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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 12/26/2024
Date Signed: 12/26/2024 04:19:39 PM

Unsubstantiated


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
10/23/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20241023142247
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:
12/26/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Lacey VincentTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff do not keep the facility free from scabies
Staff behavior poses as a risk the residents
INVESTIGATION FINDINGS:
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On 12/26/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Executive Director Lacey Vincent and explained the purpose of today's visit.

During the course of this investigation LPA Jensen conducted site visits on 3 separate occasions. LPA Jensen also interviewed 7 current staff members, 1 former staff member, 3 family members of residents and 1 external contractor paid to provide ancillary services to a resident. LPA Jensen also reviewed the infection control plan and resident records.

Allegation 1: Staff do not keep the facility free from scabies
The facility has an infection control plan that is adequate. During the course of the site visits LPA Jensen observed staff practicing appropriate infection control measures. The parties interviewed stated that the scabies outbreak was handled in a timely and appropriate manner.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
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 27-AS-20241023142247
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: 12/26/2024
NARRATIVE
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 While the facility did have a scabies outbreak there is insufficient evidence to suggest staff negligence caused the outbreak therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

Allegation 2: Staff behavior poses as a risk the residents
In the fall of 2024 (approximately October 2024), the facility underwent a change in leadership and management companies. During the course of interviews a former staff member and current staff member stated that one of the prior directors would routinely give false information to the department when complaints were being investigated. Another staff member said that a previous director gave staff insufficient information about resident needs. While these allegations are concerning and could pose a risk to residents in care there is insufficient evidence to support the allegation. The allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Technical assistance was provided on inimical conduct.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/23/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20241023142247

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:
12/26/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Lacey VincentTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff are not properly reporting incidents involving the residents
INVESTIGATION FINDINGS:
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3
4
5
6
7
8
9
10
11
12
13
On 12/26/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Executive Director Lacey Vincent and explained the purpose of today's visit.

During the course of this investigation LPA Jensen conducted site visits on 3 separate occasions. LPA Jensen also interviewed 7 current staff members, 1 former staff member, 3 family members of residents and 1 external contractor paid to provide ancillary services to a resident. LPA Jensen also reviewed the infection control plan and resident records.

LPA Jensen reviewed care staff charting notes for resident 1 (R1). Staff note that on 10/17/24 a picture of R1's rash was sent to the doctor and that R1 has scabies. On 10/18/24 staff note that scabies medication that has been administered is being tolerated well.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20241023142247
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: 12/26/2024
NARRATIVE
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While the facility states they began calling responsible parties to notify them of scabies in the facility this is not documented. During the course of interviews conducted, 2 family members advised they were made aware that there was scabies in the facility by a personal acquaintance that had been at the facility a week prior to receiving a formal phone call from staff. The allegation of "staff are not properly reporting incidents involving the residents" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20241023142247
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: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/27/2024
Section Cited
CCR
87211(a)(2)
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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences...which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours ...
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The Licensee agrees to submit a signed attestation that CCR 87211 has been read, understood and will be complied with in it's entirety.
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This requirement was not met as evidenced by LPA Jensen's verification that the Department and responsible parties were not notified with 24 hours. This poses a potential risk to the health, safety and personal rights of residents in care.
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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: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5