198601646-8-19-2021-11-AS-MVAO-C6QPBF-20210910111013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 08/18/2021
Date Signed: 08/19/2021 03:33:04 PM

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
07/26/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210726171451

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: 109	DATE:	08/18/2021
		UNANNOUNCED	TIME BEGAN:	02:08 PM
MET WITH:	Administrator Miki Lamm		TIME COMPLETED:	02:09 PM

ALLEGATION(S):

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Resident suffered multiple falls while in care.

INVESTIGATION FINDINGS:

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On 08/19/2021 around 3pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Miki Lamm.

The Investigation consisted of the following: On 08/03/2021 LPA Calderon interviewed Administrator Ruth Miki Lamm(S1) and conducted a tour of the physical plant. LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Hospital notes from 07/28/2021 fall, Physicians Report and call button log notes. On 8/03/2021 LPA Calderon interviewed S1-S3 and S4 on 08/04/2021. LPA Calderon interviewed R1 – R4 for complaint allegations. LPA Calderon noted that R1-R4 had signs of dementia.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

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-20210726171451

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: 08/18/2021

NARRATIVE

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Allegation: Resident suffered multiple falls while in care.
It is alleged Resident suffered multiple falls while in care. On 07/28/2021 LPA Calderon interviewed Witness 1 who confirmed resident 1 advised of many falls and injuries. Resident 1 also advised that money and personal items had been stolen. On 08/03/2021 LPA Calderon interviewed witness 2 who confirmed resident 1 is mother to witness 2. W2 states that R1 had lived in her home for many years until she broke her hip from a fall 2 times. R1 was moved to a facility in Long Beach CA and clamed abuse, stolen money and personal items. W2 states family moved R1 into current facility and on day 2 started to claim the exact same issues but was proven to be false. W1 does not believe that the facility ever abused R1 while in their care. On 08/03/2021 LPA Calderon interviewed S1-S4 all confirm that R1 had fallen but was not due to abuse by staff and no one had ever stolen money or personal items from R1. On 08/03/2021 LPA Calderon interviewed R1-R4 all showed signs of dementia, R1 was not able to tell LPA Calderon who stole her money and could not say why she had fallen many times. R2-R4 all claim to be happy living in the facility and staff takes care of their needs. On 08/04/2021 LPA Calderon received and reviewed Torrance Memorial Hospital notes, needs and services plan, physician report, all suggest first stages of dementia and confirm R1 had fallen with no injuries. LPA Calderon interviewed W2 and S1-S4 and according to all gathered information the resident does not wait for staff to come and assist when resident needs to transfer from her bed to her wheelchair and moves on her own causing falls. Record review reveals that staff is responding within 5 to 10 minutes after the resident pushes the call button.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

A exit interview was conducted with Administrator Miki Lamm, and a hard copy was provided for records

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC9099 (FAS) - (06/04)

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