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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 04/12/2024
Date Signed: 04/12/2024 05:48:04 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
04/08/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240408103523
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:
04/12/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff do not meet resident's needs
INVESTIGATION FINDINGS:
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On 4/12/24 at approximately 3:15 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open an investigation in to the above listed allegations. LPA Jensen met with Executive Director Cindy Lichtenhahn and explained the purpose of today's visit.

LPA Jensen requested and received a staff roster with contact information and signal system activation logs for April 5th through April 12th. LPA Jensen also toured the memory care unit. In the memory care unit 3 rooms were inspected and interviews were conducted with 3 residents. LPA Jensen observed soiled under garments and soiled briefs on a bathroom vanity counter in 1 room. LPA Jensen observed soiled undergarments in the shower of a second bathroom.

LPA Jensen reviewed the call signal activation logs which show that in a course of a week it took 20 minutes or more to respond when a resident activated their call signal 60 times.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
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 4
Control Number 27-AS-20240408103523
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: 04/12/2024
NARRATIVE
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LPA Jensen observed a resident with wounds in the memory care unit. LPA Jensen interviewed Staff 1 (S1) and asked what stage resident 1's (R1's) wounds are. S1 advised that R1's home health nurse stated the wounds are unstageable. During the course of an interview with R1, LPA Jensen asked if he was in pain and R1 confirmed he was. LPA Jensen asked if he would like pain medication and he confirmed he would. LPA Jensen reviewed the MAR for R1 and observed that he had a PRN for pain medication that was last administered on 4/4/24 and documented as being "somewhat effective". S1 also confirmed that R1's physician was not contacted to seek more effective pain medication. Technical assistance was provided on Prohibited Health Conditions. The Executive Director agreed that on this day R1 will be sent out for medical attention as he requires a higher level of care for wounds.

Based on the LPA Jensen's observation of a resident with a prohibited health condition, soiled undergarments and briefs in resident rooms, call signal logs and a lack of follow up regarding a PRN medication that did not achieve the desired outcome in effectiveness, the allegation of "Staff do not meet resident's needs" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Citations are being issued pursuant to 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, appeal rights and a confidential names list was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20240408103523
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: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/13/2024
Section Cited
CCR
87564(f)(1)
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Basic Services
Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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The Executive Director has agreed to seek a higher level of care for R1 as of this day. The facility is also setting up the call signal system to notify the Wellness Director and Executive Director when signals are not responded to promptly starting 4/15/24.
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Based on interviews conducted with staff, residents and LPA Jensen's observation of unsanitary conditions in a resident room, R1 was not receiving the care needed. This poses an immediate risk to the health, safety and personal rights or residents in care. b
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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: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4