374603231-4-24-2023-08-AS-DPOL-CRBUVS-20230428155536

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603231
Report Date: 04/21/2023
Date Signed: 04/24/2023 08:06:34 AM

Unfounded

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
04/14/2023 and conducted by Evaluator Liliana Silveira

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20230414174040

FACILITY NAME:	BELMONT VILLAGE CARDIFF		FACILITY NUMBER:	374603231
ADMINISTRATOR:	ASHLEY MARCELLUS		FACILITY TYPE:	740
ADDRESS:	3535 MANCHESTER AVE		TELEPHONE:	(760) 436-8900
CITY:	CARDIFF BY THE SEA	STATE: CA	ZIP CODE:	92007
CAPACITY:	175	CENSUS: 130	DATE:	04/21/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Executive Director Ashley Marcellus		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff restrained resident in wheelchair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint visit to open a complaint investigation. LPA identified herself, stated the purpose of the visit and was granted entry by Human Resources Generalist Teri Duniphan.

While at the facility, LPA investigated and delivered findings regarding the above-mentioned allegation. LPA reviewed the findings of the complaint with Executive Director Ashley Marcellus.

The Department’s investigation consisted of interviews with staff, interviews with outside sources and a records review. On April 14, 2023, it was alleged that facility staff restrained a resident in a wheelchair. Interviews with outside sources and the Executive Director revealed that the care staff who initiated the restraint was not hired by the facility. A records review and interviews with outside sources revealed that the care staff was hired by the resident’s family as a private caregiver from a third party agency. A records review also indicated that the facility notified all appropriate agencies about the incident as required by Title 22 regulations. (continued on LIC 9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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 08-AS-20230414174040

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: 04/21/2023

NARRATIVE

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Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained from interviews and records review, we have found that the complaint was unfounded. An unfounded determination means that the allegation was false, could not have happened and/or is without a reasonable basis. The allegations were not pertinent to this licensed facility. The Department will be cross reporting this complaint to the appropriate agency for follow-up.

The report was discussed, and an exit interview was conducted with Ashley Marcellus, Executive Director. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Ashley at the conclusion of the visit. The signature below confirms the receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

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