197610274-11-7-2023-31-AS-RRAZ-CY35KC-20231129190118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610274
Report Date: 11/07/2023
Date Signed: 11/07/2023 03:42:42 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2023 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230117090038

FACILITY NAME:	FOREVER LOVE HOME CARE INC.		FACILITY NUMBER:	197610274
ADMINISTRATOR:	BELMONTE, MARK		FACILITY TYPE:	740
ADDRESS:	44920 LOTUS LN.		TELEPHONE:	(661) 206-7518
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	11/07/2023
		ANNOUNCED	TIME BEGAN:	02:17 PM
MET WITH:	Mark Belmonte		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility admitted a resident with an unstageable pressure injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent complaint visit to this facility to conclude the investigation regarding the above allegation. On 01/17/23, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s, Investigation Branch. The complaint was accepted by CCL, IB and was assigned to Investigator Lauren Garcia on 01/19/23. LPA met with the administrator Mark Belmont and the purpose of the visit was explained.

The complaint alleged the facility admitted a resident with an unstageable pressure injury.
LPA conducted an initial complaint visit on 1/18/23 to gather copies of pertinent information from Resident #1 (R1’s) facility file. During the course of the investigation, Investigator Garcia conducted interviews, gathered hospice and wound care documents, and also subpoenaed R1’s medical records. Information obtained from interviews conducted with R1’s Power of Attorney (POA), facility staff, and registered nurse with hospice, revealed that R1 was admitted into the facility on 10/19/22. (Continued to LIC9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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 31-AS-20230117090038

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOREVER LOVE HOME CARE INC.	FACILITY NUMBER: 197610274
	VISIT DATE: 11/07/2023

NARRATIVE

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(Continued from LIC9099)

R1 was already receiving hospice services and wound care prior to being admitted to this facility. On 12/27/22 R1 was transported to a hospital and transferred to a skilled nursing facility to receive antibiotics through an IV.
A review of R1’s hospice medical records indicate R1 was receiving hospice and wound care service with an agency from 09/16/22 to 12/26/22. R1 was admitted to the hospital on 12/27/22 and then transferred to a skilled nursing facility on 01/03/23. Furthermore, when R1 was discharged from skilled nursing back to this facility on 01/03/23, R1 was also admitted to a new hospice agency with wound care services on the same date, 01/03/23. R1’s hospice and medical records revealed pressure injury was already documented and part of the care plan.

Based on the information obtained through interviews with R1’s POA, review of R1’s hospice and medical records this allegation is deemed Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit Interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2023 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230117090038

FACILITY NAME:	FOREVER LOVE HOME CARE INC.		FACILITY NUMBER:	197610274
ADMINISTRATOR:	BELMONTE, MARK		FACILITY TYPE:	740
ADDRESS:	44920 LOTUS LN.		TELEPHONE:	(661) 206-7518
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	02:17 PM
MET WITH:	Mark Belmonte		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident is unkempt while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit at this facility to investigate the above allegation. LPA met with administrator Mark Belmont and explained the reason for the visit.

Allegation: Resident is unkempt while in care. It is alleged Resident #1's (R1) looked unkempt. To investigate the allegation LPA conducted an initial complaint visit on 01/18/23 and at approximately 8:10 a.m. LPA conducted a physical plant tour of the facility. On 01/18/23 at approximately 8:45 a.m. LPA conducted a record review and obtained copies of R1's admission agreement, physician's report, hospice documents, and documents from skilled nursing facility. On 01/18/23 during physical plant tour LPA observed Resident #2 (R2) at the facility, LPA observed R2 with clean sheets, dressed for the weather, nails clean and cut short. R2's bedroom was observed clean and did not smell of urine or feces. R1 was not at the facility during visit. On 11/07/23 LPA reviewed records obtained by Community Care Licensing Division's Investigation Branch, Investigator Lauren Garcia for the same complaint. (Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20230117090038

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOREVER LOVE HOME CARE INC.	FACILITY NUMBER: 197610274
	VISIT DATE: 11/07/2023

NARRATIVE

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(Continued from LIC9099)
On 11/07/2023 LPA interviewed three (3) out of five (5) residents at the facility. One (1) resident was out in the community and another resident refused to be interviewed. Resident interviews revealed they are satisfied with the care they are receiving and facility staff are regularly making rounds to provide assistance. Furthermore, resident interviews revealed they are assisted with hygiene and grooming on a regular basis. Interview with administrator on 01/18/2023 denied the allegation. interview with administrator on 11/07/2023, administrator stated they were still surprised such an allegation was made. Administrator stated they only receive positive feed back from residents' and residents' family members. LPA did not find an individual to corroborate the allegation R1 was unkempt while in care. Therefore, based on LPA's observations and interviews this allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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