198601646-4-27-2021-11-AS-JHAD-C9PR44-20211214114053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 04/27/2021
Date Signed: 04/27/2021 03:59:32 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
02/24/2021 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20210224154607

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: 166	DATE:	04/27/2021
		UNANNOUNCED	TIME BEGAN:	02:27 PM
MET WITH:	ADMINISTRATOR MIKI LAMM		TIME COMPLETED:	02:28 PM

ALLEGATION(S):

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Resident's are being physically abused while in care.
Resident's are harrassed while in care.
Resident's are neglected.

INVESTIGATION FINDINGS:

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On 04/27/2021 around 10am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Miki Lamm.

The Investigation consisted of the following: On 3/01/2021 LPA Calderon interviewed reporting and received color photos of facility, on 03/02/2021 LPA Calderon interviewed Administrator Ruth Miki Lamm(S1) and interviewed S2-S6 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, MARS (3 months), Dermatology medical records, Physicians Report and Medication list). On 11/12/2020 LPA Calderon interviewed director (S2). On 03/02/2021 LPA Calderon interviewed Residents R1 – R10. On 03/25/2021 LPA Calderon received and reviewed records for R1.

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: 04/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

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-20210224154607

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: 04/27/2021

NARRATIVE

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The investigation revealed the following:

Allegation: Residents are being physically abused while in care.
It is alleged Residents are being physically abused while in care. On 03/02/2021 LPA Calderon interviewed S1 who states she has not received any reports from staff or residents of any staff members abusing residents. On 03/02/2021 LPA Calderon interviewed S2-S6 who state no staff member has abused residents and would report to administrator if this happened. On 03/02/2021 LPA Calderon interviewed R1-R10 who all confirm no abuse of residents and no knowledge of any abuses. On 03/25/2021 received and reviewed resident record for R1 did not observe any documentation of abuse.

Allegation: Residents are harassed while in care.
It is alleged Residents are harassed while in care. On 03/02/2021 LPA Calderon interviewed S1 who states she has not received any reports from staff or residents of any staff members harassing residents. On 03/02/2021 LPA Calderon interviewed S2-S6 who state no staff member has harassed residents and they would report to administrator if this happened. On 03/02/2021 LPA Calderon interviewed R1-R10 who all confirm no abuse of residents and no knowledge of any harassment.

Allegation: Residents are neglected.
It is alleged Residents are neglected. On 03/02/2021 LPA Calderon interviewed S1 who states she has not received any reports from staff or residents of any staff members not taking care of resident’s needs. On 03/02/2021 LPA Calderon interviewed S2-S6 who state staff members take care of all residents. On 03/02/2021 LPA Calderon interviewed R1-R10, 10 out of 10 residents interviewed state their needs are being met. On 03/25/2021, LPA Calderon received and reviewed records for R1 and did not observed any documentation to support R1 needs were not being met.

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

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

LIC9099 (FAS) - (06/04)

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