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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 07/05/2024
Date Signed: 07/05/2024 03:57:04 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
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: 72DATE:
07/05/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Teri FordTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical attention for residents in a timely manner
Resident wandered away from the facility due to lack of care from staff
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/5/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a compliant investigation in to the above listed allegations. LPA Jensen met with Health and Wellness Director Teri Ford and explained the purpose of today's visit.

Allegation 1: Staff did not seek medical attention for residents in a timely manner
During the course of the investigation LPA Jensen reviewed the resident file for resident 1 (R1), interviewed 7 staff members and 3 residents. Based on the interviews conducted R1 experienced a change in condition around March of 2024. All staff interviews conducted and records reviewed appear to indicate that staff notified R1's medical providers and treatment was sought in a timely manner. During the course of the interviews conducted 3 of 3 residents interviewed agreed that staff seek medical attention for them in a timely manner when needed. While it was difficult to ascertain precisely when R1's change in condition presented itself there was no evidence to support that it was not addressed timely therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
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 2
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: 07/05/2024
NARRATIVE
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the preponderance of evidence does not prove it.

Allegation 2: Resident wandered away from the facility due to lack of care from staff
LPA Jensen interviewed 6 staff members during the course of this investigation. None of the 6 staff members recall an incident wherein a resident wandered off without staff knowledge during the year 2024. LPA Jensen contacted law enforcement and no report for a missing person was found. It is difficult to ascertain whether there could have been a missing person instance that was resolved. Based on the interviews conducted and a lack of documentation with law enforcement of a missing person the allegation 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, a confidential names list and appeal rights were given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2