197609518-6-6-2022-29-AS-JAPL-CF8T3N-20220609142238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 06/06/2022
Date Signed: 06/06/2022 03:40:55 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
06/01/2022 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20220601135057

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:	06/06/2022
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Nancy Nelson		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not provide a safe environment for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a 10-day visit. The LPA met with Executive Director Nancy Nelson and explained the reason for the visit.

During today’s visit, the LPA interviewed staff at 11:49 a.m., 12:00 p.m., and 1:40 p.m., and interviewed emergency personnel at 12:36 p.m. and 1:30 p.m.

Regarding the above allegation, it was alleged that staff failed to provide a safe environment for Resident #1 (R1), as R1 was sent to the emergency room unaccompanied by a facility staff person. Staff interviews confirmed that for most occasions, if a resident was transferred to the hospital via an ambulance, a staff person would accompany the resident either in the ambulance or would follow the resident to the hospital in a private vehicle. Interviews and record review revealed that R1 was sent to the hospital on 5/26/2022 and 5/27/2022 and confirmed that R1 was sent alone.

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: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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-20220601135057

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: 06/06/2022

NARRATIVE

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However, R1 tested positive for COVID on 5/18/2022 and staff admitted that it was the policy of the medical personnel at the hospital to not allow additional persons in the ambulance since R1 was positive for COVID-19 and was still under quarantine guidelines. Staff said it was not their policy and that they were unable to send a staff person with R1. Interviews with medical personnel confirmed claims that if a person tests positive for COVID-19, they are not allowed to have any additional persons in the ambulance nor could that person have visitors in the emergency room, and claimed that they had trained medical professionals to provide oversight for that individual while in their care. Facility staff claimed that outside of the occasions in which they were unable to accompany R1 to the emergency room due to hospital policy, staff have accompanied R1 to all medical appointments and unexpected emergency room visits.

Based on the information obtained, there is insufficient evidence to support the claim that staff failed to provide a safe environment for residents. This allegation is deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC9099 (FAS) - (06/04)

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