Belmont Village Albany

Type of visit: Required - 1 Year

On 07/21/2026 around 9:45 AM, Licensing Program Analysts (LPA) K. Nguyen and P. Manalo arrived announced to conduct a required annual inspection. LPAs met with Assistant Executive Director, Simon Hall. LPAs were informed that Executive Director Jesus Gonzalez was not available during the annual inspection. The facility’s fire clearance was approved for 225 non-ambulatories, 50 may be bedridden and 20 are approved for hospice waivers. Upon entry and during the visit, residents were lounging in the facility, including the common areas, bistro, dining area, and courtyard. Residents reside in individual apartments, and the facility's room temperature was measured at 74 degrees Fahrenheit (F). The hot water temperature was measured at 116.4, 116.3, 115, 115.7, 116.3, 115.7, 115.8 degrees Fahrenheit. The facility has a central medication room that remains locked. First Aid Kit was complete. Smoke detectors and carbon monoxide detectors are combined with the sprinkler system. Fire alarm inspection was last conducted on 05/08/2026. The fire extinguisher was last serviced on 04/28/2026. Lunch was served while at the facility. There was adequate lighting throughout the facility. Indoor and outdoor passages were unobstructed. Emergency Disaster Drill was conducted on 6/11/2026. Earthquake Drill was conducted on 6/11/26. Pest control was last conducted on 6/12/26. Generator test was last conducted on 5/14/26. LPA reviewed eight (8) resident records and eight (8) staff records, including admission agreements and clinical files. No deficiency cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 21, 2026

Type of visit: Case Management - Incident

On 07/01/2026, at 10:30am Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 06/25/2026. LPA met with Assistant Executive Director, Simone Hall, and explained the purpose of the visit. The incident report received stated that staff were doing rounds and observed Resident 1 (R1) knee was swollen and R1 complaining of pain in right knee. Facility sent R1 to hospital for evaluation. Facility has noted R1 had multiple unwitnessed falls the day before incident. LPA reviewed and obtained the following documents: Resident’s roster, R1’s, Physician’s Report (LIC602), face sheet, assessment and service plan dated 06/22/2026, and after visit summary dated 06/12/2026. LPA also interviewed staff during visit. No deficiencies were cited during visit. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 1, 2026

Type of visit: Required - 1 Year

On 07/03/2024 around 10:00 AM, Licensing Program Analysts (LPA) L. Holmes and L. Alexander arrived announced to conduct a required annual inspection. LPAs met with Jesus Gonzalez, Executive Director and explained the purpose of the visit. The facility’s fire clearance was approved for 225 non-ambulatory, 50 may be bedridden and 20 are approved for hospice waivers. Upon entry and during the visit, residents were lounging in the facility including but not limited to the common areas, bistro, dining area and courtyard area. Residents reside in individual apartments and the facility's room temperature was measured at 70 degrees Fahrenheit (F). The hot water temperature was 112 degrees F; there are censored faucets in the residents' shared bathrooms. The facility has a central medication room that remains locked. First Aid kits were stored throughout the facility. Smoke/carbon monoxide detectors are combined with sprinkler system. Fire extinguisher was last serviced on 04/05/2025. Fire drills are performed monthly and an annual evacuation is performed in conjunction with the local police department. Lunch was served while at the facility. There was adequate lighting throughout the facility. Indoor and outdoor passages were free of obstruction. Emergency Disaster Drill was conducted on 06/12/2025. LPA reviewed seven (7) resident records and 5 staff records including admission agreements and clinical files. Continued on LIC 809C... ...continued from LIC809. -Around 11:30 AM, LPA L. Alexander observed Enoxaparian Sodium Injections and Hydrogen Peroxide unlocked in the cabinet underneath R1's bathroom sink. -Around 11:45 AM, LPA L. Alexander observed scissors, Spouts brand Multi-Use Cleaner, Meyer's brand disinfectant cleaner, and Acetaminophen 500 mg tablets in Room #323 for R2. (LIC602 indicates Dementia and unable to administer own medication) Based on information obtained and observed, a deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted and copy of this report reviewed with Jesus Gonzalez, Executive Directorthe state’s words, verbatim · CDSS document, Jul 1, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 06/06/25 around 09:40 AM, L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management for a Death Report, two (2) SOC341s and to discuss the outcomes. LPA met with Raquel Lozano, Business Office Manager (S1) and Ciara Flores, Memory Program Coordinator (S2); Jesus Gonzalez, Executive Director (ED) is not available at this time. During the visit LPA, S1 and S2 discussed Residents (R1, R2, R3, R4) LPA noted findings, ED to request a death certificate from the family and forward it to CCLD. S2 confirmed that R1 was not receiving hospice care and services. R3 and R4 resides in Memory Care (MC), the two grabbed each other while in passing which resulted in a physical altercation. Both families were notified, there has not been any addition problems between the two or complaints from the families. R3 currently has a personal one on one. S3 reported a potential incident of abuse that occurred on 05/15/25 against R2 from S4. The incident was self reported to CCLD, Empowered Aging and Albany Police Department via an SOC341. In service training provided to staff on 05/20/25. S4 was later terminated on 05/23/25. No deficiencies cited, exit interview conducted and a copy of this report was provided to Ciara Flores, Memory Program Director.the state’s words, verbatim · CDSS document, Jun 6, 2025

