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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 09/21/2023
Date Signed: 09/22/2023 07:17:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/28/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20230828162757
FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:CINDY LICHTENHANFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:72CENSUS: 57DATE:
09/21/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Terri Ford TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff are not addressing a scabies outbreak.
Staff restrained resident.
Staff do not ensure facility is clean.
INVESTIGATION FINDINGS:
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On 09/21/2023 Licensing Program Analysts (LPAs), Kimberly Viarella and Maja Jensen made an unannounced visit to this facility to continue with a complaint investigation regarding the above allegations. The LPAs identified themselves, the reason for the visit, and asked to meet with the Designated Facility Administrator. LPAs met with Terri Ford, the Director of Health and Wellness. A brief interview followed.

Staff are not addressing Scabies outbreak.
Belmare Senior Living provided this LPA with their Policy and Procedure for Scabies. The policy was issued on 09/2018 and revised on 06/2020. When residents or staff experienced symptoms, Belmare Senior Living instructed them to obtain skin scrapings as proof that they had scabies, however, at the bottom of the first page of their policy it clearly states, “Failure to positively identify scrapings does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites may cause multiple lesions.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
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 6
Control Number 27-AS-20230828162757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 09/21/2023
NARRATIVE
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Often diagnosis is made from the signs and symptoms and treatment followed without scrapings.” The facility was not following its own policy and procedure and therefore the outbreak was not being addressed. Based on the preponderance of the evidence, this allegation has been SUBSTANTIATED. The deficiency was cited on the LIC 9099 D page.

Staff restrained resident.

During a tour of memory care today, this LPA observed R1 in a wheelchair secured with a seat belt across her lap. The preponderance of the evidence has been met, this allegation has been SUBSTANTIATED and the deficiency is cited on the LIC 9099 D page.

Staff do not ensure facility is clean.

On 09/21/23, this LPA made a cursory tour of 3 resident bedrooms in Memory Care and 2 out of 3 beds did not have sheets. One room had an exposed soiled mattress cover. Another resident's bed had a dark mattress protector, with no sheets and just covers on top of the bed. The preponderance of evidence has been met, the allegation has been SUBSTANTIATED. The deficiency is cited on the LIC 9099 D page.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/28/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20230828162757

FACILITY NAME:BELMARE SENIOR LIVINGFACILITY NUMBER:
502701207
ADMINISTRATOR:CINDY LICHTENHANFACILITY TYPE:
740
ADDRESS:1450 WEST F STREETTELEPHONE:
(209) 764-3164
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:72CENSUS: 57DATE:
09/21/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Terri Ford TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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2
3
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5
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9
Staff do not ensure resident is fed timely.
INVESTIGATION FINDINGS:
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On 09/21/2023 Licensing Program Analysts (LPAs), Kimberly Viarella and Maja Jensen made an unannounced visit to this facility to continue with a complaint investigation regarding the above allegations. The LPAs identified themselves, the reason for the visit, and asked to meet with the Designated Facility Administrator. LPAs met with the Director of Health and Wellness, Terri Ford. A brief interview followed.

Staff do not ensure resident is fed timely.

Lunch was brought over from the main building at approximately 11:45 AM. LPAs arrived in the dining area of Memory Care at approximately 12:00 PM and observed 11 residents in attendance, 2 visitors, and 2 carestaff serving, with a third staff member present preparing for a resident activity. LPAs observed the process and then followed up by visiting the other residents who did not join their peers in the main dining room. LPAs observed these residents eating in their rooms. The preponderance of the evidence has not been met, this allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
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 6
Control Number 27-AS-20230828162757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
87608(a)(3)
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(a) ... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need ... maintained in the resident’s record. The licensing agency may require... The facility failed to meet the above requirement as evidenced by:
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Licensee has immediately posted a sign on the wheelchair that the seatbelt is not to be used as it is against regulations. If physician's note is provided, then sign will be removed.
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The facility did not include a doctor's note in R1's file indicating the need for a postural support.
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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: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 27-AS-20230828162757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/22/2023
Section Cited
CCR
87465
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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed...(9) The licensee shall ensure that infection control practices are maintained in the facility... The facility failed to meet the above requirement as evidenced by:


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Licensee has agreed to provide an attestation to kimberly.viarella@dss.ca.gov that in the future it will adhere to its own infection control plans and policies. This will be comleted by the close of business on 09/22/2023.
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The facility required residents and staff to provide skin-scraping tests as evidence that they had scabies when their own policy stated that it was not necessary.
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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: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20230828162757
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times...

The facility failed to meet this requirement as evidenced by:
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Licensee shall increase the number of housekeeping hours designated to Memory Care by an additional 12 hours per week and will also supply sheets when needed. Licensee will submit a template of scheduled hours to kimberly.viarella@dss.ca.gov by 09/28/2023.
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This LPA observed that 2 out of 3 resident beds either had soiled mattress protectors or were missing sheets and only had a mattress protector. One room was also malodorous.
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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: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6