Inspection Reports for
Belmont Village Senior Living Hollywood Hills

2051 Highland Ave, Los Angeles, CA 90068, United States, CA, 90068

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Deficiencies (last 6 years)

Deficiencies (over 6 years) 2.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

33% better than California average
California average: 4 deficiencies/year

Deficiencies per year

12 9 6 3 0
2021
2022
2023
2024
2025
2026

Occupancy

Latest occupancy rate 63% occupied

Based on a February 2026 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy rate over time

40% 60% 80% 100% Apr 2021 Feb 2022 Jun 2022 Jul 2024 Dec 2025 Feb 2026

Inspection Report

Complaint Investigation
Census: 94 Capacity: 150 Deficiencies: 0 Date: Feb 26, 2026

Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following an allegation that facility staff touched a resident in an inappropriate manner.

Complaint Details
The complaint alleged that staff placed their hands down resident #1's pants. Interviews with staff and the resident produced conflicting statements, but overall there was not sufficient information to verify the allegation. The complaint was determined to be unsubstantiated.
Findings
The investigation included interviews with the resident, staff, and administrator, as well as a review of facility records. The allegation was found to be unsubstantiated due to insufficient evidence to verify the claim.

Report Facts
Capacity: 150 Census: 94

Employees mentioned
NameTitleContext
Raymond ComerLicensing Program AnalystConducted the complaint investigation visit and report
Philippe Ryan MilesSenior InvestigatorConducted full investigation including interviews and records review
Nathaniel AkyemponDirectorFacility representative met during inspection

Inspection Report

Complaint Investigation
Census: 94 Capacity: 150 Deficiencies: 0 Date: Feb 26, 2026

Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that facility staff touched a resident in an inappropriate manner.

Complaint Details
The complaint alleged that facility staff placed their hands down resident #1's pants. Interviews with staff and the resident yielded conflicting statements, but overall there was not sufficient information to verify the allegation. The complaint was unsubstantiated.
Findings
The investigation included interviews with the resident, staff, and administrator, as well as a review of facility records. The allegation was found to be unsubstantiated due to insufficient evidence to verify the claim.

Report Facts
Facility capacity: 150 Census: 94

Employees mentioned
NameTitleContext
Raymond ComerLicensing Program AnalystConducted the complaint investigation visit and report
Philippe Ryan MilesSenior InvestigatorConducted full investigation including interviews and records review
Nathaniel AkyemponDirectorMet with during inspection visit
Janelle TopeteAdministratorInterviewed during investigation and refuted the allegation

Inspection Report

Complaint Investigation
Census: 126 Capacity: 150 Deficiencies: 1 Date: Feb 10, 2026

Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that due to lack of supervision, a resident eloped from the facility.

Complaint Details
The complaint was substantiated. Resident #1 eloped from the facility on 4/8/25 via a courtyard door. Staff were alerted by an audio alarm but could not identify which door was opened. Resident was found on the sidewalk by a passerby and returned to the facility. Records and interviews confirmed the resident cannot leave unassisted.
Findings
The investigation substantiated the allegation that resident #1 eloped from the facility via a courtyard door without staff awareness, posing an immediate health and safety risk. An immediate civil penalty of $500 was issued to the facility.

Deficiencies (1)
Failure to monitor residents' activities to ensure their general health, safety, and well-being, evidenced by resident eloping from the facility without staff awareness.
Report Facts
Civil penalty amount: 500 Deficiency count: 1

Employees mentioned
NameTitleContext
Raymond ComerLicensing Program AnalystConducted the complaint investigation and authored the report.
Janelle TopeteAdministratorFacility administrator interviewed during the investigation.

Inspection Report

Complaint Investigation
Census: 126 Capacity: 150 Deficiencies: 1 Date: Feb 10, 2026

Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that due to lack of supervision, a resident eloped from the facility.

Complaint Details
The complaint was substantiated. Resident #1 was found outside the facility after eloping due to lack of supervision. Interviews and record reviews confirmed the incident occurred on 4/8/25. An incident report had been previously submitted. A citation was issued and a $500 civil penalty was imposed.
Findings
The investigation substantiated the allegation that resident #1 eloped from the facility via a courtyard door without staff awareness, posing an immediate health and safety risk. An immediate civil penalty of $500 was issued to the facility.

