565802433-4-20-2023-29-AS-DPEA-CR9M4W-20230426091724

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802433
Report Date: 04/20/2023
Date Signed: 04/20/2023 02:29:54 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
01/03/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20220103142826

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: 111	DATE:	04/20/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Cyntia Drachenberg		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Inadequate lighting during power outage
Inadequate back-up power supply for healthcare devices
Inadequate staffing to ensure resident safety

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 01/11/2022 by LPA Guzman Chavez and a subsequent visit was conducted on 04/13/2023 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 01/11/2022, LPA Guzman Chavez interviewed the Nurse Liaison and requested copies of pertinent documents. On 04/13/2023, LPA Arroyo conducted a plant tour to ensure there are no immediate health and safety concerns at 11:50am, conducted a tour of the Memory Care unit and observed random resident bedrooms at 11:57am, and conducted interviews with the ED and three staff between 11:44am and 3:23pm. 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-20220103142826

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 alleged that there was inadequate lighting during power outage. It was reported that only the emergency hallway lighting was functioning, but no power was available inside the bedrooms. Interviews conducted with staff revealed there was a power outage at the facility on 12/31/2021 between 9:00am and 7:00pm. During a power outage, the facility’s generator takes over and all the emergency lighting throughout the facility turns on. Although the facility has emergency lighting all across the hallways, there is no emergency lighting that turns on inside the bedrooms. However, during the plant tour, it was revealed that every bedroom in the Memory Care unit has a window with functioning blinds that can be opened to let natural light in during the day. Furthermore, while emergency lighting is not available inside the bedrooms, the facility has at least thirty-five (35) battery operated flashlights that are available for residents during any type of emergency. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “inadequate lighting during power outage”. Therefore, the allegation is deemed Unsubstantiated at this time.

It was also alleged that there was inadequate back-up power supply for healthcare devices. It was reported that residents could not use their medical devices because they required power by a wall jack that were not functioning due to the power outage. Interviews conducted with staff revealed the facility has the capacity to switch all oxygen tanks to portables for all residents that need oxygen. Additionally, the facility has emergency outlets that work during a power outage that are sourced by the generator. Each floor has two (2) emergency outlets that are located by the panel box. During the Memory Care unit tour, it was revealed that there are two (2) emergency power outlets about twenty-five feet from the entrance. Similarly, in past events, if any medical devices require an outlet with electricity, the staff will escort the residents to the outlets so that they can continue using the necessary medical devices. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “inadequate back-up power supply for healthcare devices”. 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-20220103142826

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 there was inadequate staffing to ensure resident safety. It was reported that the front door to the facility was unlocked as was the door leading into the Memory Care unit. Additionally, staffing in the evening was usually low as there was only three staff inside the Memory Care unit. Review of staff schedules revealed the facility maintained about four (4) to five (5) staff in the Memory Care unit. On the day of the power outage, staff schedules indicate the facility had four (4) staff for morning shift, 6:30am – 2:45pm, and five (5) staff for the afternoon/evening shift, 2:30pm – 10:45pm. Correspondingly, the facility places at least two (2) staff in each floor and will move staff throughout the facility as needed during a power outage. Similarly, staff go around making sure all the residents are doing well, are aware of the situation, and making sure the residents know that they are not alone at any time. Since the doors leading into the Memory Care unit are powered by electricity, they are kept opened; however, a staff is placed on both ends of Memory Care to ensure residents do no leave the facility unassisted. Furthermore, although the facility was short staffed through their permanent staff, the facility was utilizing staff agencies to compensate and make sure they had enough staff at all times. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “inadequate staffing to ensure resident safety”. Therefore, the allegation is 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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