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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 12/29/2023
Date Signed: 01/05/2024 03:37:55 PM

Unsubstantiated


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
10/20/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20231020101853
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: DATE:
12/29/2023
UNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Cindy LichtenhanTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not addressing a scabies outbreak
INVESTIGATION FINDINGS:
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On 12/29/23 at approximately 10:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unanounced to continue a complaint onvestigation in to the above listed allegation. LPA Jensen met with the Executive Director Cindy Lichtenhan and Nurisng Director Teri Ford.

During the course of the investigation LPA Jensen conducted interviews with 4 staff members. 2 of the 4 staff members were directly responsible for resident care and 2 staff mebers were responsible for providing ancillary services. 3 of 4 staff members stated they were not informed of potential scabies exposure amongst the residents or staff in the facility.

LPA Jensen reviewed records that included "Move In & Routine Skin Assessment" for 4 residents and "Post Skin Concern Investigation/Assessments" for 12 residents. The Post Skin Concern Assessments were dated from 10/17/23 through 10/26/23.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
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 2
Control Number 27-AS-20231020101853
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: 12/29/2023
NARRATIVE
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LPA Jensen reviewed the Electronic Medical Records online with LVN Teri Ford and observed that residents were being treated for potential exposure to scabies in October of 2023 in a designated unit of the facility which corresponds to Post Skin Assessment records. LPA Jensen also reviewed Physician Communication forms for 16 residents requesting an order for scabicides as a precautionary measure. In-service training documents show that Management conducted a training on Scabies Prevention and Control on October 20, 2023. Based on the interviews conducted and the records reviewed, the allegation of Staff are not addressing a scabies outbreak 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, appeal rights and confidential names list was provided.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2