Deficiencies (1)
Failure to monitor residents' activities to ensure their general health, safety, and well-being, evidenced by resident #1 eloping from the facility without staff awareness.
Report Facts
Civil penalty amount: 500 Deficiency count: 1

Employees mentioned
NameTitleContext
Raymond ComerLicensing Program AnalystConducted the complaint investigation and authored the report.
Janelle TopeteAdministratorFacility administrator interviewed during the investigation.

Inspection Report

Complaint Investigation
Census: 92 Capacity: 150 Deficiencies: 0 Date: Dec 23, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff did not prevent a resident from engaging in self-harm, did not address a resident's change in medical condition, and that a resident developed multiple pressure injuries while in care.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to prevent self-harm, failure to address a resident's medical condition change, and development of pressure injuries. Multiple visits and interviews were conducted, including with staff, residents, and the resident involved. Documentation and records were reviewed, and the findings did not support the allegations.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. The facility was determined to have addressed the resident's medical condition changes appropriately, and there was no evidence that staff failed to prevent self-harm or that the resident developed pressure injuries while in care. All allegations were deemed unsubstantiated.

Report Facts
Capacity: 150 Census: 92 Number of staff interviewed: 4 Number of residents interviewed: 9 Total residents in facility: 95 Dates of investigation visits: 3 Duration of initial complaint visit: 5

Employees mentioned
NameTitleContext
Tuesday CabinessLicensing Program AnalystConducted subsequent visits and delivered final findings
Raymond CromerLicensing Program AnalystConducted initial and subsequent complaint visits
Nathaniel AkyempomDirector of Resident Care ServicesMet with Licensing Program Analyst during investigation

Inspection Report

Complaint Investigation
Census: 92 Capacity: 150 Deficiencies: 0 Date: Dec 23, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff failed to prevent a resident from self-harm, did not address a resident's change in medical condition, and that a resident developed multiple pressure injuries while in care.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to prevent self-harm, failure to address a resident's medical condition change, and development of pressure injuries. Multiple visits and interviews were conducted, including with staff, residents, and the resident involved. Documentation and resident records were reviewed. The resident was reported to have chronic venous ulcers and received home health services. The resident was also admitted to a skilled nursing facility during the period of declining health. The facility updated assessments and physician reports accordingly.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. The facility was found to have addressed the resident's medical condition changes appropriately, and there was no evidence that staff failed to prevent self-harm or that the resident developed pressure injuries while in care. All allegations were determined to be unsubstantiated.

Report Facts
Capacity: 150 Census: 92 Number of staff interviewed: 4 Number of residents interviewed: 9 Total residents in facility: 95 Dates of visits: 3

Employees mentioned
NameTitleContext
Tuesday CabinessLicensing Program AnalystConducted complaint investigation visits and authored report
Nathaniel AkyempomDirector of Resident Care ServicesFacility representative met during investigation and exit interview

Inspection Report

Annual Inspection
Census: 95 Capacity: 150 Deficiencies: 0 Date: Oct 31, 2025

Visit Reason
The inspection visit was an unannounced continuation of the required 1 Year Annual Inspection conducted on 10/09/2025, focusing on remaining inspection domains including medications, outdoors, staff records, and resident records.

Findings
No immediate health and safety hazards were observed during the inspection. Medication rooms, outdoor areas, staff records, and resident records were reviewed and found to be secure, complete, and current.

Employees mentioned
NameTitleContext
Janelle TopeteAdministratorMet with during inspection and named in report narrative.
Raymond ComerLicensing Program AnalystConducted the unannounced site visit and signed the report.
Nichelle GillyardLicensing Program ManagerNamed in report as Licensing Program Manager.

Inspection Report

Annual Inspection
Census: 95 Capacity: 150 Deficiencies: 0 Date: Oct 9, 2025

Visit Reason
The inspection was an unannounced required 1-year annual inspection visit to evaluate the facility's compliance with licensing requirements.

Findings
The facility was inspected for physical plant conditions, fire safety systems, kitchen, laundry, bedrooms, bathrooms, and common areas. Overall, the facility was found clean, well-maintained, and compliant with safety and health standards. The fire alarm system and safety equipment were operational, and resident areas were safe and comfortable. Due to time constraints, the annual inspection was not fully completed and will be finished at a later date.

