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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802433
Report Date: 06/25/2022
Date Signed: 06/25/2022 09:50:46 AM

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
03/11/2022 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-NP-20220311163324
FACILITY NAME:BELMONT VILLAGE THOUSAND OAKSFACILITY NUMBER:
565802433
ADMINISTRATOR:DINA DAVISFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: ZIP CODE:
91360
CAPACITY:158CENSUS: 105DATE:
06/25/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Roger AlabaTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility staff failed to seek timely medical attention resulting in the death of R1.

Facility failed to report change of condition to responsible party in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA met with Staff, Roger Alaba and explained the reason for the visit. Entrance interview.

On 03/11/2022, the Department received a complaint alleging that the facility staff failed to seek timely medical attention which resulted in the death of Resident #1 (R1). It was reported that R1 started having difficulty breathing around 3p.m., but the staff did not call 911 or inform R1’s family until 7p.m. By the time the paramedics had arrived, R1 had already passed away as R1s heart stopped, and emergency services was not able resuscitate R1. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Perter Zertuche.

...Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
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 3
Control Number 29-NP-20220311163324
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: 06/25/2022
NARRATIVE
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...Continued from LIC 9099C...

On 03/14/2022, LPA Guzman Chavez conducted an initial 10-day visit, interviewed the Executive Director, requested a copy of the resident and staff roster, and obtained copies of other pertinent documents. During the course of the investigation, Investigator Peter Zertuche conducted additional interviews on 04/14/2022 with the ED, staff, and resident. Additional interviews were conducted on 04/26/2022 with former staff, and on 05/06/2022 with R1’s family member.

Information gathered during the course of the investigation revealed R1 was admitted to the facility on 07/13/2019. Per R1’s Resident Medical Assessment (LIC 602) dated 07/10/2019, it reflected that R1 did not require assistance with basic activities of daily living (ADL’s) such as bathing, grooming, dressing, feeding self, toileting needs, and managing own cash resources. Additionally, R1’s was considered independent as they were able to administer their own prescription medications and leave the facility unassisted. Interviews with staff revealed that R1 had complained early in the afternoon of being tired; however, when R1’s vitals were taken, they appeared to be fine. R1 stated they wanted to rest but had no other complaints. Furthermore, interviews revealed the PM staff was aware of R1 not feeling well from earlier in the day and were continuously monitoring them throughout the afternoon and evening. The second time staff checked on R1, about an hour later, their vitals had not changed. However, on the third check -up, before 7p.m., R1’s oxygen level was low, so the facility called 911. Record review revealed that paramedic arrived at the facility at 7:13 p.m. after receiving a call regarding R1 having breathing problems. R1 went into cardiac arrest while in the presence of the paramedics. However, because R1 had a DNR on file, paramedics did not try and resuscitate them on the spot. Interviews with family members conducted reiterated that R1 was independent and verbal and communicated that they did not want to go to the hospital.

...Continued on LIC 9099C...

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-NP-20220311163324
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: 06/25/2022
NARRATIVE
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...Continued from LIC 9099C...

Additionally, R1’s family was aware of the DNR on file and respected R1’s decision and did not want to override it. Furthermore, interviews conducted revealed that family members had no concerns regarding facility neglecting R1. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “facility staff failed to seek timely medical attention resulting in the death of R1.” Therefore, the allegation is deemed Unsubstantiated at this time.

It was also alleged that facility failed to report change in condition to responsible party in a timely manner. It was reported that R1’s family was not informed of R1 not feeling well until 7p.m. Interviews conducted, and facility files reviewed revealed that R1 felt ill in the afternoon, to which staff took R1’s vitals and they seemed okay. It was also discovered that R1’s family had visited R1 at the facility around 1p.m. and at that time, R1 had complained about breathing issues to their family, but still appeared okay. Additionally, R1’s family member had requested that facility staff monitor R1 and provide them with updates to which they did. Furthermore, interviews revealed that R1 was independent and had communicated to their family that they did not want to go to the hospital. Based on interviews and record review, the Department does not have sufficient evidence to support the allegation of “facility failed to report change in condition to responsible party in a timely manner”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. Copy of the report was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3