198601646-7-13-2020-11-AS-AJKK-BS6PV6-20200804113837

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 07/10/2020
Date Signed: 07/13/2020 12:08:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2020 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20200326095652

FACILITY NAME:	BELMONT VILLAGE RANCHO PALOS VERDES		FACILITY NUMBER:	198601646
ADMINISTRATOR:	LAMM OBERG, RUTH		FACILITY TYPE:	740
ADDRESS:	5701 CRESTRIDGE RD		TELEPHONE:	(310) 377-9977
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	150	CENSUS:	DATE:	07/10/2020
		UNANNOUNCED	TIME BEGAN:	09:21 AM
MET WITH:	Evelyn Sandoval Human Resource		TIME COMPLETED:	09:22 AM

ALLEGATION(S):

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Staff provided care and supervision while being ill
Resident's alerts were not responded to in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jade Jordan initiated a subsequent complaint contact on behalf of Jey Cardenas to deliver complaint finding regarding the above allegations. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with .

On 3/27/2020 LPA Cardenas interviewed Reporting Party (RP), On 04/06/2020 LPA conducted initial 10-day complaint investigation and interviewed facility administrator, Ruth “Miki” Lamm. On 04/30/2020 LPA interviewed staff #1-#6 (S1-S6). On 5/6/2020 LPA interviewed residents #2-#7 (R2-R7) via facetime.

(Report Continued on Lic 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

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 11-AS-20200326095652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 07/10/2020

NARRATIVE

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The investigation revealed the following:

For allegation: Staff provided care and supervision while being ill. RP indicates that on 3/10/2020 RP saw a female staff (name unknown) wearing a mask; staff told him she was wearing mask because she was sick. LPA asked if staff said what her illness was, RP didn't ask. LPA asked if RP observed any symptoms, RP states no. RP states that other staff have also been observed wearing masks.

During interview with administrator, Miss Lamm, she indicates that when staff is ill, they know to call out and are expected to stay home. If a staff reports to the facility and are feeling ill, they are asked to go home. Recently during COVID-19 all the staff have been asked to wear masks for preventative measures, even if they are not ill. During interview with staff, they indicated that they do not report to work ill, staff is mindful of the residents, if staff is ill they can pass on the illness to the residents. Staff indicate that prior to COVID-19 per facility policy, some staff were wearing masks because they had not received the influenza flu shot. During interviews with R2-R7 they indicate that they have not observed a staff working while they were sick with flu, cold, fever, or other illness. In addition, none of the staff ever told residents that they were sick while on shift.

For allegation: Resident's alerts were not responded to in a timely manner. RP indicates on Feb 15 or 16, 2020 R1 had diarrhea, one staff was already in resident room assisting resident, but needed additional caregiver to assist. Staff pulled chord and It took about 10-15 minutes for a nurse to come assist. RP wrote down time it took for someone to respond. In addition, per facility policy staff is unable to use cellphones to call 911. If resident is having an emergency and need to call 911, staff are unable to call in that moment. They would need to call the nurse to the room and then nurse calls 911, this takes time. RP states some residents have telephone in the bedroom. And only some floor staff have a walkie talkies.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20200326095652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 07/10/2020

NARRATIVE

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Per Life Safety/ Emergency/ Disaster 24-Hr Emergency response. If a resident is injured, ill or has an emergency within their apartment they will pull the emergency cord. The emergency cord will activate an alarm at the neighborhood workstation. An employee will respond to the call, assist the resident as needed and reset the emergency cord. When it is apparent that the resident is in need of emergency medical help, the employee will contact the LVN/LPN and advise him/ her. Staff will follow the procedures below.
(A) call 911 and initiate CPR if resident is found unresponsive with no heart rate/ an or not breathing…….

Administrator, Lamm indicates that all staff have a walkie talkie and there are telephones strategically placed throughout the community. When residents call for assistance, caregiver responds first, if situation warrants, a nurse will be called, nurse arrives, assesses, and determines if 911 needs to be called. Lamm states some residents have phones in their room, these are not provided by facility, it is a choice family member have. In addition, some residents have cellphones, its a personal choice. Lamm indicates that facility has Sycor pull chord system in all residents’ rooms, and some residents have a pendant on them that will alert staff if they are in need of assistance. LPA asked if there is a goal response time when residents are calling for assistance; she indicates that time varies and there is no specific time frames.

During interviews with S4, she states that facility is three floor building; first floor has one floor staff for assisted living; memory care unit is located on first floor, however that unit has five (5) staff. Second floor has three floor staff, and third floor has four floor staff. Residents have pendants, alarm mats, and emergency pull chords and when any of those go off the floor staff will respond immediately. LPA asked what is immediately, she states within a minute or two. LPA asked if there have been any residents who have complained about staff shortage, she indicates that none of the residents have complained about staff shortages. S5 states that none residents have complained to her that staff are unresponsive when they call for assistance. S3 states that when the calls aren't answered and cleared within 1-2 minutes the front desk gets on the radio and tells staff to go check of the resident who made the call; calls are not ignored.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20200326095652

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 07/10/2020

NARRATIVE

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During interviews with residents R2-R7 they feel as if there is enough staff to assist when assistance is needed. Staff are responsive and timely when called, and have no complaints about staff response time.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted and a copy of this report was given.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

LIC9099 (FAS) - (06/04)

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