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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 09/24/2024
Date Signed: 09/24/2024 04:27:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240712161154
FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:CINDY LICHTENHANFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:72CENSUS: DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Desiree SoriaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not order resident's medication refills in a timely manner
INVESTIGATION FINDINGS:
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On 9/24/24 LPA Jensen arrived at the facility unannounced to continue a compliant investigation in to the above listed allegation. LPA Jensen met with Business Office Manager Desiree Soria and explained the purpose of today's visit.

LPA Jensen conducted interviews with staff 1 (S1), staff 2 (S2), staff 3 (S3) and Resident 1 (R1). LPA Jensen also reviewed the Centrally Stored Medication and Destruction Record (CSMDR) and Medication Administration Record (MAR) for R1 and progress notes. Based on the CSMDR R1 had a 30 day supply of medications. The CSMDR revealed that multiple prescription medication orders were filled after the 30 day mark. The MAR shows that 5 seperate medications "on hold until the medication is available".

LPA Jensen interviewed R1 who stated that she had previously had a problem with getting medication refills but the problem has been resolved since she has been assigned a new medication technician.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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 3
Control Number 27-AS-20240712161154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 09/24/2024
NARRATIVE
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Statements provided by 2 staff members corroborate that medication refills for R1 were not ordered in a timely manner in or around the month of July 2024.

Based on the interviews conducted and the records reviewed the allegation of "Staff did not order resident's medication refills in a timely manner" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20240712161154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care
....The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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The Licensee will email a plan to LPA Jensen for auditing medication administration and taking action as appropriate based on audit findings within 24 hours.
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Based on interviews conducted and records reviewed facility staff did not order refills of a resident's medication in a timely manner.
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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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3