Inspection Reports for Belmont Village Senior Living Calabasas
24141 Ventura Blvd, Calabasas, CA 91302, United States, CA, 91302
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with many complaint investigations unsubstantiated. However, several reports did cite deficiencies related primarily to resident care, medication management, and documentation, including failure to ensure continuous oxygen use, improper medication assistance, billing for services not provided, and incomplete incident reporting. The facility also had isolated issues with safeguarding resident belongings and timely response to calls for assistance, but no fines, license suspensions, or immediate jeopardy findings were noted in the available reports. The most recent inspection on May 18, 2025, included substantiated complaints about oxygen use and resident privacy but no enforcement actions. While some older reports showed more deficiencies, recent annual inspections have been clean, indicating some improvement over time.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 114
Capacity: 165
Deficiencies: 2
May 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-01-17 regarding staff not ensuring a resident had oxygen when out of the room and not safeguarding resident's personal belongings, as well as allegations of staff not checking on a resident and mismanaging medication.
Findings
The investigation substantiated that staff did not ensure Resident #1 was on continuous oxygen when out of the room from 2025-01-09 to 2025-01-17 and did not safeguard the resident's personal belongings, specifically a lost portable oxygen cord. However, allegations that staff were not checking on the resident and mismanaging medication were found unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not ensure Resident #1 had oxygen when out of the room and did not safeguard the resident's personal belongings. The allegations that staff were not checking on the resident and mismanaging medication were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff did not ensure Resident #1 was with oxygen when out of the room from approximately 2025-01-09 to 2025-01-17. | Type B |
| Staff did not safeguard Resident #1's personal belongings; portable oxygen charging cord was missing/lost. | Type B |
Report Facts
Capacity: 165
Census: 114
Deficiencies cited: 2
Plan of Correction Due Date: May 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation |
| Diana Alvarado | Director of Resident Care Services | Met with Licensing Program Analyst during investigation and involved in interviews |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 165
Deficiencies: 2
May 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-10-28 regarding billing errors and resident privacy concerns.
Findings
The investigation substantiated two allegations: the facility charged a resident for services not received and staff did not accord resident privacy by entering the resident's room without permission and removing medications. Two other allegations related to medication administration and following physician orders were unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for allegations that the facility charged a resident for services not received and that staff did not accord resident privacy. The allegations that staff did not ensure residents were provided medications as prescribed and that staff were not following physician orders were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff went into resident's room without prior permission and removed resident #1's medications. | Type B |
| Resident was billed for services not provided by facility staff. | Type B |
Report Facts
Daily private aide cost: 280
Capacity: 165
Census: 114
Plan of Correction Due Date: May 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation. |
| Diana Alvarado | Director of Resident Care Services | Met with the Licensing Program Analyst during the investigation and was involved in discussions about the findings. |
| Nancy Nelson | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 165
Deficiencies: 1
Apr 9, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2024-03-19 that staff did not administer resident's medications as prescribed.
Findings
The investigation found that during the initial visit, Resident #1's medications were not properly administered as prescribed, with multiple tablets remaining beyond the expected usage. However, during the follow-up visit, no medication errors were observed. The allegation was substantiated based on the preponderance of evidence.
Complaint Details
The complaint alleged that staff did not administer Resident #1's medications as prescribed. The allegation was substantiated based on medication review, observation, and record review.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not properly assist with Resident #1’s self-administered medications per physician’s order, posing an immediate health and safety risk to residents in care. | Type A |
Report Facts
Census: 122
Total Capacity: 165
Deficiency Type Count: 1
Medication quantities: 90
Medication quantities: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director | Met with Licensing Program Analysts during the investigation and named in findings |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation and medication reviews |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
Inspection Report
Annual Inspection
Census: 122
Capacity: 165
Deficiencies: 0
Apr 9, 2025
Visit Reason
The visit was an unannounced Case Management Annual Continuation inspection conducted to review compliance with licensing regulations, including personnel records, resident records, physical plant safety, and medication management.
