502701207-9-26-2023-27-AS-KHOS-CW5KB7-20230929074505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 09/26/2023
Date Signed: 09/26/2023 02:16:09 PM

Unsubstantiated

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
08/22/2023 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20230822134442

FACILITY NAME:	BELMARE SENIOR LIVING		FACILITY NUMBER:	502701207
ADMINISTRATOR:	CINDY LICHTENHAN		FACILITY TYPE:	740
ADDRESS:	1450 WEST F STREET		TELEPHONE:	(209) 764-3164
CITY:	OAKDALE	STATE: CA	ZIP CODE:	95361
CAPACITY:	72	CENSUS: 57	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Cindy Lichtenhan		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff is unable to provide proper supervision to resident in care.

INVESTIGATION FINDINGS:

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On 09/26/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to continue working on the complaint regarding the allegation above. The LPA identified herself, the purpose of the visit and asked to speak with the Designated Facility Administrator. LPA met with the Executive Director, Cynthia Lichtenhan, and the Director of Health and Wellness, Teri Ford.

On 08/20/23, at approximately 3:45 AM, a resident in Memory Care became aggressive and assaulted another resident and a staff member. Staff intervened and the police were notified. Police removed the resident from the facility and brought the resident to the ER for evaluation. The facility notified the resident's primary care and responsible parties. The hospital discharged the resident and sent them back to the community by 12:05 AM on 08/21/23. Once R was returned, R received 1-1 supervision in the model room of Assisted Living while waiting for the responsible parties to retrieve them. R was insistent upon returning to Memory Care to find someone R believed was their spouse (this was not the case). R pushed past the sitter yelling profanities and the sitter, S, called the police. R was taken to the ER again in an ambulance for

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230822134442

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: 09/26/2023

NARRATIVE

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further treatment. R was placed on a 72 hour hold at Doctor's ER Hospital. R did not return to Belmare Senior Living. R's responsible parties came and collected R's belongings and moved R to another facility where R could get the higher level of care needed.

As R was a direct threat to a resident in Memory Care, and as Belmare had to accept R's return to the facility from the hospital, temporarily assigning them to an empty room in assisted living with a 1-1 sitter was the most appropriate course of action.

Based on a review of records, R could sometimes be difficult and verbally aggressive. Upon a review of the care notes, this LPA observed that R's medications were reassessed and changed periodically to assist with his negative behaviors. Based on a review of records, personal observations of R during other site visits, and as well as interviews, the allegation that: Staff is unable to provide proper supervision to resident in care was UNSUBSTANTIATED.

A finding of unsubstantiated means that the preponderance of evidence has not been met to substantiate the allegation.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC9099 (FAS) - (06/04)

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