Report Facts
Fire extinguishers last serviced: 2025 Fire drill last conducted: 2025 Room temperature: 74 Hot water temperature range: 108 Hot water temperature range: 116 Facility capacity: 150 Resident census: 95 Fire clearance capacity: 125 Fire clearance capacity bedridden: 25 Hospice waiver capacity: 15

Employees mentioned
NameTitleContext
Nathaniel AkyemponResident Care DirectorMet with Licensing Program Analyst during inspection
Raymond ComerLicensing Program AnalystConducted the inspection
Nichelle GillyardLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Annual Inspection
Census: 89 Capacity: 150 Deficiencies: 0 Date: Jul 5, 2024

Visit Reason
The inspection visit was an unannounced continuation of the required 1 Year Annual Inspection conducted on 07/01/2024, focusing on remaining inspection domains including fire safety, kitchen, medications, laundry, common areas, bedrooms, bathrooms, and outdoor areas.

Findings
The facility was found to be in compliance with no immediate health and safety hazards observed. Fire safety systems were operational and maintained, kitchen and medication areas were clean and secure, laundry and common areas were clean and unobstructed, bedrooms and bathrooms were safe and sanitary, and outdoor areas were well maintained.

Report Facts
Fire extinguisher service date: Feb 8, 2024 Fire drill date: Jun 12, 2024 Hot water temperature: 118

Employees mentioned
NameTitleContext
Nathaniel AkyemponDirectorMet with Licensing Program Analyst during inspection and received exit interview
Raymond ComerLicensing Program AnalystConducted the unannounced site visit and inspection
Eva MillerLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Annual Inspection
Census: 89 Capacity: 150 Deficiencies: 0 Date: Jul 1, 2024

Visit Reason
The inspection was an unannounced required annual visit to evaluate the facility's compliance with licensing regulations and assess the physical plant, resident and staff records, and infection control measures.

Findings
The facility was found to be clean and well-maintained with proper emergency exits and infection control measures in place. Resident and staff records were complete and current, and the facility's administrator certificate was valid. No deficiencies or violations were noted in the report.

Report Facts
Fire clearance capacity: 125 Fire clearance capacity: 25 Hospice waiver capacity: 15 Hospice residents present: 4 Room temperature: 73 Disaster drills last conducted: Jun 12, 2024

Employees mentioned
NameTitleContext
Janelle TopeteAdministratorMet with Licensing Program Analyst during inspection
Raymond ComerLicensing Program AnalystConducted the inspection
Eva MillerLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Complaint Investigation
Census: 87 Capacity: 150 Deficiencies: 0 Date: Feb 29, 2024

Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including staff mishandling residents' medication, lack of access to toilet, unmet showering needs, and failure to ensure resident makes appointments.

Complaint Details
The complaint investigation was unsubstantiated based on record reviews, interviews, and observations. Allegations included medication mishandling, lack of toilet access, unmet showering needs, and missed appointments, all of which were found unsupported by evidence.
Findings
The investigation found that the allegations were unsubstantiated. Resident #1 was administered medication as prescribed despite occasional refusal, had access to a private bathroom, received scheduled showers three times a week unless refused, and did not miss any medical appointments.

Report Facts
Capacity: 150 Census: 87 Scheduled showers per week: 3 Complaint control number: 31

Employees mentioned
NameTitleContext
Jose Gary TanLicensing Program AnalystConducted the complaint investigation visit
Janelle TopeteExecutive DirectorMet with Licensing Program Analyst during investigation
Mary Jane RodriguezAdministratorFacility administrator named in report header
MargaryanLicensed Practical Nurse (LPN)Reviewed medication administration records
Troy AgardSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 86 Capacity: 150 Deficiencies: 0 Date: Oct 19, 2023

Visit Reason
An unannounced complaint investigation was conducted to investigate an allegation that facility staff were providing resident services without the resident's consent.

Complaint Details
The complaint alleged that Resident #1 did not agree for staff to assist with medication management and that staff took all of Resident #1's medication. The allegation was found unsubstantiated.
Findings
The investigation found that Resident #1 was assessed by a skilled nursing facility physician as unable to manage their own medication upon re-admission. The allegation was deemed unsubstantiated based on the information gathered during the visit.