Findings
The facility was found to be in compliance with all reviewed regulations, including personnel and resident records, physical plant safety, and medication storage and documentation. No deficiencies were cited during the inspection.
Report Facts
Personnel records reviewed: 6
Resident records reviewed: 5
Resident medications reviewed: 4
Residents interviewed: 4
Staff interviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director | Met with Licensing Program Analysts during the inspection. |
| Quoc Huynh | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Emily Peraldi | Licensing Program Analyst | Conducted the inspection. |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 165
Deficiencies: 0
Mar 12, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including failure to seek timely medical attention, inappropriate handling of residents, neglect, and violation of residents' rights.
Findings
After interviews, record reviews, and multiple attempts to contact the reporting party, all allegations were deemed unsubstantiated. No evidence of mistreatment, neglect, or retention of residents requiring higher level of care was found.
Complaint Details
The complaint included allegations of failure to seek timely medical attention resulting in a questionable death, inappropriate handling causing bruising, neglect leading to pressure injuries and falls, failure to respond to calls for assistance, violation of personal rights, and retention of residents requiring higher care. The investigation found no substantiation for these allegations.
Report Facts
Capacity: 165
Census: 122
Staff interviews: 6
Dates of attempts to contact reporting party: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Zabel Chochian | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Annual Inspection
Census: 122
Capacity: 165
Deficiencies: 0
Mar 12, 2025
Visit Reason
The inspection was a required annual unannounced visit conducted to ensure the facility's compliance with Title 22 Regulations and to check for health and safety hazards.
Findings
The facility was found to be clean, well-maintained, and in compliance with health and safety standards. No health and safety issues were observed during the visit, and resident rooms, common areas, restrooms, and kitchen were all in good condition with appropriate supplies and safety measures.
Report Facts
Water temperature range: 117
Water temperature range: 120.2
Fire extinguisher last serviced: Jan 27, 2025
Fire alarm/sprinkler system last tested: Feb 19, 2024
Fire alarm/sprinkler system next scheduled test: Mar 24, 2025
Rooms toured: 12
Residents interviewed: 4
Perishable food supply duration: 2
Nonperishable food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Zabel Chochian | Licensing Program Analyst | Conducted the annual inspection visit |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 165
Deficiencies: 0
Jan 2, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-03-01 regarding staff not meeting residents' laundry needs, falsifying care documents, failing to keep rooms free of trash, and not preventing residents from playing in their feces.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Observations, interviews, and record reviews indicated that laundry needs were met, rooms were maintained clean, care documentation was accurate, and residents were properly supervised and cared for regarding incontinence.
Complaint Details
The complaint included allegations that staff did not meet a resident's laundry needs, falsified care documents, did not ensure rooms were free of trash, and did not prevent residents from playing in their feces. All allegations were found to be unsubstantiated based on observations, interviews with staff and residents, and record reviews.
Report Facts
Capacity: 165
Census: 128
Number of allegations: 4
Number of resident rooms observed: 5
Number of staff interviewed: 6
Number of residents interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Diana Alvarado | Director of Resident Care Services | Met with the Licensing Program Analyst during the visit |
| Nancy Nelson | Administrator | Facility administrator named in the report header |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 165
Deficiencies: 1
Dec 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including staff not trained to meet residents’ incontinence needs, inappropriate handling of residents, inappropriate speech, lack of dignity and respect, unexplained bruises, unmet residents’ needs, inappropriate resident placement, and administrator's knowledge of laws and regulations.
Findings
All allegations except one were deemed unsubstantiated due to insufficient evidence based on interviews, record reviews, and observations. The only substantiated allegation was that residents were not receiving assistance timely due to staff lacking keys to access residents' rooms, posing a potential health and safety risk. A deficiency was cited related to this issue, but it was cleared due to implementation of a new FOB key system.
Complaint Details
The complaint investigation was triggered by multiple allegations including staff not trained to meet residents’ incontinence needs, inappropriate handling and speech by staff, lack of dignity and respect, unexplained bruises, unmet residents’ needs, inappropriate resident placement, and administrator's knowledge of laws. Most allegations were unsubstantiated except for the allegation regarding residents not receiving timely assistance due to lack of keys.
