleged that as R1 was on a regular diet, staff would assist R1 and other residents with making choices. Staff claimed that R1 was very cognizant and mindful of their food choices and at times, would decline dessert options. However, staff were mindful that R1 had the right to choose meal options and whereas they could suggest other items, staff stated that they did not violate R1’s personal right to choose meal options or additional servings.

Information obtained from resident interviews revealed that in general, residents felt that they had various food options, yet had experiences where food was not to their liking. However, residents revealed that staff were accommodating in meeting their needs once concerns were voiced. The LPA reviewed the facility menus, and facility offers two separate menus, one with specials for the day and a standard menu. The daily specials change weekly. The LPA reviewed the menu and observed options that could meet the needs of residents that require a special diet. The LPA reviewed R1’s last Assessment and Service Plan, dated 4/6/2022, and it indicated that R1 was on a regular diet. Whereas R1’s family members met with the facility’s dietitian to talk about food selections for R1, staff denied claims that there was a physician’s order on file that specified a special diet for R1. Whereas staff claimed that they could make suggestions for R1 regarding food options, there was no indication that R1 was incapable of selecting meal options that were suitable for their dietary restrictions or needs.

Based on the investigation, there is insufficient evidence to support the claim that the licensee failed to monitor resident's nutritional intake. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the 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: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

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