Allegation investigated: Facility staff are not providing resident with appropriate supervision, resulting in falls.

On 02/10/24 around 02:45 PM Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for a complaint investigation. LPA met with Raquel Lozano, Business Office Manager and explained the purpose of the visit. During the investigation, LPA requested a staff roster for Assisted Living and The Neighborhood/Memory Care (LIC 500), and resident roster. LPA requested the following for Residents (R1, R2, R3, R4, R5): current Physician's Report (LIC602), ID/Emergency Contact information, hospice care plan (if applicable), care notes, Unusual Incident Reports (UIRs), Centrally Stored Medication Records and Staff Scedule for 09/2024 and 10/2024. Continued on LIC9099C... Unsubstantiated continued from LIC9099. Facility staff are not providing resident with appropriate supervision, resulting in falls. For the allegation, LPA reviewed Resident’s (R1, R2, R3, R4 and R5) resident records including but not limited to UIRs, Physician’s Report (LIC602), Centrally Stored Medication Reports, Care Notes, the schedule for The Neighborhood/Memory Care from 09/2024 - 10/2024, and R1’s consent for SafelyYou fall reduction. LPA confirmed R1 was diagnosed with Osteoporosis disease, had experienced fractures, had a common condition of mobility impairment that included use of walker if needed, and Dementia. Interviews with ED, Witness #4 (W4),and Staff (S2, S5, S6) revealed that not all R1’s fall were witnessed; however, falls that were unwitnessed and witnessed were documented on a UIR, 911 was activated and SafelyYou immediately reported falls to the concierge and nurse on duty. The facility appeared to be sufficient in staff when LPA reviewed the schedule for 09/2024 0 10/2024. LPA reviewed and confirmed the facility’s latest in-service and training plan of correction for all staff dated 10/08/2024 and 12/20/2024. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies are being cited during this visit, exit interview conducted, and a copy of this report provided to Raquel Lozano, Business Office Managerthe state’s words, verbatim · CDSS document, Feb 10, 2025 · control 15-AS-20241007145119

Type of visit: Case Management - Other

On 01/15/24 around 01:15 PM L. Holmes, Licensing Program Analyst (LPA) arrived announced to conduct a case management for complaint 15-AS-20241007145119 received on 10/07//2024, and to discuss two (2) reported elopements. LPA met with Jesus Gonzalez, Executive Director (ED) and explained the purpose of the visit. During the visit LPA and ED discussed Resident #1 (R1's) admission history, and reviewed Safely You footage for the investigation on the of the above complaint. LPA noted findings, ED will forward emails related to the complaint, staff and resident roster. ED reported on 11/19/24, R2 resides in Assisted Living, (AL) exited an alarmed back door at the facility around 4:30 PM. The concierge and caregiver intercepted R2 after the alarm and camera detection by 04:35PM. R2 has exiting behaviors, MD and Responsible Party (RP) were notified. Ed reported on 01/04/25, R3 resides in AL, exited through the main entrance of the facility around 2:00 PM. A caregiver intercepted R3 at the bus stop in front of the facility at 2:02 PM. R2 doesn't have exiting behaviors, will be monitored, MD and RP's were notified. No deficiencies cited, exit interview conducted and a copy of this report was provided to ED.the state’s words, verbatim · CDSS document, Jan 15, 2025

Allegation investigated: -Staff are not responding to phone calls at the facility. -Staff are not effectively communicating with residents and their families regarding COVID outbreaks at the facility.

