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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 04/01/2022
Date Signed: 04/01/2022 12:20:43 PM

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
04/07/2020 and conducted by Evaluator Jey Cardenas
COMPLAINT CONTROL NUMBER: 11-AS-20200407120848
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:
11:00 AM
MET WITH:Director of Resident Care Services, Nina KhatchatrianTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Resident sustained serious injury from falling resulting in hospitalization
Resident sustained unexplained injury
Facility failed to reevaluate resident after falling
Facility lacked sufficient staffing to meet resident's needs
Facility failed to ensure safety of resident by not using fall preventive measures
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jey Cardenas conducted a subsequent complaint visit to deliver complaint findings for the allegations listed above. Upon arrival at the facility LPA met with front desk staff; LPA conducted a risk assessment and based on the assessment; the facility is clear of Covid-19 infection. Director of Resident Care Services, Nina Khatchatrian assisted LPA with visit and the purpose of today’s visit was explained.

The investigation consisted of the following: LPA Cardenas conducted initial complaint investigation on 4/13/2020. LPA interviewed residents and staff, obtained staff/ resident roasters, and documentation pertinent to the allegations. Investigator, Brian Slatic and investigator, Sandhu of Community Care Licensing Division’s Investigations Branch (IB) conducted investigation.

It is being alleged that R1 (Resident#1) has dementia and was a high-risk fall resident. R1 had a head injury from a fall sustained at Belmont Village Rancho Palos Verdes on 1/11/2020.
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 7
Control Number 11-AS-20200407120848
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)

In addition, on 3/3/2020 R1 was left unsupervised without the 1:1 private caregiver, nor the alarm floor mat used to prevent falls. IB’ investigation revealed the following:

Per IB’s record review: Per Admission agreement: R1 was admitted to facility 11/23/2019. Per Physician Report dated 11/22/2019 R1 primary diagnosis is Dementia “supervision/ assistance needed” Secondary diagnosis is Frailty: “assistance is needed in walking and transfers and supervision to avoid falls.” Resident is able to transfer to and from bed independently; it is noted that: “needs supervision/ reminders for walker use- to be accompanied by helper, high fall risk.” Per Torrance Memorial Medical Center records: On 1/11/2020 R1 arrived at Torrance Memorial Medical Center (TMMC) at 1717 hours due to a fall and a laceration to the face. A CT scan was done on 1/11/2020 2028 hours which revealed a close heady injury with a small amount of hemorrhage. On 3/4/2020- a CT of the brain/ head without contrast was conducted and it showed a “large left subdural hematoma…”. A consultation states the head CT showed slight increase in Subdural Hematoma.
-Per IB interviews: R1 sustained a serious injury from falling, resulting in hospitalization. R1 had arrangements for a one-on-one caregiver from 5:30pm - 1:00am due to resident was a known fall risk. During the evening, on 3/3/2020 R1 was left without adequate supervision. The facility could not find someone to cover the shift and the wellness center staff failed to notify R1’s responsible party. The floor caregiver sat R1 in a recliner inside residents’ bedroom without using available alarm floor mat. R1 got out of the recliner and fell. R1 was down on the floor for an unknown amount of time. R1 was not immediately sent out to the hospital, even though resident had a history of subdural hematoma from a fall suffered on 1/11/2020. LA county fire was dispatched on 3/3/2020 at 2238 hours to Belmont due to a complaint of back pain. On 3/3/2020, according to the medical records; R1 was diagnosed with worsening subdural hematoma likely exacerbated by the fall. Resident had to undergo a craniotomy procedure to evacuate the subdural hematoma.

-Per IB Interviews: Resident sustained unexplained injury: On the evening of 3/3/2020 R1 suffered a fall in which the resident was not sent to the hospital. Later that evening R1 fell a second time while a caregiver was assisting resident into wheelchair. R1 sustained an injury to the lower back which resulted in a welt. Facility documentation does show that R1 sustained a skin tear to left forearm and a small bruise on the back. Facility failed to notify residents responsible party about the second fall and unexplained injury to the

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 7
Control Number 11-AS-20200407120848
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)

residents back. R1 was eventually sent to the hospital that same evening after the second fall due to R1 complained of hip and lower back pain.

-Facility lacked sufficient staffing to meet resident's needs: R1s main private PAL is Staff#1(S1) According to the staff schedule; on March 1st, 2020 S1 worked from10:30pm - 6:45am. On March 2nd S1 worked 5:30pm-11pm and then continued the overnight shift into March 3, 2020 watching R1 until 6:45am. According to the staffing schedule, R1 didn’t have a private PAL on March 1st and March 3rd between the times; 5:30pm -10:30pm when the fall occurred. On 6/9/2020 Investigator Slatic interviewed Administrator Lamm who disclosed that on 3/3/2020 staff called out sick and it was S2’s responsibility to find Private Pal to cover the 5:30pm -10:30pm shift. Slatic asked if it was facility policy to notify the family when a private PAL cannot be found to cover the 5:30pm -10:30pm shift. Lamm said yes, because this represents an inability by Belmont to carry out the resident’s plan. Lamm had no information to offer that R1s responsible party was notified about the lack of private PAL on the evening of March 3rd2020.

