374603231-8-29-2023-08-AS-DPOL-CV8S82-20230831133825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603231
Report Date: 08/29/2023
Date Signed: 08/29/2023 01:58:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
06/02/2023 and conducted by Evaluator Sabel Martinez

COMPLAINT CONTROL NUMBER: 08-AS-20230602142424

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: 137	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Director of Resident Care Services, Elizabeth Smith		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Neglect/lack of supervision resulted in resident sustaining injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Director of Resident Care Services, Elizabeth Smith.

Throughout the investigation, the Department secured pertinent records and conducted interviews with staff, resident, and outside sources.

It was alleged neglect and lack of supervision resulted in resident sustaining injuries. It was reported to the Department Resident # 1 (R1) had a fall resulting in a forehead laceration and abrasion to the knee. The reporting source reported concerns as R1 had suffered approximately seven falls within a week.
Review of records obtained from the facility revealed R1 had sustained approximately five falls between 4/18/23 through 4/25/23, when R1 was transported to the hospital with a laceration to the forehead. Electronic mail communication between the facility and R1’s daughter revealed the facility and daughter had worked together to obtain a new mattress, a gait belt and a physician’s order for bed rails.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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-20230602142424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE CARDIFF	FACILITY NUMBER: 374603231
	VISIT DATE: 08/29/2023

NARRATIVE

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Although, records obtained from the facility revealed R1 had sustained nineteen incidents from 3/17/23 to 8/12/23, interviews with staff, R1 and external sources did not reveal any concerns with lack of supervision, nor neglect. It was revealed staff would encourage R1 to call staff when assistance was needed, but R1 would not. R1 would remove R1’s incontinence brief causing the floor to become slippery and as a result, R1 falling when attempting to use the bathroom.

During an interview with R1, R1 corroborated R1 often did not use R1’s call pendant to request assistance from staff. R1 did not have any concerns with assistance from staff and indicated staff continued to check in throughout the day and encourage R1 to use R1’s pendant.

Based on the evidence gathered throughout the investigation, there was not a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation was Unsubstantiated.

An exit interview was conducted with Smith, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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