Deficiencies (1)
| Description |
|---|
| Staff did not respond to residents' calls for assistance in a timely manner due to staff lacking room keys to access residents, posing a potential health and safety risk. |
Report Facts
Capacity: 165
Census: 129
Deficiency Type: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director | Met during inspection and interviewed regarding allegations and training |
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kasandra Lopez | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Complaint Investigation
Census: 133
Capacity: 165
Deficiencies: 0
Oct 24, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that the facility illegally evicted a resident and did not issue a refund to a resident in care.
Findings
The investigation found insufficient evidence to substantiate the allegations. The resident was discharged to a higher level of care facility after evaluation, and the facility followed its admission agreement policies. Although the resident did not return, it was unclear if the facility refused return or if the family/hospital made the decision. The facility did issue a refund to the resident's responsible party despite not being required to do so.
Complaint Details
The complaint involved two allegations: 1) Facility illegally evicted a resident in care, and 2) Facility did not issue a refund to a resident in care. Both allegations were deemed unsubstantiated due to insufficient evidence. The resident was discharged to a Skilled Nursing Facility after psychiatric hospitalization, and the facility admission agreement allowed termination under these circumstances. The facility issued a refund to the resident's responsible party toward the end of April or beginning of May 2024.
Report Facts
Capacity: 165
Census: 133
Complaint Control Number: 29-AS-20240325102029
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit and delivered final findings |
| Nancy Nelson | Executive Director | Met with Licensing Program Analyst during the investigation and provided documentation |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 165
Deficiencies: 0
Oct 9, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding allegations that staff were forcing residents into the shower while in care.
Findings
The investigation found no sufficient evidence to support the allegation that staff forced residents into showers. Interviews with residents and staff, as well as record reviews, indicated residents are not forced and have the right to refuse showers. The allegation was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff were forcing residents into the shower even if the resident screamed or refused. The allegation was investigated through interviews, document review, and facility tour. The complaint was found unsubstantiated.
Report Facts
Capacity: 165
Census: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Conway | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Diana Alvarado | Director of Resident Care Services | Authorized to sign reports during the visit |
| Nancy Nelson | Administrator | Facility administrator, unavailable during visit |
| Desaree Perera | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 165
Deficiencies: 0
Oct 9, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not ensure a resident was adequately fed following a physician's change in dietary orders.
Findings
The investigation found that facility staff consistently delivered pureed food to the resident, but the resident refused the meals. Hospice staff confirmed new dietary orders were followed and nutritional drinks were provided. The allegation was deemed unsubstantiated due to insufficient evidence that the resident was not adequately fed.
Complaint Details
The complaint alleged that staff did not ensure a resident was adequately fed after a physician's dietary order change. The complaint was investigated and found to be unsubstantiated.
Report Facts
Capacity: 165
Census: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Valeria Conway | Licensing Program Analyst | Conducted the complaint investigation and visits |
| Diana Alvarado | Director of Resident Care Services | Authorized to sign reports during the visit |
| Nancy Nelson | Administrator | Facility administrator unavailable during visit |
| Desaree Perera | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 165
Deficiencies: 3
Aug 29, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 02/14/2024 regarding neglect/lack of supervision, medication ordering delays, and failure to reassess a resident.
Findings
The investigation substantiated neglect/lack of supervision resulting in multiple falls and injuries to Resident #1, failure to ensure timely medication ordering, and failure to reassess the resident as necessary. Other allegations related to timely assistance, charging for services not rendered, call pendant supply, and incontinence care were unsubstantiated.