Report Facts
Census: 86 Total Capacity: 150

Employees mentioned
NameTitleContext
Janelle TopeteExecutive DirectorMet with Licensing Program Analyst during the investigation
Jose Gary TanLicensing Program AnalystConducted the complaint investigation visit
Troy AgardSupervisorSupervisor overseeing the investigation

Inspection Report

Complaint Investigation
Census: 84 Capacity: 150 Deficiencies: 0 Date: Aug 22, 2023

Visit Reason
The inspection was conducted as a complaint investigation following allegations that a resident was diagnosed at the hospital for a drug overdose and that staff sometimes administer medications directly into residents' mouths.

Complaint Details
The complaint involved two allegations: 1) a resident was diagnosed at the hospital for a drug overdose, and 2) staff sometimes administered medications directly into residents' mouths. Both allegations were found to be unsubstantiated based on interviews, observations, and record reviews.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews, observations, and record reviews indicated no health and safety hazards, and no deficiencies were cited.

Report Facts
Complaint Control Number: 31-AS-20220310132329 Number of residents interviewed: 8

Employees mentioned
NameTitleContext
LaQueena LacyLicensing Program AnalystConducted the complaint investigation and interviews
Naira MargaryanLicensing Program ManagerNamed in report as Licensing Program Manager
Janelle TopeteMet with during the investigation

Inspection Report

Complaint Investigation
Census: 84 Capacity: 150 Deficiencies: 0 Date: Aug 22, 2023

Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident was tested positive for drugs he was not taking.

Complaint Details
The complaint alleged that resident #1 tested positive for drugs he was not prescribed. The allegation was unsubstantiated after investigation.
Findings
The investigation found that medications were securely stored and administered only by staff, with no evidence residents shared medications. The toxicology report was positive for Tricyclic Antidepressants, but concerns for human or lab error were noted and no follow-up testing was requested. Based on interviews, observations, and record review, there was insufficient evidence to substantiate the allegation.

Report Facts
Capacity: 150 Census: 84

Employees mentioned
NameTitleContext
LaQueena LacyLicensing Program AnalystConducted the complaint investigation and delivered findings
Naira MargaryanLicensing Program ManagerNamed as Licensing Program Manager on report
Janelle TopeteFacility representative met during the investigation

Inspection Report

Complaint Investigation
Census: 84 Capacity: 150 Deficiencies: 0 Date: Aug 22, 2023

Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-04-25 regarding staff not assisting residents with toileting needs, not ensuring residents' showering needs are met, and a lack of water supply at the facility.

Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not assisting residents with toileting, not ensuring showering needs, and lack of water supply. Interviews with seven out of eight incontinent residents and staff confirmed assistance and no water supply issues. Records showed residents received care every two hours and showers three times per week. No corroborating evidence was found to prove violations.
Findings
After interviews with residents and staff, observations, and record reviews, there was insufficient evidence to substantiate the allegations. Residents confirmed they receive toileting assistance and showers as needed, and staff confirmed no issues with water supply. No health and safety hazards or deficiencies were cited.

Report Facts
Residents interviewed: 7 Residents interviewed: 8 Showers per week: 3 Toileting assistance frequency: 2

Employees mentioned
NameTitleContext
LaQueena LacyLicensing Program AnalystConducted the complaint investigation and interviews
Janelle TopeteFacility representative met during the investigation

Inspection Report

Complaint Investigation
Census: 80 Capacity: 150 Deficiencies: 3 Date: Jun 27, 2022

Visit Reason
The inspection was conducted as a complaint investigation following allegations received on 01/17/2020 regarding sexual abuse of Resident #1 by staff and uncleared adults working in the facility.

Complaint Details
The complaint alleged sexual abuse of Resident #1 by Staff #1 and the presence of uncleared adults working in the facility. The sexual abuse allegation was unsubstantiated based on forensic exam results, police reports, and interviews. The uncleared adult allegation was also unsubstantiated after review of employee files and interviews.
Findings
The investigation found insufficient evidence to substantiate the sexual abuse allegation and the presence of uncleared adults. However, the facility was substantiated for failing to meet reporting requirements, failing to seek timely medical attention for the resident, and failing to protect the resident from harm by allowing the alleged staff to continue care after allegations.

