198601646-10-30-2022-11-AS-JHAD-CL8R4Z-20221116114221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 10/30/2022
Date Signed: 10/30/2022 03:21:05 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
08/16/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220816111258

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:	02:00 PM
MET WITH:	Miki Lamm, Executive Directory		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not respond to residents call button timely

INVESTIGATION FINDINGS:

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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 08/17/22, LPA Soto interviewed; S#1 - Executive Director, S#2 - Director of Care Services, S#3 - S#11. On 09/13/22, LPA Soto interviewed R#1 – R#11. The LPA also requested copies of the following documents: Face sheets, Physician's report, Admission report, and Care Plan. It was determined that further investigation is needed.

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)

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Control Number 11-AS-20220816111258

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

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

Allegation 1 - Staff do not respond to residents call button timely. Interviews with S#1 - Executive Director, S#2 - Director of Care Services, communicated that R#1 family member just wants to complain. R#1 is always assistance when R#1 needs it. The staff member that was taking care of R#1, was assisting another resident and could not go right away to help R#1, but another Pal went to help R#1. Staff member was on staff member 30min break. S#2 - Director of Care Services, communicated that R#1, that all the pals respond timely to every emergency call for all the residents. S#3 – S#11, communicated that they respond asap. They may be assisting another resident, so, if they can’t get to them, they will call another Pal to help the resident. Every time they go and assist, they restore the pendant. The receptionist will get the call and they radio the pal to go assist the resident. R#1 – R#11, communicated that either they haven’t used the button and/or have, and that staff responded in a timely manner. They came to assist them and gave them the help they needed. The interviews did not concur with the allegation above.

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

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