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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602253
Report Date: 03/27/2023
Date Signed: 03/27/2023 01:31:16 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230110140238
FACILITY NAME:BELLA VISTA AT LINCOLNFACILITY NUMBER:
198602253
ADMINISTRATOR:HAMILTON, MARKFACILITY TYPE:
735
ADDRESS:2612 N LINCOLN AVETELEPHONE:
(626) 798-9118
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:50CENSUS: 35DATE:
03/27/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amada LopezTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is withholding SSI payment
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegations. LPA met with administrator Amada Lopez and explained the reason for the visit.

---Facility is withholding SSI payment

It was alleged that the facility is withholding the resident’s Social Security Income (SSI). To investigate the allegation, LPA interviewed two (02) staff at around 10:30 AM and interviewed other parties at 12:30 PM. During interviews with Staff #1 (S1), they stated that Resident #1 (R1) often disappears for extended periods of time and their whereabouts were unknown to issue their P&I money in December of 2022.

(Cont. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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 5
Control Number 31-AS-20230110140238
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLA VISTA AT LINCOLN
FACILITY NUMBER: 198602253
VISIT DATE: 03/27/2023
NARRATIVE
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Once R1’s whereabouts were known, Staff #2 (S2) attempted to issue their P&I money, but the resident refused to take it and stated that they wish to have their full SSI money issued to them. Both S1 and S2 stated that R1 made it clear that they no longer wish to reside in the facility. S1 also stated that the facility would contact the Social Security office, remove themselves as the payee and issue any SSI income in full. During a follow-up contact to S1 on 01/26/2023 at 10:15 AM, they stated that they have submitted all forms requesting they be removed as the payee and are going to issue R1 a check for January 2023 in the full amount. During interviews with other parties, they stated that R1 made it clear to the facility that they no longer wish to reside in the facility back in December of 2022, requested full payment for January 2023 but the facility refused to issue it and kept offering the P&I money instead. Based on interviews, there is enough information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230110140238
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLA VISTA AT LINCOLN
FACILITY NUMBER: 198602253
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2023
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money….
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During the visit, LPA confirmed that the facility released Resident #1’s money. Therefore, the POC will be cleared.
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This requirement is not met as evidenced by; Based on interviews, the facility failed to release resident’s money in a timely manner which poses a potential health, safety, and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230110140238

FACILITY NAME:BELLA VISTA AT LINCOLNFACILITY NUMBER:
198602253
ADMINISTRATOR:HAMILTON, MARKFACILITY TYPE:
735
ADDRESS:2612 N LINCOLN AVETELEPHONE:
(626) 798-9118
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:50CENSUS: 35DATE:
03/27/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amada LopezTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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2
3
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9
Staff failed to safeguard resident’s personal belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegations. LPA met with Amada Lopez and explained the reason for the visit.

---Staff failed to safeguard resident’s personal belongings

It was alleged that staff were stealing Resident #1’s (R1’s) belongings. To investigate the allegation, LPA conducted a physical plant tour at around 9:30 AM, interviewed two (02) staff at around 10:30 AM, requested pertinent documents at 11:45 AM and interviewed other parties at 12:30 PM. During the physical plant tour, LPA observed that R1’s room was locked and full of valuables. During interviews with Staff #1 (S1), they stated that Resident #1 (R1) often disappears for extended periods of time, their whereabouts were unknown, but that they keep R1’s room locked until he returns.
(Cont. on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230110140238
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLA VISTA AT LINCOLN
FACILITY NUMBER: 198602253
VISIT DATE: 03/27/2023
NARRATIVE
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Both S1 and Staff #2 (S2) stated that R1 made it clear that they no longer wish to reside in the facility and requested that all of their belongings be thrown away. S1 stated that although R1’s request was clear; the value of the belongings is far too great and that, to avoid any blame or false claims, R1’s belongings will be boxed and delivered to wherever they wish. Both S1 and S2 stated that staff have never stolen anything from R1 and that R1 frequently misplaces things but later finds them. Record reviews confirmed that all of the belongings listed on R1’s inventory matched the belongings found in their room. During a follow-up contact to S1 on 01/26/2023 at 10:15 AM, they stated that they have packed up all of R1’s belongings and will deliver them to his final destination upon arrival. During interviews with other parties, they stated that staff did not steal from them, they don't want any of it anyway because they are moving to a new city, will purchase new things when they arrive, and facility can throw it all away. Based on observations, interviews and record review, there is not enough information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5