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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603231
Report Date: 01/13/2022
Date Signed: 01/13/2022 03:22:05 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2021 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20210811134432
FACILITY NAME:BELMONT VILLAGE CARDIFFFACILITY NUMBER:
374603231
ADMINISTRATOR:ASHLEY MARCELLUSFACILITY TYPE:
740
ADDRESS:3535 MANCHESTER AVETELEPHONE:
(760) 436-8900
CITY:CARDIFF BY THE SEASTATE: CAZIP CODE:
92007
CAPACITY:175CENSUS: 145DATE:
01/13/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ashley Marcellus, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident's personal belongings were mishandled while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close out a complaint investigation regarding the above-mentioned allegations. LPA identified herself, was granted entry, and stated the purpose of the visit to Ashley Marcellus, Administrator.

During the visit, LPA toured the facility and conducted interviews. It was alleged that resident's (R1) personal belongings were mishandled while in care. Evidence obtained from interviews revealed that R1 had their own room upon moving into the Independent-living section of the facility in January 2016. By April 2020, R1 was moved into the assisted living where they could not take their own furniture due to sharing a room with another resident. Interviews with staff revealed that R1’s responsible party declined taking the furniture and consented to having the furniture removed. During interview, responsible party denied declining to take the furniture or consenting to having the furniture discarded.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2021 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20210811134432

FACILITY NAME:BELMONT VILLAGE CARDIFFFACILITY NUMBER:
374603231
ADMINISTRATOR:ASHLEY MARCELLUSFACILITY TYPE:
740
ADDRESS:3535 MANCHESTER AVETELEPHONE:
(760) 436-8900
CITY:CARDIFF BY THE SEASTATE: CAZIP CODE:
92007
CAPACITY:175CENSUS: 145DATE:
01/13/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ashley Marcellus, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained a pressure injury while in care
Resident was financially abused while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close out a complaint investigation regarding the above-mentioned allegations. LPA identified herself, was granted entry, and stated the purpose of the visit to xx, Caregiver.

During the visit, LPA toured the facility and conducted interviews. It was alleged that resident sustained a pressure injury while in care. Evidence obtained from interviews reveals that Resident 1’s (R1) admission date was September 29, 2020. At R1’s admission it was noted that R1 had a Stage 1 pressure injury at bilateral buttocks. As of January 25, 2021, the recertification assessment showed that R1 was still at a Stage 1 pressure injury. On February 9, 2021, it was documented that R1 had a 2cm x 2cm Stage 4 pressure injury to coccyx with surrounding Deep Tissue Injury (DTI) with wound care orders placed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20210811134432
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE CARDIFF
FACILITY NUMBER: 374603231
VISIT DATE: 01/13/2022
NARRATIVE
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Documents show on February 10, 2021, that treatment notation of pressure injury medical professionals to evaluate and treat coccyx stage 4 pressure injury with surrounding DTI. On February 15, 2021, records show that R1 continued with the 2cm x 2cm stage 4 pressure injury and that R1 was receiving wound care visits three times a week. Interviews revealed that R1’s pressure injury changed to a stage 4 within days. Interview with an outside source revealed they had no concerns or issues were noted with the care that was provided to R1 by the facility caregiving staff. The outside source and caregiving staff increased the frequency of checks on R1 and to monitor their vitals. Care staff rotated R1 every two to three hours and whenever R1 had to be changed for toileting. Based on the evidence obtained from the investigation, the above-mentioned allegation is unsubstantiated.

It was alleged that the resident was financially abused while in care. Evidence obtained from resident and staff interviews revealed that (R1) was not in charge of their finances and did not have access to their money. R1 did not maintain money at the facility and staff interviews revealed that R1 did not hand out money or loan money to anyone. Interviews revealed R1 was not observed giving money to staff. Based on the evidence obtained from the investigation, the above-mentioned allegation is unsubstantiated.

An exit interview was conducted with Ashley Marcellus, Administrator . A copy of this report, and Licensee Appeal Rights (9058 01/16) were emailed to Administrator after the conclusion of the visit, LPA Holmes requested an electronic message reply to confirm receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20210811134432
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE CARDIFF
FACILITY NUMBER: 374603231
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2022
Section Cited
CCR
87468.1(a)(12)
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Personal Rights of Residents in All Facilities.Residents in all residential care facilities for the elderly shall have all of the following personal rights:To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money.This requirement is not met as evidenced by:
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Facility has a policy in place regarding residents items. The facility staff is not allowed to get rid of residents items without written/verbal consent along with documentation. Administrator will provide the policy to CCL by POC due date 01/14/2022
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Based on interviews conducted, 1 out of 139 residents’ furniture was discarded without permission from the resident or RP in April 2020. Therefore, posing a potential 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.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20210811134432
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE CARDIFF
FACILITY NUMBER: 374603231
VISIT DATE: 01/13/2022
NARRATIVE
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Conflicting information was received during other interviews, staff were not aware of the furniture being discarded, and staff did not know what happened to the furniture. Interviews with an eye witnessed revealed that during R1’s move to assisted living, the furniture was moved outside and seen with the trash. Documents reviewed during the investigation produced a letter from the prior administrator offering compensation for the furniture and other miscellaneous items to the responsible party. Based on the evidence obtained from the investigation, the above-mentioned allegation is substantiated. The deficiency is cited in accordance with California Code of Regulations, Title 22, and are recorded on the attached 9099-D (Deficiency) Page.

An exit interview was conducted with Ashley Marcellus, Administrator. A copy of this report, the LIC 9099D, and Licensee Appeal Rights (9058 01/16) were emailed to Administrator after the conclusion of the visit, LPA Holmes requested an electronic message reply to confirm receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5