198601646-12-22-2022-11-AS-MVAO-CN7RJD-20230118120347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 12/22/2022
Date Signed: 12/22/2022 06:09:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
12/20/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221220102215

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: 106	DATE:	12/22/2022
		UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Tiffany Alisaje & Miki Lamm		TIME COMPLETED:	04:31 PM

ALLEGATION(S):

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Facility staff denied resident to have visitor present during ADL's being performed.

INVESTIGATION FINDINGS:

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On 12/22/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Memory Care Coordinator Tiffany Alisaje. LPA explained the purpose of the visit is to investigate the allegation mentioned above. Executive Director Miki Lamm later joined the visit.

The investigation consisted of the following: LPA obtained copies of the roster for residents and staff. Interviews conducted with Resident #1-#5 (R1-R5), staff #1-#6 (S1-S6) A reviewed of (R1's) service records and other pertinent documents pertinent to the allegations on this complaint. A tour of the facility was performed.

Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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-20221220102215

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 12/22/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility staff denied resident to have visitor present during ADL's being performed.
The details of the complaint stated resident #1 (R1) is deprived of visitor presence during everyday activities. The complainant claims staff do not permit a visitor present during (R1’s) care for diaper changes, bathing, or transfer to a wheelchair as the visitor interferes with the care process with the resident’s needs. According to the complainant, (R1) requested a visitor be present when staff perform activities of daily living (ADLs).

In order to interview (R1), who wasn't at the facility, the Department conducted a telephone interview. (R1) stated the facility provides adequate care and supervision. (R1) does not feel any of her rights have been violated while in care. (R1) had no preference if a visitor is present or not during (ADLs) process. (R1) verified the facility allows visitors in the room. Interviews with staff #1-#5 (S1-S5) primary caregivers and med-tech for (R1) verified that (R1) is allowed visitors in her private room. (S1-S5) claimed that (R1’s) visitor is present and is hands-on with (R1’s) (ADLs). (S1 and S6) argued that when a visitor is hand-on, the visitor could potentially interfere with the caregiver's ability to provide proper care to the resident. (S6) reported that several concerns had arisen regarding (R1) visitor's improper and/or inappropriate conduct toward the staff and management, as well as the acuity and care needs of (R1) have been documented in writing dated 10/28/22. Interviews with residents #1 - #5 (R1-R5) prefers (ADLs) are conducted in private with only staff involved and that their privacy is essential. (R1-R5) prefers professional care provided by trained staff at this facility and feels their needs are met. The Residence and Services Agreement outlines guest visits and communications. Guest are welcome to visit and participate in appropriate activities provided they respect the rights of other residents and staff and abide by the visitor guest policies. Visitors must abide by rules and are not disruptive to other residents or staff.

Based on the information gathered, the Department finds the facility is not in violation of Title 22 Regulations and no evidence supports the allegation mentioned above.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20221220102215

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 12/22/2022

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	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. No deficiencies were cited during this visit. An exit interview was conducted with Miki Lamm, and a copy of the report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC9099 (FAS) - (06/04)

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