Belmont Village Albany.

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.

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 Manager

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.

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) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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.

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).

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.

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.

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.

On 07/20/2023 at 09:40 AM, Licensing Program Analyst (LPA) L. Holmes and Associate Governmental Program Analyst (AGPA) L. Francisco conducted an unannounced annual inspection. LPA/AGPA met with Tamra Marie Tsanos, Executive Director (ED) and explained the purpose of the visit. LPA L. Holmes toured the facility with (ED) who currently holds a certificate (#604 9144740) that expires on 05/07/24. The facility’s fire clearance was approved for two hundred twenty-five (225) non-ambulatory residents; fifty (50) may be bedridden. Upon arrival, LPA observed one (1) staff attending the receptionist desk, and two families visiting in the facility's common area. LPA, ED, and two (2) staff members toured the facility, including but not limited to, common areas, wellness center, library, bathrooms, kitchen, dining room(s), medication room/nursing station, front area and courtyard(s). The facility consists of individual apartments housed by the residents and has a monitored unit for memory care (The neighborhood). All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at 71 degrees Fahrenheit (F). LP A observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature was measured at 111.2 degrees (F). All shared restrooms, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing signs, paper towels, and soap observed at all hand washing stations. Linen and hygiene products are available for all residents. PPE, sanitizer, and paper goods remain sufficient. ...continued on LIC9099C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ...continued from LIC9099. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and serviced 04/06/23. Emergency Disaster Plan is updated. Safety drills were last conducted 06/2023 and are rotational between AM and PM schedules monthly. AGPA reviewed five (5) staff records, and all staff have criminal record clearances. Five (5) residents records were reviewed and are complete. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to ED.