374603231-8-19-2021-08-AS-DPOL-C6EKZS-20210831082110

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603231
Report Date: 08/19/2021
Date Signed: 08/19/2021 11:06:03 AM

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
12/11/2019 and conducted by Evaluator Elizabeth Hamilton

COMPLAINT CONTROL NUMBER: 08-AS-20191211140826

FACILITY NAME:	BELMONT VILLAGE CARDIFF		FACILITY NUMBER:	374603231
ADMINISTRATOR:	SHERYL JOHNSTON		FACILITY TYPE:	740
ADDRESS:	3535 MANCHESTER AVE		TELEPHONE:	(760) 436-8900
CITY:	CARDIFF BY THE SEA	STATE: CA	ZIP CODE:	92007
CAPACITY:	175	CENSUS: 139	DATE:	08/19/2021
		UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Executive Director, Ashely Marcellus and Director of Resident Care Services, Deenna Lyons		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Licensee did not meet residents needs
Licensee did not maintain resident(s) room in a sanitary condition
Licensee did not assist with incontinence care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA identified herself, was granted access to the facility and met with Executive Director (ED), Ashely Marcellus and Director of Resident Care Services (DRCS), Deenna Lyons. LPA explained the purpose of the visit, which was to deliver findings for the above allegations.

The Department’s investigation consisted of records review, interviews with staff, residents and outside sources.

It was alleged that in December 2019, licensee did not meet residents needs. Interviews with staff and residents determined that all residents have a pendant and/or call light to request assistance. Statements indicated the longest response time was up to fifteen minutes. However, it could take more time depending on how many calls received, the location of the call and the amount of staff on shift. Records reviewed showed the average response time for the entire month of December 2019 was nine minutes and twelve seconds.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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 08-AS-20191211140826

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: 08/19/2021

NARRATIVE

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It was alleged that in December 2019, licensee did not maintain resident(s) room in a sanitary condition. Interviews with outside sources determined that Resident 1 (R1) and Resident 2 (R2) room was observed as clean and sanitary. Interviews with staff, other residents and records reviewed confirmed resident rooms were cleaned daily and if extra cleaning was needed, it was provided by either housekeeping or the caregivers.

It was alleged that in December 2019, licensee did not assist with incontinence care. Interviews with staff confirmed residents who need assistance are checked every two hours for incontinence care needs. Interviews with residents and staff corroborated residents can call for additional assistance with incontinence through their pendants and/or call lights as needed. Interviews with outside sources and records reviewed determined there were no concerns with incontinence care during the time frame in question.

The Department has investigated the above allegations Based on evidence obtained, including interviews and records reviewed, the allegations are determined as unsubstantiated as the Department could not meet the preponderance of the evidence standard.

An exit interview was conducted with ED Marcellus and DRCS Lyons and a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) was provided to ED via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC9099 (FAS) - (06/04)

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