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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603231
Report Date: 12/20/2019
Date Signed: 07/06/2021 03:07:22 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
12/11/2019 and conducted by Evaluator Denise Powell
COMPLAINT CONTROL NUMBER: 08-AS-20191211140826
FACILITY NAME:BELMONT VILLAGE CARDIFFFACILITY NUMBER:
374603231
ADMINISTRATOR:SHERYL JOHNSTONFACILITY TYPE:
740
ADDRESS:3535 MANCHESTER AVETELEPHONE:
(760) 436-8900
CITY:CARDIFF BY THE SEASTATE: CAZIP CODE:
92007
CAPACITY:175CENSUS: 150DATE:
12/20/2019
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sheryl Johnson, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Licensee did not store cleaning products inaccessible to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Denise Powell conducted an unannounced complaint visit to follow up on above allegation. LPA met with Administrator Sheryl Johnson then conducted inspection of memory care areas. LPA observed unlocked supply storage area, with cleaning supplies accessible to dementia residents. Based on observations and allegation is substantiated. This finding means that the preponderance of evidence has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An exit interview was conducted, plan of correction was reviewed and a copy of this report was provided to Administrator Sheryl Johnson whose signature below verifies receipt of these rights.

This is an amended report. The original report was delivered on 12/20/19.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2020
Section Cited
CCR
87705(f)(1)
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Care of Persons with Dementia - The following shall be stored inaccessible to residents with dementia: other items that could constitute a danger to the resident(s).
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Licensee stated will conduct staff inservice and send sign in and materials; and will replace lock on cabinet and send invoice by POC date as verification.
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This requirement was not met as evidenced by observation of unsecured cleaning supplies in Memory Care area, inside an unlocked cabinet. This posed an immediate safety risk to 23 residents in care.
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Licensee immediately removed potentially hazardous items and put into locked housekeeping room.
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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: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
LIC9099 (FAS) - (06/04)
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