Complaint Details
The complaint investigation was substantiated for neglect/lack of supervision causing multiple falls and injuries to Resident #1, failure to order medications timely, and failure to reassess the resident after falls. Other allegations including failure to provide timely assistance, charging for services not rendered, call pendant supply, and incontinence care were unsubstantiated due to insufficient evidence.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Basic services shall at a minimum include care and supervision as defined in Section 1569.2. Licensee did not comply, resulting in multiple falls and injuries to Resident #1. | Type A |
| Incidental and Medical Care: Medication was not given according to physician's directions; Resident #1 did not receive prescribed medications on 12/30/2023. | Type A |
| Any illness, injury, trauma, or change in health care needs requiring reassessment was not met; Resident #1 sustained 8 falls but was only reassessed twice. | Type B |
Report Facts
Falls sustained by Resident #1: 12
Falls sustained in last six months: 7
Falls documented in nurse logs: 8
Reassessments conducted: 2
Immediate civil penalty: 500
Facility capacity: 165
Census: 139
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director / Administrator | Met with Licensing Program Analyst during investigation and mentioned in findings. |
| Brian Balisi | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Kelly Penrose | LVN Director of Resident Care Services | Interviewed regarding medication ordering practices. |
| Peter Zertuche | Investigator | Assigned to initial complaint investigation. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 165
Deficiencies: 2
Aug 29, 2024
Visit Reason
The visit was an unannounced Case Management - Deficiencies inspection conducted in conjunction with a complaint investigation (Complaint control # 29-AS-20240214112429). The purpose was to investigate the complaint and assess compliance with licensing requirements.
Findings
The investigation found that the facility failed to submit incident reports for multiple unwitnessed falls of Resident #1 that required hospital visits, and also failed to submit a hospice notification when the resident was placed on hospice care. These omissions posed potential health and safety risks to residents.
Complaint Details
The visit was triggered by complaint control # 29-AS-20240214112429. The complaint was substantiated by findings of failure to report incidents and hospice placement as required.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee did not submit incident reports for Resident #1’s numerous unwitnessed falls requiring hospital visits. | Type B |
| Licensee did not submit hospice notification to Community Care Licensing when Resident #1 was placed on hospice. | Type B |
Report Facts
Census: 139
Total Capacity: 165
Deficiencies cited: 2
Plan of Correction Due Date: Sep 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director | Met with Licensing Program Analyst during inspection |
| Brian Balisi | Licensing Program Analyst | Conducted the inspection and authored the report |
| Desaree Perera | Licensing Program Manager | Supervisor and Licensing Program Manager named in report |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 165
Deficiencies: 0
Aug 27, 2024
Visit Reason
The visit was conducted as an unannounced complaint investigation following an allegation that a resident sustained unexplained bruises.
Findings
The investigation found insufficient evidence to substantiate the allegation of unexplained bruising. The resident had dementia and behaviors that made observation difficult, and no violations or citations were issued.
Complaint Details
The complaint alleged that Resident #1 sustained unexplained bruising. The investigation included interviews, record reviews, and observations. The bruising was noted but of unknown origin, and the resident refused full body observation. The allegation was deemed unsubstantiated due to insufficient evidence.
Report Facts
Facility capacity: 165
Census: 139
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Nancy Nelson | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 127
Capacity: 165
Deficiencies: 2
Mar 20, 2024
Visit Reason
The visit was an unannounced required annual inspection to ensure the facility's compliance with health, safety, and Title 22 regulations.
Findings
The inspection found the facility generally clean and well-maintained with appropriate resident accommodations and safety measures. However, deficiencies were cited related to water temperature controls exceeding regulatory limits and incomplete or missing centrally stored medication records for six residents.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Water temperature measured between 107.4–121.0 degrees Fahrenheit, exceeding the required range of 105–120 degrees, posing an immediate health and safety risk. | Type A |
| Records for centrally stored prescription medications were not updated or missing for six out of six residents reviewed, posing a potential health and safety risk. | Type B |
Report Facts
Residents with missing or incomplete medication records: 6
Resident rooms toured: 14
Residents interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director | Met with Licensing Program Analysts and discussed the inspection findings including water temperature adjustment. |
| Kelly Penrose | Director of Resident Care Services | Stated that facility staff will receive medication training and address missing medication records. |
| Emily Peraldi | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Kristin Heffernan | Licensing Program Manager | Supervised the inspection and signed the report. |
Inspection Report
Census: 119
Capacity: 165
Deficiencies: 0
Nov 15, 2023
Visit Reason
The visit was a Case Management incident investigation regarding an incident on 10/18/2023 involving Resident 1 who was admitted to the hospital with severe dehydration and sepsis.
