565802433-4-20-2023-29-AS-DPEA-CRASGQ-20230427135218

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802433
Report Date: 04/20/2023
Date Signed: 04/20/2023 03:39:02 PM

Unsubstantiated

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
11/08/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20221108164440

FACILITY NAME:	BELMONT VILLAGE THOUSAND OAKS		FACILITY NUMBER:	565802433
ADMINISTRATOR:	DINA DAVIS		FACILITY TYPE:	740
ADDRESS:	3680 N MOORPARK RD		TELEPHONE:	(805) 496-9301
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	158	CENSUS: 111	DATE:	04/20/2023
		UNANNOUNCED	TIME BEGAN:	02:36 PM
MET WITH:	Cyntia Drachenberg		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident sustained multiple falls at the facility.
Facility staff did not ensure resident's personal hygiene is maintained.
Facility did not maintain resident room odor free.
Facility staff did not clean resident room.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 11/17/2022 by LPA Chochian and a subsequent visit was conducted on 04/14/2023 by LPA Arroyo. On today’s visit, LPA Arroyo met with Executive Director (ED), Cyntia Drachenberg and the reason for the visit was explained. Entrance interview.

During the initial visit on 11/17/2022, LPA Chochian toured random resident rooms at 3:20pm and conducted a resident file review and obtained copies of resident records at 4:15pm. On 04/14/2023, LPA Arroyo conducted a plant tour to ensure there are no immediate health and safety concerns at 10:48am, toured Resident #1 (R1) room at 10:58am, and conducted interviews with the ED, one staff, and one resident between 10:50am and 11:12am. At 11:25am, the LPA also conducted a resident file review and obtained copies of pertinent documents relevant to the investigation.
Report Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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 29-AS-20221108164440

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: 04/20/2023

NARRATIVE

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Report Continued from LIC 9099...

It was alleged that resident sustained multiple falls at the facility. It was reported that R1 was observed to have numerous sores and some scrapes on the forearms and elbows. Review of documents revealed that on R1’s Physician’s Report dated 04/12/2022, indicates R1 is ambulatory and is able to independently transfer to and from bed. Interviews conducted revealed R1 is not considered to be high-risk for falls; however, the staff will normally check on residents throughout the day to make sure they are doing well. On several occasions, during the wellness checks, staff has found R1 on the floor or R1 will report they had an unwitnessed fall. Record review of nurse’s notes for R1 revealed staff was communicating all incidents with R1’s Primary Care Physician (PCP) and requesting guidance as well as treating the resident for basic first-aid. Additionally, all incidents pertaining to R1 were also being reported to Community Care Licensing (CCL) as per the reporting guidelines. Furthermore, although R1 has sustained multiple falls at the facility, the staff has continuously been redirecting and advising R1 to use a walker if necessary, as R1 is able to ambulate on their own and do not require assistance. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation is due to facility/staff neglect. Therefore, the allegation is deemed Unsubstantiated at this time.

It was also alleged that facility staff did not ensure resident’s personal hygiene is maintained. It was reported that feces was observed running down both R1’s legs. Review of documents revealed that on R1’s Physician’s Report dated 04/12/2022, states R1 does not require assistance with activities of daily living (ADL) such as bathing, dressing/grooming, feeding self, caring for own toileting needs, managing own cash resources, and does not require continuous bed care. Interviews conducted revealed R1 had diarrhea for approximately two (2) weeks and was not making it to the bathroom on time. Additionally, staff was offering to shower R1 while conducting wellness checks and were willing to assist R1 in bathing if R1 agreed to be helped. Interview conducted with R1 revealed R1 does not like staff inside their room and stated they are a private person and do not need assistance from anyone. Furthermore, during the interview, R1 reported to LPA they felt the facility was meeting their needs and had no concerns while living there. Based on interviews and record review, the Department does not have sufficient evidence to support the allegation of “facility staff did not ensure resident’s personal hygiene is maintained”. Therefore, the allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221108164440

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: 04/20/2023

NARRATIVE

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Report Continued from LIC 9099C...

It was further alleged that facility did not maintain resident room odor free and facility staff did not clean resident room. It was reported that R1’s room was ‘unlivable’ with foul odors permeating the space and feces on the floor throughout. Additionally, concerns were made for R1’s safety and well-being due to the living conditions at the facility. During the tour of random resident rooms, the LPA observed the bedrooms to be clean and free of malodorous odors. However, R1’s bedroom had a few dirty dishes and had a slight smell of tobacco. Interviews with staff revealed R1 had smoked a few times inside the room before staff addressed smoking not being allowed inside the rooms. Since then, R1 has continued to smoke, but in the open patio area only. However, R1 will roll their own cigarettes inside the room causing the faint smell of tobacco at times. Similarly, interviews with staff revealed they have tried numerous times to clean R1’s room, but R1 refuses to allow anyone inside. Staff stated R1 will only allow housekeeping inside the room to change the bedsheets every week. Interviews with staff also revealed that R1 has been going to the hospital at least once a month, and that is when the staff will take advantage and conduct a deep clean in R1’s room while it is vacant. Additionally, R1 will order their meals to be taken to the room, but the staff will struggle to get the dirty plates and utensils out afterwards. Furthermore, R1 stated they did not like letting anyone inside their room and preferred to clean themselves rather than having anyone touch their things. Nevertheless, R1’s room had a clear passageway in case of an emergency and staff continue to try and clean R1’s bedroom whenever possible. Based on observation and interviews, the Department does not have sufficient evidence to support the allegations of “facility did not maintain resident room odor free” and “facility staff did not clean resident room”. Therefore, these allegations are deemed Unsubstantiated at this time.

Exit interview. A copy of report given to the Executive Director.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

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