Deficiencies (3)
Failure to comply with reporting requirements for suspected physical abuse within 24 hours.
Failure to arrange or assist in arranging medical examination after suspicions of sexual abuse.
Failure to protect resident from punishment, humiliation, or interference with daily living functions.
Report Facts
Capacity: 150 Census: 80 Staff interviewed: 16 Plan of Correction Due Date: Jun 28, 2022 Plan of Correction Due Date: Jul 1, 2022

Employees mentioned
NameTitleContext
Allyson YoungAdministratorMet with during inspection and explained reason for visit
Brian BalisiLicensing Program AnalystConducted complaint investigation and authored report
Desaree PereraLicensing Program ManagerOversaw complaint investigation
Sonia SandovalInvestigatorReviewed forensic exam records and police report
Deborah KroeplinBuilding EngineerAccompanied LPA during initial complaint visit
Staff #1Alleged staff involved in sexual abuse allegations

Inspection Report

Routine
Census: 78 Capacity: 150 Deficiencies: 0 Date: Jun 17, 2022

Visit Reason
The visit was a one-year required infection control inspection conducted unannounced to evaluate the facility's compliance with infection control and safety standards.

Findings
The facility was found to have an approved mitigation plan, proper fire clearance, adequate COVID-19 prevention measures, clean and well-maintained physical plant including kitchen, bedrooms, bathrooms, medication storage, laundry, and common areas. No deficiencies were cited during the inspection.

Report Facts
Fire clearance capacity: 125 Fire clearance capacity: 25 Hospice waiver capacity: 15 Number of floors: 4 Water temperature range: 106.7 Water temperature range: 119.1 Number of rooms observed: 12 Number of bathrooms observed: 12 Number of first aid kits: 2

Inspection Report

Complaint Investigation
Census: 82 Capacity: 150 Deficiencies: 0 Date: Mar 30, 2022

Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a toilet was in disrepair and unusable by a resident.

Complaint Details
The complaint alleged that a toilet was broken and unusable. The investigation found no substantiated violation after interviews, observations, and record review. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff and residents, observation of multiple bathrooms, and review of repair records. Although some concerns were raised, all toilets inspected were operational, and there was insufficient evidence to substantiate the complaint. The allegation was determined to be unsubstantiated.

Report Facts
Residents interviewed: 8 Rooms observed: 9

Employees mentioned
NameTitleContext
LaQueena LacyLicensing Program AnalystConducted the complaint investigation
Naira MargaryanLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 84 Capacity: 150 Deficiencies: 1 Date: Mar 9, 2022

Visit Reason
The visit was conducted as a Case Management investigation regarding an incident reported on 09/11/2021 involving a resident receiving an additional dose of a prescribed medication.

Complaint Details
The complaint involved a medication error where a nurse administered an additional dose of prescribed medication to resident #1. The nurse resigned prior to the investigation. The complaint was substantiated based on interviews and record review.
Findings
The investigation confirmed that a nurse administered an additional dose of medication to a resident without using the facility's Accuflow system, posing an immediate health and safety hazard. The resident did not experience complications and was monitored hourly. A deficiency was cited for failure to follow medication dispensing procedures.

Deficiencies (1)
Failure to ensure staff follow procedures when dispensing medications, resulting in an immediate health and safety hazard to residents.
Report Facts
Deficiencies cited: 1 Plan of Correction Due Date: Mar 10, 2022

Employees mentioned
NameTitleContext
LaQueena LacyLicensing Program AnalystConducted the investigation and authored the report
Naira MargaryanLicensing Program ManagerSupervisor overseeing the investigation
Allyson L YoungAdministratorFacility administrator during the investigation

Inspection Report

Complaint Investigation
Census: 84 Capacity: 150 Deficiencies: 1 Date: Mar 9, 2022

Visit Reason
The visit was a subsequent Case Management investigation regarding an incident on 09/11/2021 where a nurse administered an additional dose of a prescribed medication to a resident.

Complaint Details
The complaint involved an incident where a nurse administered an additional dose of medication to a resident. The nurse resigned, and the facility provided in-service training to medication dispensing staff. The citation was cleared during the visit.
Findings
The investigation confirmed that a staff member administered an extra dose of medication without using the facility's Accuflow system, posing an immediate health and safety hazard. The resident did not experience complications and was monitored hourly. A deficiency was cited under CCR 87465(c)(2).

