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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701207
Report Date: 12/30/2024
Date Signed: 01/13/2025 12:39:53 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
08/07/2024 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240807121831
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: 87DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lacy Vincent TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not seek medical attention to resident in a timely manner.
Staff did not notify CCL of incidents
INVESTIGATION FINDINGS:
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On 12/30/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Lacy Vincent and explained the purpose of the visit.
The purpose of this visit was to deliver complaint findings for the allegations above.

Current census was 87. A brief interview with FDA Vincent was conducted.
Allegation: Staff did not seek medication attention to resident in a timely manner
It was alleged that the staff did not seek medication attention to a resident in a timely manner. During the course of this investigation, interviews were conducted, and facility records were reviewed. Based on interviews conducted it was learned that on 07/26/2024 R1 was found on the floor next to their bed by staff. It was stated by staff that they were unsure how long R1 was on the floor for and upon assessment the facility asked if R1 they wanted to get assessed by emergency services however reminded R1 that they could refuse to medical attention.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
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-20240807121831
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: 12/30/2024
NARRATIVE
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It was also stated that it was observed that R1 was not at their baseline of consciousness as they were unsure of how they fell and stated they were in a different town other than where they currently resided. It was learned that R1 has a diagnosis in which can impede in the resident’s decision making. After 20 minutes passed, facility staff contacted R1’s responsible party and notified them that R1 fell however will not be sending because of R1’s refusal. R1’s responsible party asked why the facility was not sending out R1 and staff stated that R1 could refuse medical emergency regardless of the resident’s current state. After 20 minutes, R1’s responsible party persuaded R1 to go to the hospital to obtain medication attention. A review of the facilities plan of operation was conducted. It states that under medical emergencies that if a resident show any sign or symptom of distress including but not limited to shortness of breath, chest pain or change of level of consciousness, emergency medication services will immediately be summoned. Based on the information gathered, the facility staff did not seek medical attention to a resident in a timely manner.

Allegation: Staff did not notify CCL of incidents

It was alleged that the staff did not notify CCL of incidents. During the course of this investigation, interviews were conducted and facility records were reviewed. Based on interviews conducted it was learned that R1 fell on 06/18/2024 and was sent out to the hospital and diagnosed with a hip fracture. Subsequently, on 07/26/2024, the R1 fell a second time and was sent out of the facility after R1’s responsible party convinced for the resident to go obtain medical services. An interview with the facilities Health and Wellness Director was conducted and it was learned that the facility was unsure when to send out incident reports when a resident frequently falls. LPA was able to obtain an incident report for the fall on 06/18/2024 and 07/26/2024 from the facility on 08/13/2024, however did not have an attached fax confirmation sheet. The facility was unable to provide proof that this incident report was sent via email or fax. A review of the departments facility records do not have any incident reports regarding any type of incident regarding R1 within the months of June and July 2024. In addition, a review of the R1’s care notes do not have documented falls within the months of March 2024-August 2024. Based on the information gathered, the facility staff did not notify CCL of incidents.

Based on the information gathered, the facility staff did not notify CCL of incidents. Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

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: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
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
08/07/2024 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240807121831

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: 87DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lacy Vincent TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident developed a UTI while in care.
INVESTIGATION FINDINGS:
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On 12/27/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Lacy Vincent and explained the purpose of the visit.
The purpose of this visit was to deliver complaint findings for the allegations above.
Current census was 87. A brief interview with FDA Vincent was conducted.

Allegation: Resident developed UTI while in care.
It was alleged that a resident developed a UTI while in care. During the course of this investigation, facility records were reviewed and interviews were conducted. Based on interviews conducted, it was learned that R1 did have frequent UTI’s however the resident was able to provide hygiene care to themself. Based on records reviewed, R1’s physician report and care plan states that the resident was able to care for their own hygiene needs such as toileting, bathing, and grooming.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
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-20240807121831
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: 12/30/2024
NARRATIVE
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 Based on the information gathered, it is unclear if the resident developed a UTI while in care.
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: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240807121831
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: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/31/2024
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...This requirement was not met as evidence by. Based on file review and interviews,
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A statement of correction and acknowledgement shall be provided to the LPA by POC date 12/31/2024.
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The Licensee did not ensure to seek timely medical attention for R1. R1 was not provided timely medical attention due to stating that R1 had the option of refusal of medical services. However, based on facility records staff are to call 911 if they R1 was not at their level of consciousness. This posed an immediate health and safety risk to R1.
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Request Denied
Type A
12/31/2024
Section Cited
CCR
87211(a)(1)
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(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.This requirement was not met as evidenced by: Based on file review and interview,
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A statement of correction and acknowledgement shall be provided to the LPA by POC date 12/31/2024.
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The licensee did not ensure that facility reported R1's falls that occured on 06/18/2024 and 07/26/2024 were reported to the department. LPA reviewed facility records and found that there were no reported incidents regarding falls or R1 within the months of March 2024-August 2024. This poses an immediate health,safety and personal rights risks to persons 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: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5