565802433-2-14-2025-29-AS-KHEN-DE92Y6-20250225164808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802433
Report Date: 02/14/2025
Date Signed: 02/14/2025 12:57:19 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
07/26/2024 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20240726110738

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: 110	DATE:	02/14/2025
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Cyntia Drachenberg		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not seek medical attention in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the above listed allegation. Upon arrival, LPA met with staff who informed Executive Director (ED), Cynthia Drachenberg of LPA's visit. Reason for the visit was stated. Entrance interview conducted with ED.

LPA Zabel Chochian conducted an initial complaint visit on 08/05/2024. During that visit, LPA obtained copy of the resident and staff roster and pertinent information relevant to the investigation was also gathered. LPA Dulek conducted a subsequent complaint visit on 02/05/2025. During the subsequent visit, LPA reviewed and obtained copies of pertinent documents, conducted staff interviews at 12:18PM, 01:10PM, 02:30PM, 02:39PM, and 02:56PM. LPA also obtained a copy of the resident and staff roster. Throughout the course of the investigation, LPA reviewed all documents obtained, conducted telephonic interviews with additional staff and other relevant parties. The following was then determined:
Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

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-20240726110738

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: 02/14/2025

NARRATIVE

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Allegation: “Staff did not seek medical attention in a timely manner:”

The complaint alleges that Resident #1 (R1) had an infection in their toe and the facility staff did not obtain medical treatment timely. LPA reviewed medical records and facility documents for R1. R1’s history indicates that R1 had a diagnosis of neuropathy in both feet. R1 was seen by a visiting podiatrist at the facility on 11/14/2023. Podiatrist assessed R1 to have “contusion hallux toe left foot” and “complete onycholysis hallux toe left foot.” Plan of care ordered by the podiatrist on the same date indicated “toenail hallux toe left foot cleansed; antibiotic dressing applied….continue triple antibiotic dressing changes every day for 2 weeks.” An order for triple antibiotic dressing change every day for 2 weeks was given to the facility for treatment of R1’s left toe. Additionally, R1 reported to facility nurse that their right toe was hurting on 12/06/2023. Nurse took a photograph of R1’s right toe and sent it to R1’s physician the same day, which was documented through email correspondence. R1’s medical provider corresponded with the facility on 12/06/2023 and 12/07/2023 related to R1’s toe to assess and provide a treatment plan. On 12/07/2023, R1’s physician indicated for R1 to “see podiatrist ASAP.” R1’s family member took them to the podiatrist/Emergency Department on 12/08/2023. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

No citations issued related to this allegation. Exit interview conducted. A copy of today’s report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

LIC9099 (FAS) - (06/04)

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