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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:30:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20231002135058
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: 60DATE:
10/26/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Teri FordTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Licensee does not ensure staff properly respond to call button system for residents
INVESTIGATION FINDINGS:
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On 10/26/23 at approximately 3pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings related to a compliant investigation for the above listed allegations. LPA Jensen met with Health and Wellness Director, Teri Ford, and explained the purpose of todays visit.

During the course of the investigation LPA Jensen conducted in person interviews with 3 residents. 3 of 3 residents indicated there have been occasions when staff are too busy to respond in a timely manner. LPA Jensen also reviewed the Signal System Response Time Report for the period of September 22, 2023 through October 2, 2023. According to the report provided to the Department, the signal system was activated 797 times during the selected period. The response times were as follows:
Response time between 0-10 minutes - 449 activations (56%)
Response time between 11-29 minutes - 262 activations (33%)
Response time between 30-56 minutes - 86 activations (11%)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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 4
Control Number 27-AS-20231002135058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
VISIT DATE: 10/26/2023
NARRATIVE
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Facility staff required longer than 10 minutes to respond to the signal system 44% of the time it was activated. Based on the interviews conducted and the signal system response time report, the allegation of Licensee does not ensure staff properly respond to call button system for residents is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report, an LIC 811 and appeal rights were provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20231002135058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELMARE SENIOR LIVING
FACILITY NUMBER: 502701207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2023
Section Cited
CCR
87411(a)
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Personnel Requirements
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....This requirement was not met as evidenced by:
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The Health and Wellness Director agrees to conduct an in-service training and weekly audits for one month. Proof of completion of the plan of correction will be emailed to maja.jensen@dss.ca.gov by the due date.
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Based on interviews conducted and the signal system response time report, staff took more than ten minutes to respond to the signal system 44% of the time during the course of a randomly selected 10 day period. This poses a potential risk to the health, safety and personal rights of residents in care.
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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: Stephenie Doub
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20231002135058

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: 60DATE:
10/26/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Teri FordTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not ensure residents call signal system is in good working order
INVESTIGATION FINDINGS:
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On 10/26/23 at approximately 3pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings related to a compliant investigation for the above listed allegations. LPA Jensen met with Health and Wellness Director, Teri Ford, and explained the purpose of todays visit.

During the course of this investigation LPA Jensen interviewed 3 residents and the Executive Director Cindy Lichtenhan. The Director denies any issues with the functioning of the signal system. 3 of 3 resident stated the signal system has always operated as intended to the best of their knowledge. LPA Jensen requested a signal system response time report and verified that during the course of a 10 day period, specifically between September 22, 2023 through October 2, 2023 the call signal system was activated 797 times. Based on the interviews conducted and the signal system report reviewed the allegation of Staff do not ensure residents call signal system is in good working order is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4