Findings
Based on the information obtained, the resident's needs are being met according to the care plan and medical orders. No deficiencies were observed during the visit.
Report Facts
Incident date: Oct 18, 2023
Hospital return date: Oct 21, 2023
Home health nurse visits per week: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director | Interviewed regarding the incident report for Resident 1 |
| Zara Khatchatrian | Resident Care Director, RN | Interviewed regarding the incident report for Resident 1 |
| Teresa Camara | Licensing Program Analyst | Conducted the Case Management visit |
Inspection Report
Census: 127
Capacity: 165
Deficiencies: 1
Mar 6, 2023
Visit Reason
The visit was an unannounced Case Management - Other visit to discuss the community's current COVID-19 outbreak and address the facility staff's failure to follow reporting requirements related to the outbreak.
Findings
The facility was found not to be complying with local public health department reporting requirements for the COVID-19 outbreak, including failure to submit daily update reports and maintain a complete and regularly updated line list, posing potential health, safety, and personal rights risks to persons in care.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87211(a)(2) Reporting Requirements. Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. The facility is not following reporting requirements to the local public health department. | Type B |
Report Facts
Capacity: 165
Census: 127
Plan of Correction Due Date: Due date for correcting the cited deficiency is 03/08/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Nancy Nelson | Executive Director | Facility representative met during the visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 115
Capacity: 165
Deficiencies: 0
Jan 13, 2023
Visit Reason
Licensing Program Analyst Ashley Smith arrived unannounced to conduct a required annual visit to ensure the facility is in compliance with Title 22 Regulations.
Findings
The facility was found to be in compliance with no health and safety hazards observed. Common areas, kitchen, outside areas, restrooms, and infection control measures were all adequate and well maintained. No deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the annual inspection visit. |
| Nancy Nelson | Administrator | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 165
Deficiencies: 0
Sep 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 04/13/2022 regarding medical assistance timeliness, medication administration, and communication issues at Belmont Village Calabasas.
Findings
The investigation found insufficient evidence to substantiate the allegations that staff failed to provide timely medical assistance, did not assist with medication administration as prescribed, or failed to communicate with the resident's responsible parties. No deficiencies were cited.
Complaint Details
The complaint involved three main allegations: 1) Staff did not provide medical assistance in a timely manner; 2) Resident was not provided medications as prescribed; 3) Staff did not provide communication to the resident's responsible parties. All allegations were deemed unsubstantiated based on the investigation.
Report Facts
Facility capacity: 165
Census: 128
Complaint received date: Apr 13, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nancy Nelson | Executive Director | Met with Licensing Program Analyst during investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 165
Deficiencies: 0
Jun 6, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not provide a safe environment for a resident.
Findings
The investigation found that a resident was sent to the emergency room unaccompanied by staff on two occasions due to hospital COVID-19 policies preventing staff accompaniment. The allegation was deemed unsubstantiated due to insufficient evidence that staff failed to provide a safe environment.
Complaint Details
The complaint alleged that staff failed to provide a safe environment for Resident #1 by sending the resident to the emergency room unaccompanied. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 165
Census: 131
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Nancy Nelson | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 165
Deficiencies: 0
May 17, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including failure to assist with resident self-administration of medication, insufficient staffing, failure to provide regular laundry service, and failure to monitor resident's nutritional intake.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Staff assisted residents with medication self-administration as prescribed, staffing levels were generally sufficient, laundry services were provided regularly with occasional resident refusal, and nutritional intake monitoring met facility standards. No deficiencies were cited.
