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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:56:48 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20230814152346
FACILITY NAME:BELMONT VILLAGE ALBANYFACILITY NUMBER:
019200721
ADMINISTRATOR:MOROS, MICHELLEFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 137DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Erik Holzherr/Assistant Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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-Staff are not responding to phone calls at the facility.

-Staff are not effectively communicating with residents and their families regarding COVID outbreaks at the facility.
INVESTIGATION FINDINGS:
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On this day, 12/17/24, at 1:45 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Assistant Executive Director (AED) Erik Holzherr, and informed the reason for visit.

During the initial 10-day complaint visit on 8/21/23, LPA Lisha Holmes interviewed staff (S1, S2), obtained information, and requested for including but not limited to the following documents: staff and resident rosters; Emergency Contact information sheet for COVD-19 residents and staff; staff training log; Infection Control Plan (ICP), and proof of COVID-19 notification to residents, responsible parties, and Local Public Health.

....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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 2
Control Number 15-AS-20230814152346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BELMONT VILLAGE ALBANY
FACILITY NUMBER: 019200721
VISIT DATE: 12/17/2024
NARRATIVE
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Page 2

LPA Delmundo obtained copies of resident roster and staff schedule and conducted interviews.

Allegation: Staff are not responding to phone calls at the facility.
FM1 stated that on 08/2023 facility has COVID-19 cases and FM1 called the facility and no one was responding.

LPA Delmundo interviewed staff (S2, S3, S4 and AED) who all stated that never was there an occasion when facility phone was broken nor left unanswered. These staff stated there's always 2 staff in front - front desk and concierge - during the day and one at NOC shift. If the staff goes on break, another staff covers. LPA also interviewed a family member (FM2) who stated that whenever FM2 calls the facility, it goes through and answered. Therefore, the allegation is unsubstantiated.

Allegation: Staff are not effectively communicating with residents and their families regarding COVID-19 outbreaks at the facility.
FM1 stated the above.

LPA Holmes interviewed staff (S1 and S2) who both stated they did what they need to do when it comes to reporting and that they are very involved in reporting. LPA Delmundo interviewed AED who stated that he sends email blast to the residents' family whenever facility has COVID-19 outbreak. LPA Delmundo reviewed the documents obtained during the course of investigation which showed that the facility sent email to the residents' responsible persons informing that the facility has positive cases of COVID-19. LPA interviewed FM2 who stated that FM2 receives notifications when facility has positive cases. Therefore, the allegation is unsubstantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2