198601646-10-30-2022-11-AS-JHAD-CL9PZS-20221117104557

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 10/30/2022
Date Signed: 10/30/2022 03:19:47 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, 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
07/08/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220708143443

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: 104	DATE:	10/30/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Miki Lamm, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents are being neglected while in care.
Residents’ needs are not being met while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Miki Lamm, Executive Director.

The investigation consisted of following: Interviews and Record reviews. On 07/18/22, LPA Soto interviewed; S#1 - Executive Director, S#2 - Director of Care Services, S#3 - S#10. R#1 - R#10. Toured rooms 216, 220, 223,248, 303, 320, 321, 336, Lounge area, pool area, and dining room. On 07/18/22, LPA also requested copies of the following documents for C#1 - C#3: Face sheets, Physician’s report, Care Plan, Mars June and July, Admissions agreement, (Hospice records for R#1 & R#2.)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2022

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 3

Control Number 11-AS-20220708143443

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: 10/30/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on the LPA's investigation, the investigation revealed the following.

Allegation 1 – Residents are being neglected while in care. Interviews with Executive Director, Director of Care Services, S#3 – S#10, communicated that all the residents are not neglected. Some residents have a 1:1 pal, which get personal care 24 a day 7 days a week. The 1:1 pal assist with showers, hygiene, feeding, dressing, cleaning up room, reposition, and anything the resident needs help with. The other residents that do not have 1:1 pal, the facility has enough pals to assist all the resident in care. They also help with showers, hygiene, dressing, feeding, dressing, cleaning up room, repositioning, and anything else the need help with. Interviews with R#1, R#2, R#5. R#8, & R#9 were not available and/or willing to speak to LPA. R#3, R#4, R#6, & R#7; communicated that the staff meet every need they have. The staff is always helpful and nice. They go above and beyond to get residents needs met. LPA observed the residents while interviewing them, they all looked well. They were dressed, hair combed, hygiene needs were met, and they looked cared for. LPA reviewed hospice records for R#1 & R#2, they have been coming to facility and taking care of both residents. Hospice and pals have been assisting with the care of R#1 & R#2, R#1 refuses to get help from Hospice, so, they randomly come to help her. R#3 has been taking care of also, but worries about R#2, R#3 husband, and forgets to get R#3 own needs, but the staff makes sure R#3 get her needs met also. The family members for R#1 – R#3, have not communicated that their family members have been neglected to LPA Soto. The interviews and records reviewed did not concur with the above allegation.

Allegation 2 - Residents’ needs are not being met while in care. Residents are being neglected while in care. Interviews with Executive Director, Director of Care Services, S#3 – S#10, communicated that all the residents are being taken care of. Some residents have a 1:1 pal, which get personal care 24 a day 7 days a week. The 1:1 pal assist with showers, hygiene, feeding, dressing, cleaning up room, reposition, and anything the resident needs help with. The other residents that do not have 1:1 pal, the facility has enough pals to assist all the resident in care. They also help with showers, hygiene, dressing, feeding, dressing, cleaning up room, repositioning, and anything else the need help with. Interviews with R#1, R#2, R#5. R#8, & R#9 were not available and/or willing to speak to LPA. R#3, R#4, R#6, & R#7; communicated that the staff meet every need they have. The staff is always helpful and nice. They go above and beyond to get residents needs met. LPA observed the residents while interviewing them, they all looked well. They were dressed, hair combed, hygiene needs were met, and they looked cared for.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20220708143443

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: 10/30/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA reviewed hospice records for R#1 & R#2, they have been coming to facility and taking care of both residents. Hospice and pals have been assisting with the care of R#2 and tries to help with R#1 care. R#3 has been taking care of also, but worries about R#2, R#3 husband, and forgets to get R#3 own needs, but the staff makes sure R#3 get her needs met also. The interviews and records reviewed did not concur with the above allegation.

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

An exit interview was conducted with Miki Lamm, Executive Director and a hard copy of report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3