198601646-10-14-2022-11-AS-JHAD-CL8QXR-20221116113357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 10/12/2022
Date Signed: 10/14/2022 08:42:39 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221005151408

FACILITY NAME:	BELMONT VILLAGE RANCHO PALOS VERDES		FACILITY NUMBER:	198601646
ADMINISTRATOR:	LAMM OBERG, RUTH		FACILITY TYPE:	740
ADDRESS:	5701 CRESTRIDGE RD		TELEPHONE:	(310) 377-9977
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	150	CENSUS: 106	DATE:	10/12/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Miki Lamm, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility is not addressing ants issue.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a unannounced complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Miki Lamm, Executive Director.

The investigation consisted of following: Interviews and Record reviews. On 10/12/22, LPA Soto interviewed Executive Director, Building Engineer, S#3 - S#6, R#1 - R#7. LPA requested and received the following documents on 10/12/22: Resident Roster, Staff Schedule, Work order dated 10/04/22 and Orkin contract. LPA and building engineer toured the front parking lot lights and the dining area.

Based on the LPA's investigation, the investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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 11-AS-20221005151408

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 10/12/2022

NARRATIVE

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Allegation 1 – Facility is not addressing ants issue. Interviews with Building Engineer, S#3, and S#5, communicated that a resident family member reported that they had seen ants on their table and were crawling on their plate of food. S#3 checked and did not see any ants on the plate or table. Building engineer and S#5 communicate they did see ants near the window in the dining room area, near the A/C drain. S#3 completed a work order on 10/04/22 and Building engineer called Orkin pest control on 10/05/22, they came on the same day and treated the ants. The facility no longer has ants. Residents #1 - R#7, communicate that none of them have seen ants in the dining room or their rooms. Executive Director, S#4, and S#6, communicated they had not seen or received any complaint of ants. LPA toured the dining room area near the A/C drain and saw dead ants on the window seal. LPA did not observe any live ants in the dining room area. LPA reviewed the work order dated 10/04/22, ant issue was reported and Orkin statement for 10/05/22, company did come out to treat the ants. The interviews and records reviewed did not concur with the above allegation.

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

An exit interview was conducted with Miki lamm, Executive Director, and a hard copy of report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221005151408

FACILITY NAME:	BELMONT VILLAGE RANCHO PALOS VERDES		FACILITY NUMBER:	198601646
ADMINISTRATOR:	LAMM OBERG, RUTH		FACILITY TYPE:	740
ADDRESS:	5701 CRESTRIDGE RD		TELEPHONE:	(310) 377-9977
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	150	CENSUS: 106	DATE:	10/12/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Miki Lamm, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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9

Facility parking lot lights are not working.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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 11-AS-20221005151408

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 10/12/2022

NARRATIVE

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Allegation 1 - Facility parking lot lights are not working. Interviews with S#3 - S#6 communicated that they have not noticed that the front parking lot light are not working. They have sufficient light when they exit the facility and head to their cars. Haven't really paid any attention to the parking lot lights. Executive Director communicated that no resident or staff has reported that the lights are not working. Building engineer communicated that they take it upon themselves to check monthly on the parking lot lights and the last time they checked them they were all working properly. Building engineer does not keep a formal log on the inspection he conducts on a monthly basis. R#1 - R#6, communicated that they don't really go out at night, so they do not know anything about the parking lot lights working or not. LPA toured the parking lot and observed 8 out of 12 light poles had the lights out and the one light outside the main entrance is out too. The facility called electrician and will have parking lots lights fixed. LPA observations did concur with the above allegation.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Miki Lamm, Executive Director and a hard copy of report was provided along Appeal Rights.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 11-AS-20221005151408

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/25/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidence by: Based on 8 of 12 parking lot light poles are out and 1 main entrance light out too.	1 2 3 4 5 6 7	Executive Director will create a bi-monthly log for maintenance to report monthly check on parking lot lights and provide pictures of parking lot light fixed. Provide to LPA on or before POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5