On this day, 12/17/24, at 1:45 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Assistant Executive Director (AED) Erik Holzherr, and informed the reason for visit. During the initial 10-day complaint visit on 8/21/23, LPA Lisha Holmes interviewed staff (S1, S2), obtained information, and requested for including but not limited to the following documents: staff and resident rosters; Emergency Contact information sheet for COVD-19 residents and staff; staff training log; Infection Control Plan (ICP), and proof of COVID-19 notification to residents, responsible parties, and Local Public Health. ....continued on 9099C (page 2) Unsubstantiated Page 2 LPA Delmundo obtained copies of resident roster and staff schedule and conducted interviews. Allegation: Staff are not responding to phone calls at the facility. FM1 stated that on 08/2023 facility has COVID-19 cases and FM1 called the facility and no one was responding. LPA Delmundo interviewed staff (S2, S3, S4 and AED) who all stated that never was there an occasion when facility phone was broken nor left unanswered. These staff stated there's always 2 staff in front - front desk and concierge - during the day and one at NOC shift. If the staff goes on break, another staff covers. LPA also interviewed a family member (FM2) who stated that whenever FM2 calls the facility, it goes through and answered. Therefore, the allegation is unsubstantiated. Allegation: Staff are not effectively communicating with residents and their families regarding COVID-19 outbreaks at the facility. FM1 stated the above. LPA Holmes interviewed staff (S1 and S2) who both stated they did what they need to do when it comes to reporting and that they are very involved in reporting. LPA Delmundo interviewed AED who stated that he sends email blast to the residents' family whenever facility has COVID-19 outbreak. LPA Delmundo reviewed the documents obtained during the course of investigation which showed that the facility sent email to the residents' responsible persons informing that the facility has positive cases of COVID-19. LPA interviewed FM2 who stated that FM2 receives notifications when facility has positive cases. Therefore, the allegation is unsubstantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 15-AS-20230814152346

Allegation investigated: -Resident (R1) lost a large amount of weight while in care. -Facility did not contact resident's (R1) representative on status of resident's health. -Facility did not adhere to the resident's (R1) care plan. -Resident did not receive medical care in a timely manner.

