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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 04/01/2022
Date Signed: 04/04/2022 08:06:53 AM

Substantiated


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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2019 and conducted by Evaluator Jey Cardenas
COMPLAINT CONTROL NUMBER: 11-AS-20191203144823
FACILITY NAME:BELMONT VILLAGE RANCHO PALOS VERDESFACILITY NUMBER:
198601646
ADMINISTRATOR:LAMM OBERG, RUTHFACILITY TYPE:
740
ADDRESS:5701 CRESTRIDGE RDTELEPHONE:
(310) 377-9977
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:150CENSUS: 111DATE:
04/01/2022
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Director of Resident Care Services, Nina KhatchatrianTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident developed multiple pressure wounds while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced subsequent complaint visit to the above facility to deliver findings. Upon arrival at the facility LPA met with front desk staff and conducted a Covid-19 risk assessment, based on the assessment, the facility is clear of Covid-19 infection. LPA met with Director of Resident Care Services, Nina Khatchatrian and the purpose of the visit was explained.

Investigation consisted of: Initial complaint visit was conducted on 12/04/19. LPA conducted interviews with staff, tour of physical plant, and obtained facility documentation pertinent to the complaint allegation. Community Care Licensing Division (CCLD) requested and obtained medical records from Torrance Memorial Medical Center (TMMC) for hospitalizations relating to the pressure injurie (PI) incident. It is alleged that: Resident#1 (R1) developed multiple pressure wounds while in care

Per LPA record review of resident’s Physician Report dated 6/8/2012 physical health status: “history of skin condition or breakdown- NO; ambulatory status: ambulatory”. Per Physician Report dated 3/22/2019
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
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 4
Control Number 11-AS-20191203144823
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
MONTERY PARK, CA 91754
FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES
FACILITY NUMBER: 198601646
VISIT DATE: 04/01/2022
NARRATIVE
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(Continued pg 2)

physical health status: “history of skin condition or breakdown- YES “buttocks.” Ambulatory status: non-ambulatory.

On 5/05/2021 LPA Brown interviewed Administrator, Miki Lamm; she indicated that R1 was on home health with Torrance Memorial Home Health, the request was made on 11/20/19. First pressure injury was observed on 11/21/19 which was located on residents left heel. On 11/27/19 resident was admitted to Torrance Memorial Hospital due to shortness of breath. LPA Cardenas conducted resident file review and there is no available evidence that Home Health was treating R1’s pressure injuries. There isn’t documentation of a Home Health care plan with a start date for pressure injuries. LPA Cardenas interviewed Lamm, and according to the administrator the resident’s Physician “did not want to place the resident on home health.”

Per Medical records from Torrance Memorial Medical Center Hospital Progress Note from 10/21/19; Reason for visit: RESPIRATORY INFECTIONS & INFLAMATION W MCC & MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS. Diagnosis Pneumonia. Pressure Ulcer present on admission, Other: BUTTOCK/SACRUM/ COCCYX, Stage I; Wound Care Consultation 10/21/19; discharged 10/22/19. Resident given patient education materials, prescriptions, and follow up with your Physician within two weeks of discharge.



Facility Staff#7 (S7) stated to TMMC that, Patient was supposed to be on service with Dynamic Home Health upon discharge from Torrance Memorial Medical Center on 10/22/19. However, Dynamic Home Health only came out once and then patient was discharged due to insurance problems. Since 10/22/19, S7 states that no Home Health has been coming out to manage wounds. Patient is being followed by Primary Care Provider (PCP).

On 11/28/19 Resident was admitting into the hospital diagnosis is Respiratory Infections & Inflammation. Also present were Pressure Ulcer of Left heel - Stage 3; Pressure Ulcer of Right heel – Unspecified Stage; Pressure Ulcer of Sacral Region – Stage 2.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20191203144823
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
MONTERY PARK, CA 91754
FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES
FACILITY NUMBER: 198601646
VISIT DATE: 04/01/2022
NARRATIVE
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(Continued pg 3)

Per LPA Cardenas record review of Torrance Memorial Case management notes dated 11/29/19: PT “presented with respiratory failure, patient “(PT) also with multiple wounds on his heels/ buttocks. “Per Torrance Memorial – social services record dated 11/29/19 patient (PT) was brought in with pneumonia… “RN noticed wounds on heel of foot which patient did not have at last hospital admission (10/19/19 )…” called assisted living facility and spoke with LVN staff#6 (S6) who stated that they have tried to obtain home health services however, encountered some insurance problems and also the home health agency "couldn't take because they were overbooked."

Per Facility Licensed Nurse Notes dated 11/20/19; “Currently finding a new home health facility for resident to be seen. Called Miracle & Oceanside both require MD referral DRCS (delivery receipt confirmation system) faxed resident’s PCP for referral.

Based on LPA’s observations, interviews, and record review(s), the preponderance of evidence standard has been met. On 11/28/19 R1 was admitted to Torrance Memorial Medical Center, present during admission: Pressure Ulcer of Left heel- Stage 3; Pressure Ulcer of Right heel – Unspecified Stage; Pressure Ulcer of Sacral Region – Stage 2. Staff indicated that Home Health was not assigned due to insurance, and agency being overbooked. Therefore, the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, “a serious physical condition, including, but not limited to, the following: loss of consciousness, concussion; bone fracture; protracted loss of impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1)

Exit interview conducted, appeal rights were discussed, and a copy of this report was provided to Director of Resident Care Services, Nina Khatchatrian.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20191203144823
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
MONTERY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES
FACILITY NUMBER: 198601646
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/02/2022
Section Cited
HSC
1569.49(c)(1)
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Civil penalties; Any violation that the department determines resulted in the injury...This requirement not met as evidenced by: On 11/28/19 R1 was admitted to Torrance Memorial Medical Center with Pressure injuries of Left heel, Right heel,Sacral Region.
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Administrator to ensure staff is properly trained to observe, document, report, and seek medical attention/ Home Health services in a timely manner. Submit in written plan to conduct training,topics to be covered. ....3 weeks to complete training. Email.
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This poses an immediate health and safety risk to resident in care.
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Type B
04/08/2022
Section Cited
CCR
87463(a)
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The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes...This requirement not met as evidenced by: During investigation, facility failed to provide reappraisal relating to pressure injureis. THis poses a potential Health and safety risk.
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Facility will ensure that residents are assessed when changes are observed to ensure facility can continue to care for resident. Written certification shall be submitted to LPA by POC date.
Type B
04/08/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights- To be accorded safe, healthful and comfortable.... This requirement not met as evidenced by: Facility failed to seek appropriate health care needs from October 2019 – November 2019 while at the facility. This poses a potential health and safety risk to resident.
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Facility will review personal rights regulations and ensure residents are provided safest, healthful, and comfortable setting. Submit self certification indicating regulations were reviewed and understood.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4