198601646-3-16-2021-11-AS-JHAD-C2B2VL-20210421174408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 03/15/2021
Date Signed: 03/16/2021 02:07:57 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
12/03/2020 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20201203112407

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: 120	DATE:	03/15/2021
		UNANNOUNCED	TIME BEGAN:	02:21 PM
MET WITH:	MIKI LAMM		TIME COMPLETED:	02:22 PM

ALLEGATION(S):

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Staff did not seek medical attention for resident.

INVESTIGATION FINDINGS:

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On 03/16/2021 around 3pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Miki Lamm.

The Investigation consisted of the following: On 11/06/2020 LPA Calderon interviewed Administrator Ruth Miki Lamm(S1) and conducted a tour of the physical plant. LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Physicians Report and Medication list). On 3/02/2021 LPA Calderon interviewed Staff #2 and Residents R2 – R10. LPA was unable to R1 due to communication barriers as the resident has a diagnosis of Dementia.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

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 11-AS-20201203112407

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: 03/15/2021

NARRATIVE

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Allegation: Staff did not seek medical attention for resident
It is alleged resident tested positive for COVID-19 and staff failed to transport the resident to the hospital for COVID related symptoms. On 12/07/2020 LPA Calderon interviewed Resident #1 Responsible Party (R1-RP), she stated that resident was receiving excellent medical service from facility staff and did obtain Covid-19 while living at the facility but did not have any symptoms of Covid-19. On 12/10/2020 LPA Calderon interviewed Administrator Ruth Lamm, she stated R1 did have Covid-19, but no symptoms and has received excellent medical service from staff. On 2/24/2021 LPA Calderon interviewed S2 LVN, she stated R1 received excellent medical services and did have Covid-19 but had no symptoms. S2 informed LPA R1 had an unwitnessed fall and was transported to the hospital for evaluation, but nothing COVID related. On 3/2/2021 LPA Calderon interviewed R1-R10 who state no issues with medical services and that they had no concerns with living at the facility. On 2/19/2021 LPA Calderon reviewed the facility file and observed the facility did have a COVID-19 Outbreak, it was reported timely to Community Care Licensing and Los Angeles County Public Health Department. Based on daily updates from the facility during the Outbreak there is no documentation to support R1 was symptomatic and required immediate medical care.

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

A telephonic exit interview was conducted with Administrator Miki Lamm, and a hard copy was provided via email for records

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

LIC9099 (FAS) - (06/04)

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