On this day, 12/17/24, at 12:30 pm Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Assistant Executive Director Erik Holzherr, and informed the reason for the visit. During the course of the investigation, the Department conducted interviews with staff (S1, S2, S3, S4, S5, S6, S7, S8, S9), resident (R4) and former executive director on 9/08/21, 4/17/23, 4/26/23, 5/15/23, 9/17/24 and 10/25/24. Resident’s family member (FM) was also interviewed. Resident (R1)’s record was reviewed and copies including but not limited to the following were obtained: LIC602A Physician’s Report; medical record; Unusual Incident Reports (UIRs); death report; weight record; doctor’s visit notes; health provider/medical professional’s correspondence to the facility; Medication Administration Record; doctor’s order of medications ...continued on 9099C (page 2) Unsubstantiated Page 2 Allegation: Resident (R1) lost a large amount of weight while in care. FM stated R1 lost 40 lbs while in facility’s care. Two of the 9 staff who provided care to R1 were interviewed. These 2 staff stated they noticed R1 losing weight but R1 at times refused to eat. When R1 refused to eat, they either changed the food, provide options or switch caregiver. Two facility LVNs and facility RN stated if resident lose weight they inform the resident’s primary care physician. Review of medical records showed that prior to R1’s passing away, R1 had appointments with medical professional of which FM brought up the issue of R1 losing weight; however, R1’s weight was not recorded due to the visits were virtual. On 4/07/21, the medical professional sent correspondence to the facility and requested to send R1’s weekly weight record. Weekly weight records from 4/05/21 to 7/23/21 ranged from 112 lbs to 120 lbs. LIC602A dated 5/04/21 showed R1 weight was 118 lbs. LPA was not able to interview R1 as R1 was no longer at the facility when complaint was received. Therefore, the allegation is unsubstantiated. Allegation: Facility did not contact resident's (R1) representative on status of resident's health. FM stated that on 8/03/21, day prior to R1 passing away, FM went to the facility and found R1 unresponsive with sunken cheeks and mouth open, and that the facility did not inform FM. Review of records showed that prior to R1’s death, facility’s hospice visit note dated 8/03/21 showed hospice agency staff were at the facility with FM. All 3 caregivers interviewed stated if there’s a change in resident’s condition, they inform the facility med-tech and/or nurse. All 4 facility nurses including Director of Resident Care Services (DRCS) stated they inform the resident’s family/responsible person and primary care physician (pcp) of the changes in resident’s conditions. DRCS also stated she conducts care conference with the resident's family and/or responsible person to discuss and let them know that she will contact the pcp. One of the facility nurse (S2) stated that if resident is on hospice and actively dying, they call hospice staff and resident's family to inform of the change in condition. Resident (R4) stated that the facility staff are good in providing update for him and his wife who is also a resident of the facility. Therefore, the allegation is unsubstantiated. .....continued on 9099C (page 3) Page 3 Allegation: Facility did not adhere to the resident's care plan. FM stated that it is in the care plan that staff agreed to weigh R1 regularly, but this did not happen. FM also stated the staff were not giving R1 pain pills and that FM fought to have staff continue the pain management. All staff interviewed stated that residents in the Memory Care are weigh every month. R2’s husband stated that R2 is weighed every month. Review of R1 record showed that on 4/07/21, R1’s medical professional sent correspondence to the facility and requested to send R1’s weekly weight records. Records from 4/05/21 to 7/23/21 showed R1 was weighed once a week. Review of resident’s record showed there were changes over time in R1’s doctor’s order of pain medications and the medications were administered. Therefore, the allegation is unsubstantiated. Allegation: Resident did not receive medical care in a timely manner. FM stated that on 8/03/21 FM came to the facility and found R1 unresponsive, with sunken cheeks and mouth open. R1 was taken to the hospital and died on August 4, 2021. FM also stated that FM believes that R1 should have been taken to the hospital sooner. Review of records showed R1 was placed and admitted on hospice care on 7/02/21 due to advanced dementia and failure to thrive. Staff interviewed stated that if resident is on hospice and actively dying, they call the hospice agency unless the resident fall or sustained head trauma, 9-1-1 is called. Records showed R1 was visited by hospice on the following dates: 7/06/21 to 7/09/21; 7/14/21 to 7/23/21; 7/26/21 to 7/30/21; 8/03/21. Death Report showed R1 passed away on 8/04/21 and death certificate showed senile degeneration of the brain as cause of death. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 15-AS-20210902091458

Allegation investigated: Illegal eviction

On 12/12/24 around 10:40 AM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to deliver the finding for the complaint investigation. LPA met with Jesus Gonzalez, Executive Director (ED) and explained the purpose of the visit. During the investigation LPA interviewed ED, Staff (S1, S2, S3, S4, S5) Witnesses (W1, W2, W3, W4) obtained a resident roster, and requested the following for Resident #1 (R1): current Physician's Report, Admission Agreement, ID/Emergency Contact information, hospice care plan, care notes, incident reports, hospice notification, facility's regulations and documentation regarding Stage 3 and Stage 4 pressure wounds, emails and/or written communications to R1's family regarding pressure wounds. Allegation: Illegal eviction SUBSTANTIATED Continued on LIC9099C... Substantiated ...continued from LIC9099. Interviews conducted with the ED, S1, S2, S3, S4, S5, W1, W2, W3, & W4 confirmed that emergency services were initiated for R1 to be transported to Alta Bates Medical Center in Berkeley, CA for a stage 3 to 4 pressure wound. S2 stated that on July 14, 2024 a nurse’s aide (S4) called the paramedics, R1 was on hospice, under hospice care, and was being transported for 1st aid; W2 was present. W4 stated that W1 and W2 were blindsided; W1 and W2 did not know that the facility would not allow R1 to return after treatment of the wound on 07/14/24. W1, R1’s Power of Attorney (POA), was not present and was out of the country at that time. W4 further stated that S2 outright refused to accept R1 back to the facility although R1 was under the care of hospice. With the efforts of W4, R1 was successfully placed at another Residential Care for the Elderly (RCFE) in Pinole, CA with the services of Sutter VNAH Alameda Hospice. S2 did not seek counsel for joint determination from the Community Care Licensing Department (CCLD), the resident, R1’s Power of Attorney (POA), the hospice agency, physician, and licensee to determine that R1’s continued retention at the facility would pose a health and safety risk. Based on interviews and records reviewed, the preponderance of evidence for the violation has been met; therefore, the allegation is SUBSTANTIATED. Deficiencies cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided to ED.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 15-AS-20240716140724

