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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 12/26/2024
Date Signed: 12/26/2024 04:14:16 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
11/08/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20241108155944
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:
12/26/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lacey VincentTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff did not prevent a resident from dragging another resident
INVESTIGATION FINDINGS:
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On 12/26/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Executive Director Lacey Vincent and explained the purpose of today's visit.

During the course of this investigation LPA Jensen interviewed 4 current staff members, 1 former staff member, 3 family members of residents and 1 external contractor paid to provide ancillary services to a resident. LPA Jensen also reviewed resident records.

Based on the records reviewed and interviews conducted the facility was hosting a regularly scheduled happy hour. Resident 2 (R2) had placed her belongings on a chair and left her seat to dance. Resident 3 (R3) attempted to take over the already occupied seat and a disagreement ensued with R3 attempting to physically assault R2. Staff were within approximately 5 feet of the residents when this incident occurred.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
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 5
Control Number 27-AS-20241108155944
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: 12/26/2024
NARRATIVE
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Additional staff promptly arrived to assist including 2 other care staff, the business manager and the Health and Wellness Director. Due to the fact that the event was appropriately staffed and resident behaviors can be highly unpredictable the allegation of "staff did not prevent a resident from dragging another resident" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence does not prove it.

Since this incident the facility has called a care conference with the family of R3 and are working with R3's physician to determine if medication adjustments are in order.

An exit interview was conducted a copy of this report was given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/08/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20241108155944

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: 67DATE:
12/26/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lacey VincentTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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2
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9
Staff is unable to meet the needs of the residents while in care
INVESTIGATION FINDINGS:
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On 12/26/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Executive Director Lacey Vincent and explained the purpose of today's visit.

During the course of this investigation LPA Jensen interviewed 4 current staff members, 1 former staff member, 3 family members of residents and 1 external contractor paid to provide ancillary services to a resident. LPA Jensen also reviewed resident records.

Multiple current staff members, a former staff member and staff from an outside agency stated that the facility did not have enough people working, particularly in memory care. Staff members advised that as a result of being under staffed residents are missing showers and have had numerous falls. Current staff members confirmed that multiple residents required 2 person assist either due to behaviors or physical limitations but there was often only 1 person working in memory care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20241108155944
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: 12/26/2024
NARRATIVE
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A staff member from an outside agency reported their client has been receiving their meals late. A responsible party stated that their family member has 2-3 altercations with another resident. A different responsible party stated that their family sustained fracture to the spine and hit their head as a result of staff not being adequately trained. Based on records reviewed and interviews conducted with current staff, former staff, outside agency staff and family members the allegation of "staff is unable to meet the needs of the residents while in care" is SUBSTANTIATED. A finding of substantiated means the preponderance of evidence standard has been met. The consensus amongst interviewees is that the facility was understaffed for a period of time which resulted in residents not receiving adequate care and supervision.

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 and appeal rights was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20241108155944
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: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/31/2024
Section Cited
CCR
87411
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Personnel Requirements - General
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 Licensee agrees to submit a plan to the Department outlining what measures will be taken to ensure resident needs are being met.
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This requirement was not met based on staff and family interviews as well as incident reports sent to the Department. 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: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5