Complaint Details
The complaint investigation was unannounced and focused on allegations that staff were not assisting with resident self-administration of medication, insufficient staffing, failure to assure regular laundry service, and failure to monitor nutritional intake. After extensive interviews, record reviews, and observations, all allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 165
Census: 131
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director | Met with Licensing Program Analyst during investigation |
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Annual Inspection
Census: 127
Capacity: 165
Deficiencies: 0
Mar 4, 2022
Visit Reason
The Licensing Program Analyst arrived unannounced to conduct a required annual visit with an emphasis on infection control practices and procedures.
Findings
The facility was found to be in compliance with Title 22 Regulations, with no health or safety hazards observed. Infection control practices, including PPE supply, cleaning protocols, and vaccination records, were adequate. No deficiencies were cited during the visit.
Report Facts
Water temperature range: 105
Water temperature range: 120
Fire extinguisher last serviced: 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the annual inspection visit |
| Nancy Nelson | Executive Director | Met with Licensing Program Analyst during the visit |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 165
Deficiencies: 0
Feb 15, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that memory care residents were being video-recorded with the Safely-U Monitoring system without their consent.
Findings
The investigation found that the SafelyYou system is used for fall detection and is monitored by artificial intelligence, not staff. Consent for video monitoring was obtained from residents' legally authorized representatives, and no evidence supported the allegation of unauthorized recording. The allegation was deemed unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that memory care residents were being video-recorded without their consent. The investigation concluded there was insufficient evidence to support this claim, as consent was obtained from the residents' legally authorized representatives. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 29-AS-20211109162243
Capacity: 165
Census: 127
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nancy Nelson | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 165
Deficiencies: 0
Dec 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-12-14 regarding poisoning and financial abuse of a resident at Belmont Village Calabasas.
Findings
The investigation found insufficient evidence to support the allegations of poisoning and financial abuse of Resident #1. Interviews with the resident, staff, and conservator, as well as document reviews, did not substantiate the claims. No deficiencies were cited.
Complaint Details
The complaint involved allegations that the facility was poisoning and financially abusing Resident #1. Both allegations were deemed unsubstantiated based on interviews and document reviews.
Report Facts
Capacity: 165
Census: 123
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Elsie Campos | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Nancy Nelson | Executive Director | Facility Executive Director unavailable during the visit |
| Kelly Adair | Director of Resident Care Services | Met with investigators and provided information during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 165
Deficiencies: 1
Apr 27, 2021
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on an elopement incident involving Resident #1 (R1) who left the assisted living apartment unassisted, posing a safety risk.
Findings
The facility failed to ensure that Resident #1 did not leave the facility unassisted as required by the physician's report, resulting in an elopement and injury. The resident was later reassessed and moved to a secured Memory Care Unit.
Complaint Details
The visit was triggered by a complaint regarding an elopement incident reported by the Executive Director on 4/9/2021 involving Resident #1 who was absent from their apartment on 4/8/2021 for 2-3 hours and sustained scratches.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure that Resident #1 did not leave the facility unassisted per the physician report, posing an immediate health and safety risk to residents in care. | Type A |
Report Facts
Census: 104
Total Capacity: 165
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Nelson | Executive Director | Met with Licensing Program Analyst during the visit and reported the elopement incident |
| Ashley Smith | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 165
Deficiencies: 1
Dec 31, 2020
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation of unlawful eviction of a resident.
Findings
The investigation found sufficient evidence to substantiate the allegation that the facility issued an unlawful eviction to Resident #1. The eviction notice did not explicitly state the violation of general policies as required and did not correlate to the facility's inability to meet the resident's needs.
Complaint Details
The complaint investigation was substantiated. It was alleged and confirmed that the facility issued an unlawful eviction to Resident #1. The eviction notice did not explicitly state the violation of policies and did not justify the eviction based on the resident's needs.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Eviction Procedures. The licensee did not comply with the requirement that eviction notices must correlate to the resident's needs and circumstances, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 165
Census: 111
Deficiency Type: 1
Plan of Correction Due Date: Jan 6, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nancy Nelson | Administrator | Facility administrator involved in the investigation and interview |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation process |
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