Deficiencies (1)
Failure to ensure staff follow procedures when dispensing medications, resulting in an additional dose given to a resident without using the Accuflow system.
Report Facts
Deficiencies cited: 1 Capacity: 150 Census: 84

Employees mentioned
NameTitleContext
LaQueena LacyLicensing Program AnalystConducted the case management visit and investigation
Naira MargaryanSupervisorSupervisor overseeing the licensing evaluation
Allyson L YoungAdministratorFacility administrator mentioned in the report

Inspection Report

Complaint Investigation
Census: 83 Capacity: 150 Deficiencies: 0 Date: Feb 1, 2022

Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility did not have hot water for the residents.

Complaint Details
The complaint was unsubstantiated. The facility was found to be taking appropriate actions to resolve the hot water issue and offered alternatives and compensation to residents.
Findings
The investigation found that a section of the building had fluctuating hot water temperatures for about three weeks. The facility offered affected residents alternative solutions such as moving rooms or using vacant rooms' bathrooms and provided some compensation. The allegation was deemed unsubstantiated as the facility was actively addressing the issue.

Report Facts
Water temperature range in affected rooms: 105 Water temperature range in non-affected rooms: 116.2 Complaint received date: Jan 27, 2022 Complaint control number: 31

Employees mentioned
NameTitleContext
Jose Gary TanLicensing Program AnalystConducted the complaint investigation
Allyson YoungExecutive DirectorMet with Licensing Program Analyst and involved in investigation
Naira MargaryanLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Census: 78 Capacity: 150 Deficiencies: 0 Date: Dec 23, 2021

Visit Reason
The visit was an unannounced case management visit regarding a serious incident report that occurred on 09/11/2021, specifically related to a staff member's positive COVID-19 test reported on 12/22/2021.

Findings
The Licensing Program Analyst obtained relevant documents and determined that further investigation is required at this time. Mass testing for staff began on 12/22/21 and for residents on 12/23/21.

Employees mentioned
NameTitleContext
Adriana SaisDirector of Resident ServicesMet with Licensing Program Analyst during the visit and provided information about the incident.
LaQueena LacyLicensing Program AnalystConducted the unannounced case management visit and obtained documents relevant to the incident.
Naira MargaryanLicensing Program ManagerNamed in the report as Licensing Program Manager.

Inspection Report

Census: 74 Capacity: 150 Deficiencies: 0 Date: Aug 4, 2021

Visit Reason
An unannounced case management visit was conducted to deliver an immediate exclusion order to the facility on behalf of the Monterey Park Adult and Senior Care Office.

Findings
The Licensing Program Analyst met with the Resident Services Director to review the Immediate Exclusion Order. An exit interview was conducted.

Employees mentioned
NameTitleContext
Wendell SmithLicensing Program AnalystConducted the unannounced case management visit and delivered the immediate exclusion order.
Adrianna SaisResident Services DirectorMet with the Licensing Program Analyst during the visit.
Cassandra HarrisLicensing Program ManagerNamed in the report header.

Inspection Report

Annual Inspection
Census: 74 Capacity: 150 Deficiencies: 5 Date: Jun 22, 2021

Visit Reason
One (1) Year Required - Infection Control visit for this facility as part of the annual inspection.

Findings
The facility was generally clean and well-maintained with proper infection control measures in place, including PPE availability and signage. However, several deficiencies were noted including hot water temperature issues, unlocked biohazard room, improper use of bed rails without physician orders, broken grab bars and dresser, and delayed staff response to emergency pull cords.

Deficiencies (5)
Hot water temperature controls were not maintained within the required range of 105°F to 120°F.
Biohazard room was observed to be unlocked during the visit.
Resident in room 338 had full bed rails without hospice care plan specifying need.
Grab bars in rooms 101, 123, 222, 420, and 413 were loose; dresser in room 101 was broken.
Resident in room 225 had half bed rails without a written physician's order.
Report Facts
Capacity: 150 Census: 74 Hot water temperature: 109.6 Hot water temperature: 109.7 Hot water temperature: 111.7 Fire extinguisher last serviced: Sep 21, 2020 Care staff response time: 12

Employees mentioned
NameTitleContext
Jose Gary TanLicensing Program AnalystLicensing evaluator who conducted the inspection and signed the report.
Naira MargaryanLicensing Program ManagerSupervisor and Licensing Program Manager overseeing the inspection.
Adriana SaisDirector for Resident ServicesFacility staff met during the inspection.
Zara KarchatrianNurse LiaisonFacility staff met during the inspection.

