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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802433
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:08:38 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 OAKSFACILITY NUMBER:
565802433
ADMINISTRATOR:CYNTIA DRACHENBERGFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:158CENSUS: 106DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Cyntia DrachenbergTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not properly treat resident's wound
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. LPA Dulek conducted an additional subsequent visit on 02/14/2025. During this visit, LPA reviewed and obtained copies of
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 5
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: 02/20/2025
NARRATIVE
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additional relevant documents and discussed the allegations with the ED, who also communicated with their corporate office. 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:

It was alleged that staff did not properly treat Resident #1 (R1)’s wound. LPA reviewed R1’s records, which indicate R1 was seen by a podiatrist on 11/14/2023. The podiatrist diagnosed R1 with “contusion hallux toe left foot” and complete onycholysis hallux toe left foot.” Plan of treatment indicated “toenail hallux toe left foot cleansed; antibiotic dressing applied. Continue triple antibiotic dressing changes every day for 2 weeks.” On the same date, podiatrist wrote a prescription for triple antibiotic ointment. Medication Administration Records (MAR) for R1 indicates routine med order for Wound Care. Orders read “apply triple antibiotic ointment to left foot big toe and cover with bandaid daily for 2 weeks.” MAR indicates treatment was administered on 11/16, 11/17, 11/18, and 11/19/2023. Treatment was discontinued on 11/20/2023 with a note indicating the wound was “healed up.” Staff interviews revealed that R1 was receiving wound treatment as ordered on their foot, however at the time of the interviews, staff could not recall which foot was being treated. Additionally, interviews and documents reviewed revealed that once the wound was healed and all skin on R1’s left toe was observed intact, wound treatment was discontinued. On 12/06/2023, R1 reported to facility staff R1 had something on their toe. One of the facility nurses looked at R1’s right big toe and noted it to be discolored and swollen. Nurse took a photograph of R1’s right big toe and sent the photograph to R1’s primary care physician. After communicating with R1’s physician via email, R1’s physician sent an order to discontinue use of R1’s compression socks, an order for Doxycycline, and wrote to see podiatrist ASAP. R1’s responsible party took R1 to the podiatrist the following day. The medication order was filled, however, was never administered on the MAR, as R1 was taken out of the facility on 12/08/2023 and did not return. 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: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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 OAKSFACILITY NUMBER:
565802433
ADMINISTRATOR:CYNTIA DRACHENBERGFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:158CENSUS: 106DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Cyntia DrachenbergTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not notify resident's responsible party of a change in resident's condition.
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. LPA Dulek conducted an additional subsequent visit on 02/14/2025. During this visit, LPA reviewed and obtained copies of additional relevant documents and discussed the allegations with the ED, who also communicated with their corporate Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 02/20/2025
NARRATIVE
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office. 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:

The complaint alleges that facility staff did not notify Resident #1 (R1)’s responsible party when R1’s toe was infected. LPA reviewed care notes for R1, which do reflect regular communication with R1’s responsible person related to medication refills and other concerns. However, interview with R1’s responsible person revealed that although R1’s left toe was treated in November, facility staff did not communicate this with R1’s responsible person. Facility staff interviewed indicated that while residing at the facility, R1 was very alert and communicated daily with their responsible person via telephone. Staff interviews revealed that staff also regularly communicated with R1’s responsible person in person, via telephone, and also via email. However, there were staff changes at the facility from the time R1 resided at the facility to the time of the complaint investigation and emails were unable to be retrieved. Staff interviewed stated that they don’t recall reporting this particular change in condition to R1’s responsible party, however, typically when staff call a responsible person, it is noted in the resident’s care notes. Review of R1’s care notes showed communication with R1’s responsible person on 12/07/2023, after R1 reported their right toe was hurting. There were no care notes indicating staff informed R1’s responsible person about R1’s left toe contusion identified on 11/14/2023 during a visit with the podiatrist. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation that “staff did not notify resident’s responsible person of a change in condition,” therefore, the allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2025
Section Cited
CCR
87466
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87466 The licensee shall ensure that residents are regularly observed for changes...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement is not met as evidenced by:
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Executive Director agreed to provide training to all nurses, med techs, and care staff related to observation of the resident and documenting changes observed. Training will be provided and documentation of training will be sent to CCL by POC due date.
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Based on interview and record review, the facility did not comply with the above cited section, as R1 was diagnosed with a contusion of their left toe, however no documentation could be found indicating facility staff notified R1’s responsible person, which posed a potential health risk to resident.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5