565802433-8-21-2024-29-AS-KDUK-D8CNNQ-20240821103708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 08/21/2024
Date Signed: 08/21/2024 10:37:38 AM

Document Has Been Signed on 08/21/2024 10:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	CYNTIA DRACHENBERG		FACILITY TYPE:	740
ADDRESS:	3680 N MOORPARK RD		TELEPHONE:	(805) 496-9301
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	158	CENSUS: 116	DATE:	08/21/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Cyntia Drachenberg		TIME COMPLETED:	10:40 AM

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On 08/21/2024, Licensing Program Analyst (LPA), Kelly Dulek met with Executive Director Cyntia Drachenberg for an unannounced Case Management visit to issue a civil penalty per Health & Safety (H&S) Code §1569.49(e).

On April 13, 2023, the Department concluded a complaint investigation which alleged the following allegation: Neglect and lack of supervision resulted in injury/death of a resident (R1).

The allegation was substantiated, and the licensee was cited under H&S Code §1569.312(a) Basic Services Requirements.

The investigation reviewed that on December 20, 2021, Staff (S1) called on their radio for assistance in bringing additional gloves, but the radios were not working properly. 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, 9-1-1 was contacted and R1 was transported to the hospital. Record review revealed that on December 20, 2021, R1 was admitted to the hospital with a diagnosis of a forehead laceration and traumatic subdural hematoma. R1 was discharged from the hospital on December 22, 2021, back to the facility. Upon discharge, R1 was admitted to hospice care. Per hospice admission records, R1 “fell and hit head and now has subdural hemorrhage” with a terminal diagnosis of, “traumatic subdural hemorrhage.” Ultimately, R1 passed away while at the facility on December 27, 2021.

At the time of the complaint visit on April 13, 2023, an immediate civil penalty of $500 was assessed for H&S 1569.312(a), and the licensee was informed that an additional civil penalty might be assessed based on H&S Code §1569.49(e).

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/21/2024

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The Department has concluded an analysis and has determined that a civil penalty is warranted for the death of R1 while under the care of the licensee. This is evidenced by the licensee not ensuring that R1 was afforded with adequate care and supervision in violation of H&S 1569.312(a). R1 sustained a subdural hematoma as a result of blunt force head trauma from a fall resulting in the death of R1.

Today, 08/21/2024, the Department is issuing a civil penalty per Health and Safety Code §1569.49 in the amount of $15,000 for a violation that the Department determined resulted in the death of R1. However, since an immediate civil penalty of $500 was previously issued on April 13, 2023, the amount of the civil penalty issued is reduced to $14,500.

A copy of the LIC 421D was given to the Executive Director Cyntia Drachenberg and the originals were signed.

Exit interview conducted. A copy of the report issued. Executive Director’s signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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