435202351-5-25-2021-26-AS-KHOS-C3ZJZ2-20210615072850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202351
Report Date: 05/21/2021
Date Signed: 05/25/2021 10:55:57 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201020104933

FACILITY NAME:	BELMONT VILLAGE SUNNYVALE		FACILITY NUMBER:	435202351
ADMINISTRATOR:	SINGH, RADHIKA		FACILITY TYPE:	740
ADDRESS:	1039 E EL CAMINO REAL		TELEPHONE:	(408) 720-8498
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	150	CENSUS: 110	DATE:	05/21/2021
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Sante Dhakal		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Resident was severely dehydrated.
Resident was not accorded dignity in relationships with staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted a subsequent investigation visit to deliver a complaint result. LPA met with the Director of Residence Care Services (DRCS) Sante Dhakal.

On 10/21/2020, LPA conducted an unannounced initial investigation tele-visit. LPA obtained a copy of staff rosters.

Between 11/10/2020 and 04/20/2021, the Department interviewed 3 staff, the alleged victim (AV), and 2 AV’s relatives. The Department also reviewed AV’s medical notes.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

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 26-AS-20201020104933

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
	VISIT DATE: 05/21/2021

NARRATIVE

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3 out of 3 staff stated there were observations and communication logs about AV being anxious and refusing to eat and drink. AV was in independent living, which meant AV did not require supervision on daily activities such as dressing, bathing, and eating from staff in the facility. AV had his/her own freedom to choose to eat or drink. 3 out of 3 staff denied AV was not accorded dignity in relationships with staff.

2 out of 2 AV’s relatives stated they were aware of AV’s psychological issue resulting in AV not consuming enough food and liquid.

Interview with AV revealed that AV was aware there were fruit juice, bottled water, and drinkable tap water readily available with AV’s meals and in AV’s room. AV believed the reason of his/her dehydration was due to his/her chronic vomiting and diarrhea. Medical notes revealed that AV had a history of hallucination. AV admitted being paranoid and anxious. AV was consciously not eating and drinking due to psychotic episode. AV denied being not accorded dignity in relationships with staff.

Based on the Department's interviews and records review, the allegations are UNFOUNDED, meaning they were false, could not have happened and/or are without a reasonable basis.

This report was reviewed with DRCS and a copy of this report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC9099 (FAS) - (06/04)

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