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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200721
Report Date: 02/10/2025
Date Signed: 02/10/2025 03:26:27 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
10/07/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241007145119
FACILITY NAME:BELMONT VILLAGE ALBANYFACILITY NUMBER:
019200721
ADMINISTRATOR:BLACKWELL,CAROLFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 173DATE:
02/10/2025
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Raquel Lozano, Business Office ManagerTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff are not providing resident with appropriate supervision, resulting in falls.
INVESTIGATION FINDINGS:
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On 02/10/24 around 02:45 PM Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for a complaint investigation. LPA met with Raquel Lozano, Business Office Manager and explained the purpose of the visit.

During the investigation, LPA requested a staff roster for Assisted Living and The Neighborhood/Memory Care (LIC 500), and resident roster. LPA requested the following for Residents (R1, R2, R3, R4, R5): current Physician's Report (LIC602), ID/Emergency Contact information, hospice care plan (if applicable), care notes, Unusual Incident Reports (UIRs), Centrally Stored Medication Records and Staff Scedule for 09/2024 and 10/2024.

Continued on LIC9099C...


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
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 2
Control Number 15-AS-20241007145119
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: 02/10/2025
NARRATIVE
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continued from LIC9099.

Facility staff are not providing resident with appropriate supervision, resulting in falls.
For the allegation, LPA reviewed Resident’s (R1, R2, R3, R4 and R5) resident records including but not limited to UIRs, Physician’s Report (LIC602), Centrally Stored Medication Reports, Care Notes, the schedule for The Neighborhood/Memory Care from 09/2024 - 10/2024, and R1’s consent for SafelyYou fall reduction. LPA confirmed R1 was diagnosed with Osteoporosis disease, had experienced fractures, had a common condition of mobility impairment that included use of walker if needed, and Dementia. Interviews with ED, Witness #4 (W4),and Staff (S2, S5, S6) revealed that not all R1’s fall were witnessed; however, falls that were unwitnessed and witnessed were documented on a UIR, 911 was activated and SafelyYou immediately reported falls to the concierge and nurse on duty. The facility appeared to be sufficient in staff when LPA reviewed the schedule for 09/2024 0 10/2024. LPA reviewed and confirmed the facility’s latest in-service and training plan of correction for all staff dated 10/08/2024 and 12/20/2024.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies are being cited during this visit, exit interview conducted, and a copy of this report provided to Raquel Lozano, Business Office Manager
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2