435202351-3-26-2024-26-AS-KHOS-D6BHRZ-20240617062621

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202351
Report Date: 03/26/2024
Date Signed: 03/26/2024 09:07:54 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2022 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220928084540

FACILITY NAME:	BELMONT VILLAGE SUNNYVALE		FACILITY NUMBER:	435202351
ADMINISTRATOR:	LOLA BULLOCK		FACILITY TYPE:	740
ADDRESS:	1039 E EL CAMINO REAL		TELEPHONE:	(408) 720-8498
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	150	CENSUS: 121	DATE:	03/26/2024
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	LOLA BULLOCK		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not assist resident with obtaining medical care

INVESTIGATION FINDINGS:

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On 3/26/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Lola Bullock and explained the purpose of today's visit.

Regarding the allegation of Staff did not assist resident with obtaining medical care, the Reporting Party (RP) stated that resident (R1) fell during an outing, was assessed, and did not refuse to be sent out to the emergency room, however staff took 3-4 hours before deciding to send R1.

Based on record reviews, progress notes obtained from the facility stated that R1, despite complaints of back pain, was just provided first aid and water during the outing. No calls were made to 911 to send R1 to emergency room for further assessment. When R1 has returned to the facility and was assessed, the facility then called 911 and R1 was sent to emergency room.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 26-AS-20220928084540

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
	VISIT DATE: 03/26/2024

NARRATIVE

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LPA Donato also interviewed 2 staff members, S1 & S2, and both confirmed that 911 was not called when the incident happened.

Therefore, based on interviews and records review and information collected, the above allegation is
determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22
cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

A copy of this report and the Appeal Rights are provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20220928084540

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/27/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. ... and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.	1 2 3 4 5 6 7	Licensee to submit a plan to ensure compliance to provide Incidental and Medical care to residents. Licensee to submit by POC due date
	8 9 10 11 12 13 14	This was not met as evidenced by: Based in interviews & record reviews, no calls were made to 911 to send R1 to emergency room for further assessment when R1 fell during outing which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2022 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220928084540

FACILITY NAME:	BELMONT VILLAGE SUNNYVALE		FACILITY NUMBER:	435202351
ADMINISTRATOR:	LOLA BULLOCK		FACILITY TYPE:	740
ADDRESS:	1039 E EL CAMINO REAL		TELEPHONE:	(408) 720-8498
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	150	CENSUS: 121	DATE:	03/26/2024
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	LOLA BULLOCK		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility signal system not maintained operable

INVESTIGATION FINDINGS:

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On 3/26/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Lola Bullock and explained the purpose of today's visit.

Regarding the allegation of facility signal system not maintained operable, RP stated that R1s personal signal system was not working in the room. RP states that during the time that the signal system was broken, RP also mentioned that R1 t had to wait "for hours" to receive assistance.

LPA Dolores visited the facility on 10/03/2022 and tested the response time of staff together with Director of Resident Services (DRS) Joshua Lambengco. LPA Dolores tested the signal system in three rooms and the response time was between 3-10 minutes. DRS also mentioned during an interview that the expectation to acknowledge the call is 5-10 minutes.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20220928084540

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
	VISIT DATE: 03/26/2024

NARRATIVE

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Based on records review, from 09/09/2022 – 09/10/2022, the room of R1 pulled the switch for assistance fifteen times. Acknowledgement time was between 0-17 minutes. There was only one instance where the time was 17 minutes and this was during dinner time in the facility.

Based on interviews and records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5