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(i) · Plan of correction due date: Dec 14, 2024

87224 Eviction Procedures (i)…a ... resident receiving hospice services ... resident's condition has changed ... joint determination has been made by the Department, the resident or resident's health care surrogate decision maker, the resident's hospice agency, a physician... - This requirement was not met as evidenced by: Based on interviews and records reviewed, Licensee failed to ensure the facility sought joint determination before denying R1’s return to the facility after being released for treatment of emergency services which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: ED agreed to provide in-service training to all staff that are involved in decision making procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.

Type of visit: Case Management - Deficiencies

On 12/12/24 around 10:40 AM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management for complaint #15-AS-20240716140724 received on 07/16/2024. LPA Jesus Gonzalez, Executive Director (ED) and explained the purpose of the visit. During the investigation of the above complaint, LPA interviewed ED, Staff (S1, S2, S3, S4, S5) Witnesses (W1, W2, W3, W4), obtained a resident roster, and requested the following for Resident #1 (R1): current Physician's Report, Admission Agreement, ID/Emergency Contact information, hospice care plan, care notes, incident reports, hospice notification, facility's regulations and documentation regarding Stage 3 and 4 pressure wounds, emails and/or written communications to R1's family regarding pressure wound injuries. -On 07/23/24, LPA requested R1’s Initiation of Hospice notification and Physician’s Report (LIC602) from S1. LPA requested the reports be provided to the Community Care Licensing Department (CCLD) by 07/30/2024 for preliminary review. The records weren’t provided to LPA during the investigation. -On 07/23/24, LPA requested R1’s Unusual Incident Reports (UIRs) from S1. R1 was transported to Alta Bates Medical Center in Berkeley for emergency services to treat a stage 3 to 4 pressure wound. Notification of deviation of R1’s hospice care plan on 07/14/24 was not provided to CCLD. Continued on LIC809C... ...continued from LIC809. -W1 and S5 confirmed that Private PALs were not available throughout the entire duration of R1’s admission agreement. The licensee did not provide any written notice (30 or 60 days) for the change in services noted below on pages 5, 10 and 30. Records and interviews revealed that W1 hired a private caregiver from 12/2022 to 07/2024 to aid in the care of R1. Page 5 II. Personal Assistance and Care “… Appendix A. We may change the scope and pricing of the services and our discretion upon sixty (60) days’ written notice to you. Page 10 C. Private PALs and Services from Home Health Agencies “To accommodate additional resident needs and preferences, we offer private care-giving and companion services for an additional fee as set forth in Appendix B” Page 30. B. Termination by Us. (1) Upon (30) Days’ Notice. We may terminate this Agreement upon (30) days’ written and verbal notice to you and your personal representative if any of the following events occur: d. If, after admission, we determine that you have a need not previously identified and a reappraisal has been conducted pursuant to Section 87463 of Title 22 of the California Code of Regulations, and we and the person who performs the reappraisal believe that the community is no longer appropriate for you. Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided to ED.the state’s words, verbatim · CDSS document, Dec 12, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(d)(2) · Plan of correction due date: Dec 19, 2024

