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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206861
Report Date: 12/12/2023
Date Signed: 02/01/2024 02:49:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20231201085752
FACILITY NAME:BELMAR VILLAFACILITY NUMBER:
107206861
ADMINISTRATOR:HRIPSIME MAKARYANFACILITY TYPE:
740
ADDRESS:2020 NORTH WEBER AVENUETELEPHONE:
(559) 486-5977
CITY:FRESNOSTATE: CAZIP CODE:
93705
CAPACITY:100CENSUS: 71DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Hripsime, MakaryanTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident was restrained in bed
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Sarah Hurt and conducted an unannounced facility visit to deliver findings on the above allegations. LPA met with facility Administrator, Hripsime, Makaryan, and explained the purpose of the visit.

Regarding the allegation Resident was restrained in bed. LPA Hurt observed Resident 1’s bed to have full bed rails. Resident 1 is not currently on hospice, and there is no written orders for full bed rails. LPA also reviewed photos documenting a mattress pad wedged between the full bed rails of Resident 1’s bed preventing them from getting out of bed. Based on LPA's observation, and records reviewed during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time.
The following Deficiencies are being cited Per Title Regulations. Exit interview conducted with Administrator, Hripsime, Makaryan, and a copy of this report along with appeals rights provided.










Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
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 3
Control Number 24-AS-20231201085752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BELMAR VILLA
FACILITY NUMBER: 107206861
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2023
Section Cited
CCR
87608(a)(5)
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87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The following requirement has not been met as evidenced by:
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Administrator will remove the full bed rails from Resident 1's bed, and send proof to LPA by POC date of 12/13/2023.
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Based on observation and records reviewed Resident 1 is not on hospice, but their bed has full bed rails, which poses an immediate, health, safety, or personal rights risk to resident in care.
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12/05/2023
Section Cited
CCR
87468.1(a)(6)
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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: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20231201085752

FACILITY NAME:BELMAR VILLAFACILITY NUMBER:
107206861
ADMINISTRATOR:HRIPSIME MAKARYANFACILITY TYPE:
740
ADDRESS:2020 NORTH WEBER AVENUETELEPHONE:
(559) 486-5977
CITY:FRESNOSTATE: CAZIP CODE:
93705
CAPACITY:100CENSUS: 71DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Hripsime, MakaryanTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was locked in a room
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) Sarah Hurt and conducted an unannounced facility visit to deliver findings on the above allegations. LPA met with facility Administrator, Hripsime, Makaryan and explained the purpose of today's visit.


Regarding the allegation Resident was locked in a room. LPA Hurt interviewed three facility staff, and all stated Resident 1 is re directed often to prevent them from having any falls, but no staff has ever witnessed Resident 1 being locked in any areas of the facility to prevent falling. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited Per Title 22 Regulations. Exit interview conducted with Administrator, Hripsime, Makaryan, and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
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 1