-Facility failed to ensure safety of resident by not using fall preventive measures; Per IB investigation; Lamm told investigator Slatic that the use of the floor mat alarm and escort assistance was used to reduce R1’s fall risk. Lamm confirmed that the alarm mat has long cables so it can be moved around the room. Per Investigator Slatic and LPA Cardenas record review; none of the nursing notes or incident report reviewed mentioned the use of the floor mat, or time when the mat was activated and how long it took floor pal to get to it and deactivate it, no indication that the alarm sound is what alerted the caregiver to R1s first fall on 3/3/2020. On 07/27/2020 investigator Sandhu, interviewed S2 who indicated that she believes the floor mat was not utilized by S3 at the time of the incident.

-Facility failed to reevaluate resident after falling. Per record review by Slatic; R1 was reassessed on 1/3/2020 and a change of support services needed was required as of 1/3/2020. On 06/09/2020, Slatic interview Lamm; Lamm confirmed R1 had a reassessment on 1/3/2020. Lamm said R1 was not reassessed again for the fall on 1/11/2020 due to it was “very unusual circumstances”. Lamm felt such a fall was unlikely to happen again. Investigator Slatic questioned Lamm about R1s hospitalization from 1/11/2020 to 1/13/2020 and the diagnosis of a subdural hematoma. Slatic asked if upon return from the hospital with such diagnosis, would it have result in change to care? Lamm said yes plan should have been

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 7
Control Number 11-AS-20200407120848
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 4)

updated. Lamm checked computer and said she was dependent on her director of resident care services who is directly responsible for such clinical tasks. Lamm didn’t see anything in her computer to indicate that any updates were made to the care plan.

Based on interviews and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D.

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 copy of this report and copy of appeal rights provided to 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: 4 of 7
Control Number 11-AS-20200407120848
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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Any violation that the department determines resulted in the injury or illness of a resident. On 3/3/2020 R1 was left unsupervised and fell, resident sustained injury which resulted in subdural hematoma, “likely exacerbated by fall.” This poses an immediate health and safety risk to residents in care.
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Submit written plan on how facility plans to ensure residents are provided with the services required and outlined in their service care plan.
Type B
04/08/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights- To be accorded safe, healthful & comfortable accommodations… This requirement not met as evidenced by: On 3/3/2020 Resident #1 sustained an unexplained injuries at the facility. This poses an potential personal rights risk to resident in care.
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Submit written plan on how facility will ensure staff are capable of using transferring techniques without injuries to resident.
Type B
04/08/2022
Section Cited
CCR
87411(a)
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Personnel Req- Facility personnel shall at all times be sufficient in numbers, and competent...This requirement not met as evidenced by: on 3/3/2020 facility was unable to find/ secure a private pal for R1. This poses a potential health and safety risk to resident in care.
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Submit written plan on how facility plans to ensure that residents have a private pal if service is required.
Type B
04/08/2022
Section Cited
CCR
87463(a)
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Reappraisals The pre-admission appraisal shall be updated, in writing... This requirement not met as evidenced by: On 1/11/2020 R1 was hospitalized due to a fall, R1 had a c head injury with a small amount of hemorrhage, an appraisal is not available. Poses a potential health and safety risk.
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Administrator will review Title 22 section 87463, submit written statement indicating moving forward will ensure to document and update reappraisals of residents for changes in their physical, medical, mental and social condition.
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: 5 of 7
Control Number 11-AS-20200407120848
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)
Type B
04/08/2022
Section Cited
CCR
87411(d)
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All personnel shall be given on the job training... This requirement not met as evidenced by: On 3/3/2020 facility failed to ensure safety of resident by not using fall preventatives. This poses a potential health and safety risk to residents in care.
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Administrator will submit written statement indicating staff will be appraised about residents needs, if safety equipment is utilized, staff will be trained on how, when, and where equipment/ safety measures are to be used.
Type B
04/08/2022
Section Cited
CCR
87405(h)(5)
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Provide or ensure the provision of services to the residents... This requirement not met as evidenced by: Administrator didn’t not ensure that staff provided R1 with the services needed to meet residents needs. This poses a potential health and safety risk to resident in care.
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The Administrator shall review the performance of each staff members assisting the residents. The actions will be taken based on staffs performance, to assure that the residents are receiving services per their care plan.
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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: 6 of 7
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
04/07/2020 and conducted by Evaluator Jey Cardenas
COMPLAINT CONTROL NUMBER: 11-AS-20200407120848

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: DATE:
04/01/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Director of Resident Care Services, Nina KhatchatrianTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff did not timely respond to resident's call for help
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jey Cardenas conducted a subsequent complaint visit to facility to deliver complaint findings for the allegation listed above. Upon arrival at the facility LPA conducted a risk assessment and based on the assessment; the facility is clear of Covid-19 infection. Director of Resident Care Services, Nina Khatchatrian assisted LPA with visit and the purpose of the visit was explained.

-Staff did not timely respond to resident's call for help- Six out of seven resident interviewed indicated that staff respond in a timely manner when residents request for assistance. R7 indicates that one time staff was called and staff didn’t show up until ten minutes later, reason for call couldn’t be recalled. None of the staff interviewed reported that residents calls are not being answered in a timely manner.
Based on LPA’s interviews conducted the preponderance of evidence standard has not been met. Therefore, the above allegation is found to be unsubstantiated Per California Code of Regulations. Exit interview conducted copy of this report provided to Nina Khatchatrian.
Unsubstantiated
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: 7 of 7