87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents...(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services...or within five working days of admitting a resident already receiving hospice care services. The notice ...include...name...date of admission... name and address of the hospice.-This requirement was not met as evidenced by: Based on interviews and records reviewed the Licensee did not comply with the section cited above by not providing R1's Initiation of Hospice notification and LIC602 to CCLD which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: ED agreed to provide in-service training to all staff that are involved in decision making & procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(g) · Plan of correction due date: Dec 19, 2024

87633 Hospice Care of Terminally Ill Residents (g) In addition to...Section 87211, Reporting Requirements... report...hospice services are interrupted or discontinued for any reason...any deviation from the resident’s hospice care plan, or other incident...- This requirement was not met as evidenced by:the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: ED agreed to provide in-service training to all staff that are involved in decision making & procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Dec 19, 2024

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.-This requirement was not met as evidenced by: Based on interviews and records reviewed the Licensee did not comply with the section cited above by not abiding by R1's admission agreement which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: ED agreed to provide in-service training to all staff that are involved in decision making & procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: Dec 19, 2024

87705 Care of Persons with Dementia (c) Licensees... with dementia shall be responsible ...(5) Each resident with dementia shall have an annual medical assessment ... annually, ... a reassessment of the resident’s dementia care needs.-This requirement was not met as evidenced by: Based on interviews and records reviewed the Licensee did not comply with the section cited above by not abiding by R1's admission agreement which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: ED agreed to provide in-service training to all staff that are involved in decision making & procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.

Type of visit: Case Management - Other

On 10/08/24 around 10:35 AM Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management. LPA met with Executive Director (ED) Jesus Gonzalez and explained the purpose of the visit. On 09/03/24, LPA L. Holmes received a call from LPA L. Fontanilla requesting COVID-19 status for Belmont Village Albany as a result of a UIR report presented to licensing. LPA L. Holmes requested that ED confirm the number of Staff & Residents that were COVID-19 positive and advised that both should be reported to CCLD as the facility becomes aware of the positive results. Through email, LPA was advised by ED that there were positive COVID-19 cases dated from 08/23/24 - 09/02/24 along with a spreadsheet. During the visit, ED provided LPA with a facsimile and Unusual/Incident Reports (UIRs). LPA advised ED of the regulatory guidelines for reporting infectious diseases within 24 hours. Based on information obtained a deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights, and copy of this report provided to Executive Director (ED) Jesus Gonzalez.the state’s words, verbatim · CDSS document, Oct 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Oct 15, 2024

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports…(2) Occurrences…epidemic outbreaks…major accidents which threaten the welfare, safety or health of residents, personnel or visitors…within 24 hours either by telephone or facsimile… - This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by notifying CCLD of the incident within 24 hours which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: ED agreed to conduct in-service staff retraining on reporting per the regulation and submit proof of completed certifications to CCLD by POC.

Allegation investigated: Residents are being neglected during overnight shift while in care Staff are not meeting the needs of the residents Staff are yelling and mistreating residents Staff are placing residents in an unsafe environment

On 9/26/2024 at 2:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with Executive Director (ED), Jesus Gonzalez and explained the purpose of the visit. ED was unable to stay to sign the reports and stated that Memory Care Coordinator, Ciara Flores will sign CCLD reports During the investigation, LPA interviewed 5 residents and 5 staff. LPA reviewed and obtained documents including staff roster with contact information, staff schedule, physician's report, emergency information, service plan, care notes, and incident reports. (Continue on LIC9099C...) Unsubstantiated Residents are being neglected during overnight shift while in care Interview with residents revealed that staff would always respond to call buttons. R1 stated that overnight staff would come and check on R1 and pendent response time varies. Interview with staff indicated that if one staff cannot respond to call button, then another staff would get the call and would respond to the call button. Staff are not meeting the needs of the residents Interview with residents indicated that staff are good about assisting residents with ADL (Activities of Daily Living) care. R1 stated that staff assist with diaper changes and would always get help from staff. Interview with staff revealed that residents are checked for incontinence care at the beginning and end of each shift. S4 stated residents diaper changes are about 2-3 times per shift, but some residents are checked more frequent. Staff are yelling and mistreating residents Interview with residents revealed that staff are nice to residents and have not witnessed staff yell or scream at residents. R8 stated that staff treats resident well. Staff are placing residents in an unsafe environment Interview with residents and staff revealed that when staff mop the floors, there are yellow triangle signs that is put up warning of wet floors. Staff stated these signs are available at each floor for staff to put on the floor after mopping the floors. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted with Ciara Flores. A copy of this report provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 15-AS-20231115153223

