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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802433
Report Date: 02/11/2021
Date Signed: 02/11/2021 02:58:22 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20200917131943
FACILITY NAME:BELMONT VILLAGE THOUSAND OAKSFACILITY NUMBER:
565802433
ADMINISTRATOR:KEITH PAYNEFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:158CENSUS: 107DATE:
02/11/2021
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Keith PayneTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Due to physical abuse, resident sustained hip fractures while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced complaint visit to deliver the findings for the above allegation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation was conducted telephonically with Executive Director Keith Payne.

On 9/17/2020, the Department received a complaint stating that on 9/15/2020, Resident #1 (R1) was admitted to the hospital with bi-lateral hip fractures. Community Care Licensing Division’s Investigations Branch (IB) Investigator Douglas Real was assigned to the case. On 9/18/2020, the LPA interviewed the Executive Director at 9:18am. Investigator Real reviewed medical records on 9/30/2020, reviewed police notes on 11/23/2020, and conducted staff interviews on 11/13/2020.

CONT 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021
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 2
Control Number 29-AS-20200917131943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE THOUSAND OAKS
FACILITY NUMBER: 565802433
VISIT DATE: 02/11/2021
NARRATIVE
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The investigation revealed that on 9/15/2020, R1 was seated in their shower chair and was tended to by Staff #1 (S1) and Staff #2 (S2). While sitting in the shower chair, R1 suddenly leaned their head back and body became stiff. Witnesses claimed that R1’s eyes were wide open, teeth clenched, and R1 began to shake. It appeared that R1 was experiencing a seizure. R1’s head and shoulders were leaned back while R1’s legs and hips were locked forward. During the seizure, R1’s legs were crossed at the ankle. S1 remained with R1, and S2 went to call for help. S1 claimed they heard two loud snaps and assumed that R1 had broken one or more bones. Thereafter, R1 loss consciousness. Paramedics were called and R1 was taken to the hospital.

During the seizure, witnesses claimed R1 never fell, hit their head, or injured any part of their body. R1 was assessed and staff did not find any marks, bruising, or external injuries indicating a fall or other incidents. A review of Facility Progress Notes did not mention any falls prior to the 9/15/2020 incident. Interviews revealed that none of the facility residents nor the staff ever reported any abuse or neglect by S1 or S2.

Hospice admittance paperwork revealed that it was suspected that R1 had a seizure, as R1 had elevated lactic acid. A CT scan showed displaced left and right proximal femur fractures and an L1 compression fracture. In addition, no external marks or injuries were noted in the hospital notes. A review of R1’s facility appraisal and physician’s report revealed that R1 had a diagnosis of generalized weakness, was non-ambulatory, and required a two-person assistance for most activities of daily living. A review of R1’s Medication Administration Record (MAR) demonstrated that R1 was prescribed diazepam and gabapentin, which is prescribed to treat muscle spasms, anxiety, and seizures. In addition, R1 was prescribed glucosamine chondroitin and cholecalciferol (Vitamin D), which is commonly used to treat osteoporosis pain. According to Mayo Clinic, osteoporosis ‘causes bones to become weak and brittle – so brittle that a fall or even mild stresses such as bending, or coughing can cause a fracture’. Hospital notes revealed that R1 primarily ambulated with a wheelchair for mobilization and had not walked in years. R1’s family opted for comfort measures and non-operative care management, and R1 passed away on 9/18/2020.

Based on the investigation, evidence supports the claim that the cause of the injury is consistent with a medical issue. Hospital records note that R1 suffered a seizure and combined with R1’s immobility, osteoporosis pain and generalized weakness, it does not indicate that R1 suffered injuries as a result of physical abuse. A review of sheriff’s notes revealed that the incident was ruled a medical issue and abuse was not suspected. There is insufficient evidence to support the claim that R1 sustained fractures as a result of abuse. This allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was provided via email for signature.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021
LIC9099 (FAS) - (06/04)
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