198601646-12-9-2024-11-AS-UCOL-DFTQ2E-20250417114658

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 12/09/2024
Date Signed: 12/09/2024 04:41:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2024 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240807143729

FACILITY NAME:	BELMONT VILLAGE RANCHO PALOS VERDES		FACILITY NUMBER:	198601646
ADMINISTRATOR:	BALBIN, RALPH		FACILITY TYPE:	740
ADDRESS:	5701 CRESTRIDGE RD		TELEPHONE:	(310) 377-9977
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	150	CENSUS: 130	DATE:	12/09/2024
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Ralph Balbin, Executive Director		TIME COMPLETED:	04:52 PM

ALLEGATION(S):

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Lack of supervision resulting in resident wandering away from the facility.
Staff not administering resident’s medication as prescribed.
Staff did not provide medical attention to resident.
Staff confiscated resident’s belongs.

INVESTIGATION FINDINGS:

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On 12/09/24 The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted a subsequent, unannounced, complaint visit at the facility. CCLD was met by staff one, Ralph Balbin Executive Director (S1), and the purpose of the visit was explained.

The investigation consisted of the following:
On 12/09/24 CCLD staff interviewed four (4) residents out of one-hundred and thirty (130), and two (2) staff, out of one-hundred and fifty-four (154). CCLD requested additional facility documents, including the personnel report and training records of four (4) staff and communications between the two (2) parties in question. On 08/09/24 LPA requested facility documents, which include the medication admission record (MAR) of three (3) residents. LPA interviewed five (5) residents and four (4) staff.

Report continues, see LIC-9099C

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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-20240807143729

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 12/09/2024

NARRATIVE

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The investigation revealed the following: Regarding the allegation: “Lack of supervision resulting in resident wandering away from the facility.”, it has been alleged that a staff member brought a resident down to the ground floor and left the resident unobserved which resulted in a resident leaving the facility. Record reviews show that one resident (R1) had left from the facility on 11/26/24. The facility had notified CCLD of the incident of R1's departure. In the details of the nurse's notes, R1 had departed the facility with their private caregiver (PC) and two (2) additional staff from the facility. Staff were aware of R1's departure and followed the resident (R1) and PC. This resident (R1) was located and were transported back to the facility, without any changes of conditions noted. Interviews have revealed that all nine (9) residents and all six (6) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Regarding the allegation “Staff not administering resident’s medication as prescribed.”, it has been alleged a resident was not administered half of their medication for 5 days. Record reviews have revealed that R1 was in transition between the initial lease agreement, which was conducted on 09/29/23, and R1's actual date of admission on 11/22/23. The facility was not in possession of the medications in question, yet placed an order for the medications in question on 11/22/23. Interviews revealed that all nine (9) residents and all six (6) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Regarding the allegation “Staff did not provide medical attention to resident.”, it has been alleged that staff members did not provide medical attention to resident’s chronic condition which led to an infection. Record reviews have indicated that the community nurse, staff two (S2), had arrived to R1's room after the report of R1's cough, received on 07/30/24. R1's PC then informed S2 that the "as-needed" medication had already been provided. According to the facilities' medication management plan, "Residents receiving medication management services at the community, other than dementia Neighborhood residents, are expected to receive their medication at the wellness center or other designated area." which is against the facilities standard of practice. Interviews have revealed that all nine (9) residents and all six (6) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Report continues, see LIC-9099C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240807143729

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 12/09/2024

NARRATIVE

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Therefore, the above allegation has been Unsubstantiated.
Regarding the allegation “Staff confiscated residents’ belongings.”, it has been alleged that during a resident’s visit to the Dr.’s office, staff had taken all the over-the-counter, "as needed", medication from R1's room. Record reviews revealed the following: R1 was admitted under "Circle of friends" which is a program targeted towards residents with cognitive decline, with programs specifically tailored to support a variety of residents in care. According to the admissions agreement, "Residents receiving medication management services at the community, other than dementia Neighborhood residents, are expected to receive their medication at the wellness center or other designated area.". Upon discovering that the medication had already been administered by the PC, S2 held the medication to prevent a potential overdose. S1 further stated, "upon discovering the fact that medication(s) were being stored in R1's room, facility staff conducted a medication audit in R1's room which resulted in the discovery of multiple medicines being stored outside of the facilities' medication practice. This, in turn, resulted in the medication being confiscated and was later provided to R1's family member." Interviews have revealed that all nine (9) residents and all six (6) staff have denied the allegation has taken place, with Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was held with Ralph Balbin, Executive Director (S1), and a copy of this report has been provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC9099 (FAS) - (06/04)

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