Type of visit: Case Management - Other

On 08/20/24 around 02:25 PM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to conduct a case management for the recent diagnoses and relocation of Resident #1 (R1). LPA met with Jesus Gonzalez, Executive Director (ED) and Carol Blackwell, Director of Resident Care Services (S2). LPA explained the purpose of the visit. W1 email the following information to CCLD. R1 is a resident at Belmont Village Albany (BVA) and was admitted to the Highland Hospital in Oakland, CA after a fall at BVA during the night on 08/05/24. R1 has a severe fracture to the femur and hip area, and given his age, has decided not to receive treatment to repair the injury. R1 is expected to be completely bed-bound and receiving only pain and comfort medications. He is currently in a short-term skilled nursing facility (SNF), Richmond Post Acute. R1 require 24-7 care for his remaining time; R1 also has multiple other health conditions. The Unusual Incident/Injury Report (UIR) states that the incident occurred on 08/06/24 around 10:40 PM. W1 stated that in order to waive the 30-day termination notice requirement in the agreement, BVA is requiring a "health condition relocation order" from the Department of Social Services. Per Title 22 Division 6 Chapter 8 Article 11 Health-Related Services and Conditions, 87637 Health Condition Relocation Order is not initiated by R1 or W1 and the onus is on the licensee to follow the regulations. Given R1's current health condition and situation, LPAand ED discussed the options available to R1 and W1; R1 is currently at a SNF. ED stated that the 30-day notice had been activated by W1 and that he/she is willing to work with W1. LPA confirmed with Erik Holzherr, Assistant Executive Director (AED) that even if R1 is not returning to the facility, W1 would need to make arrangements to remove R1's personal belongings from the unit in order for maintenance to begin renovations and for BVA to retain a possible new resident. No deficiencies cited. Exit interview conducted and copy of this report provided to AED.the state’s words, verbatim · CDSS document, Aug 20, 2024

Type of visit: Case Management - Other

On 08/20/24 around 02:25 PM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to conduct a case management for an Unusual Incident/Injury Report (UIR) for Resident #1 (R1). LPA met with with Carol Blackwell, Director of Resident Care Services (S2) and Erik Holzherr, Assistant Executive Director (AED). LPA explained the purpose of the visit. Upon interviewing S2 regarding R1's bowel movements, S2 immediately knew who R1 was and stated that R1 resides in an Independent Living (IL) unit and that the caregivers would not normally keep record of the IL residents' bowel movements. Now that the facility is aware, there will be some follow-up conversations with R1 and R1's spouse to aid with R1's condition. AED confirmed that the UIR was sent to CCLD and was aware of the incident as Assisted Living (AL) and IL support both sides. No deficiencies cited. Exit interview conducted and copy of this report provided to Erik Holzherr, Assistant Executive Director (AED).the state’s words, verbatim · CDSS document, Aug 20, 2024

Allegation investigated: Staff handled resident in a rough manner. Staff hit resident.

On 8/6/2024 at 09:45am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial complaint visit, investigation, and to deliver complaint findings for the allegations above. LPA met with Jesus Gonzalez, Executive Director, and explained the reason for the visit. During the investigation LPA obtained and reviewed the resident roster, nurse notes, incident report, and identification and emergency contact for R1. S1 stated the caregiver was hired by the family and does not work for any agency. The family was contacted about the incident but decided to let the private caregiver continue to care for R1. S1 stated the facility will provide some training and make private caregiver aware of the facility rules. Continued on LIC9099C. Unfounded Continued from LIC9099. This agency has investigated the complaint and have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 15-AS-20240731093834