Inspection Report

Follow-Up
Census: 74 Capacity: 150 Deficiencies: 2 Date: Jun 22, 2021

Visit Reason
An unannounced case management follow-up visit was conducted regarding an incident on 03/31/2021 where a resident (R1) fell and sustained injuries requiring hospitalization and surgery.

Findings
The investigation concluded that R1 fell due to being left unattended on a wheelchair without footrests while staff went to ask for assistance. R1 was not assessed for pain prior to being moved from the floor to bed, and complained of pain after staff lifted R1 by pulling under the arms. Deficiencies related to supervision and assistance after the fall were cited, and a $500 civil penalty was issued with potential for additional penalties.

Deficiencies (2)
The licensee did not ensure that the resident was supervised as required, resulting in a fall and injury.
The licensee did not provide required assistance to the resident after the fall.
Report Facts
Civil penalty amount: 500

Employees mentioned
NameTitleContext
Jose Gary TanLicensing Program AnalystConducted investigation and signed report.
Naira MargaryanLicensing Program ManagerConducted investigation and signed report.
Allyson L YoungAdministratorFacility administrator named in report header.
Adriana SaisResident Care DirectorMet with during inspection and informed of findings.

Inspection Report

Follow-Up
Census: 74 Capacity: 150 Deficiencies: 2 Date: Jun 22, 2021

Visit Reason
An unannounced case management follow-up visit was conducted regarding an incident on 03/31/2021 where a resident (R1) fell and sustained injuries requiring hospitalization and surgery.

Complaint Details
The visit was complaint-related, triggered by an incident report of a resident fall on 03/31/2021. The investigation substantiated deficiencies in supervision and assistance. Immediate civil penalties were issued.
Findings
The investigation concluded that R1 fell due to being left unattended on a wheelchair without footrests while staff sought assistance. R1 was not assessed for pain prior to being moved from the floor to bed, and complained of pain after being lifted improperly. Deficiencies related to supervision and assistance were cited, and a $500 civil penalty was issued.

Deficiencies (2)
Failure to ensure resident supervision resulting in a fall and injury due to being left unattended on a wheelchair without footrests.
Failure to provide required assistance to the resident after the fall, posing an immediate health and safety hazard.
Report Facts
Civil penalty amount: 500 Capacity: 150 Census: 74

Employees mentioned
NameTitleContext
Jose Gary TanLicensing EvaluatorConducted the inspection and investigation.
Naira MargaryanLicensing Program Manager / SupervisorSupervised the inspection and investigation.
Adriana SaisResident Care DirectorMet with during the inspection and was informed of findings.

Inspection Report

Complaint Investigation
Census: 74 Capacity: 150 Deficiencies: 0 Date: Apr 9, 2021

Visit Reason
The visit was conducted as an unannounced Case Management follow-up to obtain more information regarding a fall incident involving facility resident #1 (R1) that occurred on 03/31/2021.

Complaint Details
The complaint involved a fall incident of resident #1 on 03/31/2021 resulting in fractured clavicle and humerus. The complaint investigation found that staff left R1 unattended on the wheelchair without footrests, failed to assess pain before moving R1, and improperly lifted R1 from the floor. The complaint is substantiated based on the findings.
Findings
The investigation revealed that R1 fell due to being left unattended on a wheelchair without footrests while staff went to ask for assistance. R1 was not assessed for pain prior to being moved from the floor to bed, and staff lifted R1 by holding under the arms, which may have contributed to injuries. The incident report was incomplete and required additional clarification.

Report Facts
Capacity: 150 Census: 74 Date of incident: Mar 31, 2021 Number of caregivers per shift: 3 Radios broken: 1 Party assistance required: 2

Employees mentioned
NameTitleContext
Allyson YoungExecutive DirectorMet during visit and involved in incident explanation
Naira MargaryanLicensing Program AnalystConducted the unannounced Case Management visit and investigation
Nichelle GillyardLicensing Program ManagerNamed in report as Licensing Program Manager

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