198601646-2-23-2023-11-AS-JHAD-CRMRB6-20230508125211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 02/21/2023
Date Signed: 02/23/2023 08:24:47 AM

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
02/13/2023 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230213104446

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: 138	DATE:	02/21/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Miki Lamm, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff abandoned resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted an initial complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Miki Lamm, Executive Director.

The investigation consisted of following: Interviews and Record reviews. On 02/21/23, LPA Soto interviewed S#1 - Executive Director, S#2 - Nina Khachatrian (Director of Resident Care Services), S#3 - S#6 and R#1 - R#6. Toured the administration offices, dining room, and lobby. LPA requested and received the following documents on 02/21/23:Resident Roster, Staff Schedule, Emails between management and Resident family member, New assessment dated 12/22/22, Letters from attorney to residents family member, Medical notes for resident, Medical records from hospital dated 12/20/22, Note from nurse for puree food, Notice to vacate from Resident family member dated 12/29/22.

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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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-20230213104446

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: 02/21/2023

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following. For Allegation – Staff abandoned resident. Interviews with Executive Director and Director of Residents of Care Services, they communicated that the resident's family member sent the facility a Notice to Vacate for resident dated 12/27/22. Family member decided not to have resident return to the facility. The executive director advised family member that the Director of Resident Care Services would be going to reassess resident before allowing resident to return. The facility needed to make sure that resident was still compatible with the facility. The re-assessment was conducted on 12/22/22, then the Notice to Vacate dated 12/29/22 was received, therefore the facility did not go forward with completing the process for resident to return to the facility. Interviews with S#3 - S#6 & R#1 - R#6, communicated that they have never been aware of the facility refusing a resident re-entry to the facility for any reason. The interviews and records reviews did not concur with the above allegation.

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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC9099 (FAS) - (06/04)

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