Type of visit: Required - 1 Year

On 07/03/2024 around 12:30 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA met with Erik Holzherr, Assistant Executive Director (AED) and explained the purpose of the visit. The facility’s fire clearance was approved for 225 non-ambulatory, 50 may be bedridden and 20 are approved for hospice waivers. Upon entry and during the visit, residents were lounging in the facility including but not limited to the common areas, bistro, and courtyard area. The facility has a central medication room that remains locked. First Aid kits are stored throughout the facility. Smoke/carbon monoxide detectors are combined with sprinkler system. Fire extinguisher was last serviced on 05/16/2024. Fire drills are performed monthly and an annual evacuation is performed in conjunction with the local police department. Lunch was served while at the facility. Residents reside in individual apartments and the hot water temperature was a comfortable temperature with the censored faucet in the residents' shared bathroom. There was adequate lighting throughout the facility. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 06/2024. LPA reviewed ten (10) resident records and 5 staff records. LPA also reviewed a sample of residents' clinical files. Exit interview conducted and copy of this report reviewed with Erik Holzherr, Assistant Executive Director.the state’s words, verbatim · CDSS document, Jul 3, 2024

Type of visit: Case Management - Incident

On 2/27/2024, at 10:00am Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/14/2024. LPA met with Executive Director, Jesus Gonzalez and explained the purpose of the visit. The incident report received stated that Resident 1 (R1) was observed walking back into the community through the front door by the concierge. Record review of R1's physician's report dated 3/21/2023, indicated that R1 is not able to leave the facility unassisted. Staff 2 (S2) stated that staff checked cameras and did not catch her leaving, but there are exits where a PIN code is not needed and staff assume R1 left through rear door. LPA obtained a copy of the staff roster, resident roster, Resident 1 (R1) physician's report and progress notes for the month of February during the visit. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report was provided.the state’s words, verbatim · CDSS document, Feb 27, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Mar 5, 2024

87705 (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s... safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidence by: Based on LPAs interviews and record review the Licensee did not comply with the section cited above in supporting R1's needs, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Execuive Director implemented a plan to have a private companion for R1 starting 2/29/2024. Deficiency cleared.

Allegation investigated: Facility failed to follow adequate COVID mitigation procedures

On 11/30/23 starting at 9:40 AM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to deliver findings for the above allegation. AGPA met with Executive Director, Jesus Gonzalez and explained the purpose of the visit. During the course of the investigation, AGPA obtained information, reviewed records, interviewed staff and attempted to interview residents and collected including but not limited to the following documents: Resident Roster, Staff Roster, Physician's Report, Care Plan, COVID-19 Outbreak Notification, and Email Communication. It was alleged facility failed to follow adequate COVID mitigation procedures. During a tour of the dining room in memory care on 7/22/2022, AGPA L. Francisco and LPA K. Nguyen observed 5 residents on wheelchairs sitting in one round dining table and not physically distancing in accordance to local public health guidance and PIN 21-49-ASC REPORT CONTINUES ON 9099C Substantiated Based on AGPA and LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director. It was alleged facility failed to provide adequate staffing levels. However, based on interview with staff, if a staff is unable to report to work, then residents assigned to that staff will be distributed to the staff that are scheduled to work. S3 and S4 stated that caregivers in assisted living would assist in memory care if needed to. It was alleged there are unqualified staff working at facility. However, AGPA reviewed a sample of staff records on 7/20/23 and observed staff had completed the required training. It was alleged resident was left in soiled diaper and bedding at an extended period of time. Interview with 5 staff revealed that residents are checked every 2 hours or as needed. S4 stated most caregivers are familiar with the residents that staff are assigned to and how frequently those assigned residents needs to be checked. AGPA attempted to interview 3 residents, but AGPA was unable to obtain additional information. AGPA was unable to prove or disprove allegation. It was alleged facility is not kept clean. However, interview with staff revealed that dining room tables are cleaned after every meal. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided to Executive Director.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 15-AS-20220714091744

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Dec 7, 2023

87405(d)(2) ADMINISTRATOR - QUALIFICATIONS AND DUTIES (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on observation on 7/22/22, Licensee did not comply with the regulation cited above by not physically distancing residents in accordance to PIN 21-49-ASC and local public health guidance. AGPA and LPA observed 5 residents on wheel chairs in one round dining table in memory care which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: By POC date, Administrator agrees to review facility's infection control plan with all staff and submit a self-certification letter to CCLD.