198601646-9-2-2021-11-AS-JHAD-C9PR88-20211214114732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 09/02/2021
Date Signed: 09/02/2021 02:13:52 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
10/05/2020 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20201005152801

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: 112	DATE:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	ADMINISTRATOR MIKI LAMM		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained a fracture while in care.
Staff mismanages residents medications.
Facility does not maintain adequate staffing to meet residents needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Calderon conducted a subsequent visit regarding the above-mentioned allegation and to deliver the Investigation Bureau findings. LPA Calderon met with Administrator Miki Lamm who allowed entry into the facility.

The investigation consisted of the following: interviews with facility staff and residents, conducted a face to face interview with Administrator Miki Lamm and conducted a tour of the physical plant for health and safety. Copies obtained were current staff/resident rosters, admission agreements, medical records, unusual incident reports, previous complaint investigation reports, and other pertinent documents. The complaint was referred to the Community Care Licensing Investigations Branch and assigned to a Special Investigator.

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: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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-20201005152801

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: 09/02/2021

NARRATIVE

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Allegation: Resident sustained a fracture while in care.
It is alleged Resident sustained a fall resulting in a fracture while in care. During this investigation, IB Investigator could not interview R1 as the resident has dementia and could not answer questions. Review of R1 medical records revealed R1 was hospitalized from 9/8/20-9/13/20, for respiratory failure, likely due to congestive Heart Failure. On 9/25/21, R1 was admitted to the ER for abnormal pain, nausea, vomiting, compression fracture and the ED stated R1 was positive for a Urinary Tract Infection which may have contributed to vomiting and falls and neglect was not identified. The Reporting Party for the complaint was not a direct witness of any neglect or witness to any falls but overheard facility staff complaining about staffing concerns that contributed to R1 fall. IB Investigator interviewed R1 Family Member and she denied any neglect and stated the facility does everything to ensure the safety of R1. All Staff interviewed denied any neglect of abuse of R1. Based on records reviewed and interviewed conducted they’re in insufficient evidence to support neglect by facility staff.

Allegation: Staff mismanages resident’s medications.
Regarding the allegation it is alleged Staff mismanages residents’ medications. During this investigation, it was disclosed that LPA Calderon interviewed S1 who confirms that R1 medications is taken care of by her med-techs and there is strict documentation for each resident as to what medication is given, how much is given and to which resident so that no mistakes are made. LPA Calderon interviewed S2 who also confirms no mistakes are made regarding resident’s medications. LPA Calderon interviewed R2-R10 all confirm that their medications are correct, given on time and that staff notes in their log books the time, date, type of medication and amount for each resident. LPA Calderon reviewed R1 medications and Medication Administration Record and did not observe any discrepancies.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20201005152801

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: 09/02/2021

NARRATIVE

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Allegation: Facility does not maintain adequate staffing to meet resident’s needs.
Regarding the allegation it is alleged Facility does not maintain adequate staffing to meet resident’s needs. During this investigation, it was disclosed that LPA Calderon reviewed medical records for R1, reviewed incident reports and staff roster for the month of October 2020 and staff schedule. Based on review of the records the facility has a total of (2 of Caregivers, 1 of med techs, 1 of Nurses and 2 of Housekeepers) LPA Calderon interviewed S1 who provided staffing documentation and confirmed that she has adequate staffing to meet resident’s needs. LPA Calderon interviewed R2-R10 all confirm there are no issues with staffing, residents confirm that if they need help there is a staff member able to help or when they push the call button it takes minutes for a response.

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 face to face exit interview was conducted with Administrator Miki Lamm, and a hard copy was provided by hand for records.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

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