565802433-9-20-2022-29-AS-DPEA-CKEV63-20221021160853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802433
Report Date: 09/20/2022
Date Signed: 09/20/2022 01:12:37 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
08/16/2021 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20210816143842

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: 113	DATE:	09/20/2022
		UNANNOUNCED	TIME BEGAN:	11:56 AM
MET WITH:	Collette Philipp (Memory Program Director)		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Illegal eviction.
Resident was able to elope from facility.

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 8/23/2021 by LPA M. Guzman Chavez. On today’s visit, LPA Arroyo met with Customer Service Specialist, Cindy Carrillo and Memory Program Director, Collette Philipp. Entrance interview conducted.

During the initial visit on 8/23/2021, LPA Guzman Chavez conducted a physical plant tour, interviewed the Interim ED, two facility staff, and obtained copies of documents pertinent to the investigation.

It was alleged that Resident #1 (R1) was illegally evicted. It was reported that R1 was being evicted from the facility and would need to leave that day immediately. Interviews conducted revealed that R1’s family member was called to the facility on 4/08/2021 by the ED following an incident. The ED then informed the family about R1’s recent behavior changes since the move-in.
(...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: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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-20210816143842

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: 09/20/2022

NARRATIVE

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(...Report Continued from LIC 9099...)

Interviews with staff revealed that R1 required a higher level of care and supervision which R1’s family expressed concern as they could not afford it. It was also revealed that R1’s family returned to the facility the following day to gather all of R1’s belongings as R1 remained at the Veterans Affairs Hospital (VAH) for five (5) months following the incident at the facility. Furthermore, interviews with R1’s family members revealed that although the ED had mentioned eviction was a possibility due to a change in behavior which the facility was not able to provide to R1, an eviction notice was not given to either R1 or their family members. Additionally, record review revealed there was no eviction notice submitted to Community Care Licensing (CCL) for R1. Based on interviews and information gathered and reviewed, the Department does not have sufficient evidence to support the allegation of “illegal eviction”. Therefore, the allegation is deemed Unsubstantiated at this time.

It was also alleged that resident was able to elope from facility. It was reported that R1’s family was asked to come to the facility because R1 had managed to exit the premises. Record review revealed that facility sent CCL an incident report for R1 regarding incident from 4/08/2021. Incident report stated R1 was able to access the secured patio area and then exit the secured area through the egress doors. ED stated on incident report that R1 was accompanied at all times by the Memory Program Director (MPD), Wellness Coordinator (WC), and Senior Enrichment Leader (SEL), in attempt to redirect R1 back to the facility. Interviews conducted revealed that R1’s family was called as soon as R1 exited the facility. R1’s family arrived at the facility and attempted to speak with R1; however, R1 refused to talk to both staff and family as R1 was agitated and aggressive. Additionally, ED stated to R1’s family that R1 was a danger to the facility and staff. Still, staff remained with R1 at all times as soon as R1 walked out the egress doors. Interviews with R1’s family reiterated that facility staff was with R1 from the moment R1 walked out the egress door and let R1 playout whatever R1 was trying to do. Based on the information obtained and reviewed during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “resident was able to elope from facility”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. A copy of report provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC9099 (FAS) - (06/04)

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