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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601646
Report Date: 01/05/2024
Date Signed: 01/05/2024 01:35:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/29/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20231229084545
FACILITY NAME:BELMONT VILLAGE RANCHO PALOS VERDESFACILITY NUMBER:
198601646
ADMINISTRATOR:BALBIN, RALPHFACILITY TYPE:
740
ADDRESS:5701 CRESTRIDGE RDTELEPHONE:
(310) 377-9977
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:150CENSUS: 125DATE:
01/05/2024
UNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Ralph Balbin/Executive DirectorTIME COMPLETED:
01:34 PM
ALLEGATION(S):
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Facility staff are not taking measures to prevent the spread of contagious diseases.
INVESTIGATION FINDINGS:
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On 1/5/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Ralph Balbin /Executive Director. LPA explained the purpose of this visit.

Investigation Consisted of the Following:
Administrator’s Interview (A#1), Resident interviews (R#1-R#11), Staff interviews (S#1-S#11), a complete tour of the facility. LPA obtained and reviewed the following documents: Resident’s Roster, Personnel Roster, Copy of the LIC 9282-Residential Infection Control Plan, Copy of LIC 610E-Emergency and Disaster Plan for Residential Care Facilities for the Elderly, Copy of COVID-19 Overview and Infection Prevention and Control Priorities in non-U. S Healthcare Settings, Copies of Staff In-Services from January-November 2023 and sign in sheets.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
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 3
Control Number 11-AS-20231229084545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES
FACILITY NUMBER: 198601646
VISIT DATE: 01/05/2024
NARRATIVE
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Allegation: Facility staff are not taking measures to prevent the spread of contagious diseases.

The details of the complaint alleged that facility staff are not taking measures to prevent the spread of contagious diseases.


During the records review, LPA observed the Facility’s Residential infection control plan and the Emergency and disaster plan for residential care facilities for the elderly; both plans are current and updated. Also, LPA observed guidelines regarding how to prevent infection by COVID-19. In addition, LPA reviewed the In-services done by the facility to the staff from January to November 2023. LPA observed in the in-service topics such as Universal precautions for infection control, COVID-19 plan, COVID-19 testing sites and kits, Use of PPE (Personal Protective Equipment) when handling COVID-19-positive residents, and Bloodborne pathogens and PPE.

During a physical tour of the facility, LPA observed sanitation stations distributed in the common areas and signs regarding washing hands at all times.

During an interview with the Administrator (A#1), he stated that as of today, there is no outbreak at the facility, and when it comes to following proper infection precautions, LPA asked the Executive Director what the protocol is. He responded ‘’When we have an infection precaution happening with the residents. First, we isolate the possible positive resident; we do contact tracing to see how many people the resident has been in contact with, and then we disinfect common areas and surface areas. For the resident in isolation in their apartment, we used PPE and have a station outside their room for the staff. When we have a positive case, we serve food in their apartment and use disposable plates. We do have 24/7 nurses at the facility, and we check frequently the positive resident.’’ In addition, LPA asked the Executive Director if the facility was following PIP (Proper Infections Precautious). Does the facility have an emergency plan in place for an infectious outbreak? Is your staff trained to follow PIP? Would your staff follow PIP (Proper Infections Precautions) during an outbreak? He answered yes to all the questions.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20231229084545
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES
FACILITY NUMBER: 198601646
VISIT DATE: 01/05/2024
NARRATIVE
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During interviews with staff (S#1-S#11), (11) out of (11) stated that currently there is not an outbreak at the facility, and the protocol when it comes to following proper infection precautions is the following: Once a resident tested positive, we quarantine the resident then we put a PPE station outside their room then we informed their physician and family members then we do contact tracing and disinfection of surfaces. After the sixth day, they can leave their room if they are not showing symptoms. Also, (11) out of (11) staff stated that the facility is following proper infection precautions, has an emergency plan in case of an infectious outbreak, is trained in following proper infection precautions, and would follow the steps.

During interviews with residents (R#1-R#11), (10) out of (11) residents stated that the facility does a good job when it comes to following proper infection precautions, and they have seen staff wearing masks in the past or when needed.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.


California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of the Complaint Report was given to Ralph Balbin /Executive Director.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3