565802433-4-13-2023-29-AS-DPEA-CR9K58-20230426073532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802433
Report Date: 04/13/2023
Date Signed: 04/13/2023 10:46:56 AM

Substantiated

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
12/29/2021 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20211229143919

FACILITY NAME:	BELMONT VILLAGE THOUSAND OAKS		FACILITY NUMBER:	565802433
ADMINISTRATOR:	KEITH PAYNE		FACILITY TYPE:	740
ADDRESS:	3680 N MOORPARK RD		TELEPHONE:	(805) 496-9301
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	158	CENSUS: 112	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cyntia Drachenberg		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Lack/Neglect of supervision resulted in injury/death.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Executive Director (ED), Cyntia Drachenberg and explained the reason for the visit.

On 12/29/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) falling and sustaining a traumatic subdural hematoma which resulted in death. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Robert Kujawa.

Report Continued on LIC 9099C...

Substantiated

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: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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-20211229143919

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: 04/13/2023

NARRATIVE

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Report Continued from LIC 9099...

On 12/30/2021, from 1:30pm to 3:15pm, LPA conducted an initial complaint visit for the above allegation. LPA met with the Administrator, Dina Davis and explained the reason for the visit. During the visit the LPA interviewed the Executive Director and Nurse Liaison, reviewed files and obtained copies of pertinent documents relevant to the investigation.

On 03/15/2022, at approximately 4:57pm, Investigator Kujawa conducted interviews with the Administrator; on 4/21/2022, from approximately 11:45am to 4:25pm, with the facility LVN, staff, and residents. Additionally, Investigator Kujawa reviewed hospital medical records and facility file documents related to R1 including the Unusual/Injury Incident report (SIR), Assessment and Care Plan, Hospice care patient information, and County of Ventura Certificate of Death.

Interviews conducted and facility records reviewed revealed that R1 was admitted to the facility on 5/21/2021. Per R1’s Resident Assessment and Service Plan dated 10/05/2021, reflected that R1 required assistance for both continence and toileting and was a fall risk. Interviews conducted revealed that on 12/20/2021, Staff #1 (S1) called on their radio for assistance in bringing additional gloves, but the radios were not working properly. Hence, R1 was left unattended in the bathroom while S1 exited the room, walked down the hallway, and retrieved the gloves from the laundry room. When S1 returned to R1’s room, R1 was found on the bathroom floor with a cut to their left eyebrow. R1 was assessed and 911 was called which then transported R1 to the hospital.

Record review revealed that on 12/20/2021, R1 was admitted to the hospital with a diagnosis of a forehead laceration and traumatic subdural hematoma. Furthermore, R1 was discharged from the hospital on 12/22/2021 back to the facility; however, upon discharge, R1 was admitted to Assisted Hospice Care where it stated, ‘fell and hit head and now has subdural hemorrhage’ and for terminal diagnosis stating, ‘traumatic subdural hemorrhage’. Ultimately, R1 passed away while in the facility on 12/27/2021.

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: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211229143919

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: 04/13/2023

NARRATIVE

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Report Continued from LIC 9099C...

Based on all information gathered during the course of the investigation, the Department determined that the facility staff failed to provide care and supervision to R1 by leaving them unattended, which resulted in R1 falling and sustaining a traumatic subdural hematoma which subsequently resulted in the death of R1. Therefore, the allegation “Neglect/Lack of Supervision resulted in injury/death of Resident #1 (R1)” is deemed substantiated at this time.

A $500 immediate civil penalty is assessed today. The Executive Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20211229143919

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/13/2023 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	§1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan on how the facility will ensure appropriate resident care and supervision to all residents and submit to CCL by 04/24/2023.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff did not supervise R1 which resulted in R1’s fall sustaining a traumatic subdural hematoma resulting in death, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)
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	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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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