Belmont Village Cardiff.

[Continued from LIC 9099] R1 and R2 were residents at the facility, both with a diagnosis of Dementia. R1 moved into the facility in January 2024 and R2 had moved in to the facility in January 2023. Per administrative staff member interview, both had resided at home or with family prior to moving to the community and neither had lived at another residential facility for the elderly before coming here. R1 had initially shared the allegation to another resident who then reported it to staff. Details were that R2 had assaulted R1 at another facility they lived at together four to six years ago. Interviews with R1 (by the Community Care Licensing Department and by the Sheriff's Department) revealed inconsistent statements, timelines, and details about the incident. File review of the initial crime/incident report and subsequent follow up report by the San Diego County Sheriff's Department's reveal that their investigation was closed due to inconsistencies of details and timelines provided by R1. Interviews with staff and R1's responsible party reveal that the allegation is likely false and is a symptom of R1's Dementia. Based on interviews and records review, while the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred – therefore the allegation has been determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Lavender to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

Regarding the allegation Staff did not ensure medical care for resident. Records confirm Resident 1 was under the care of Tri-City physicians and AccentCare Home Health nurses. Facility staff followed medical instructions and family also retained private caregivers. Allegations that staff failed to ensure medical care could not be corroborated with available documentation. Based on records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. Regarding the allegation Facility retained resident who required higher level of care. Reporting party alleged Resident 1 should have been transferred to skilled nursing due to the wound. However, treating clinicians documented the wound required simple dressing changes and that Resident 1 remained ambulatory, alert, and appropriate for RCFE level of care with home health support. There is insufficient evidence to establish that the facility retained a resident beyond its licensed capacity. Based on records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. Regarding the allegation staff did not administer medications as prescribed. The complaint alleged medication errors; however, available records do not contain documentation of missed or incorrect medication administration. No corroborating evidence was provided to show Resident 1’s prescribed medications were not administered properly. Based on records reviewed, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged did or did not occur. No deficiencies cited Per title 22 regulations. An exit interview was conducted with facility Administrator Wesley Lavender. A copy of this report along with appeal rights were provided.

Licensing Program Analysts (LPA) Liliana Silveira conducted an unannounced visit to continue a Required Annual Inspection, which began on 06/17/2024. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Wes Lavender. According to the facility’s license, the facility has a maximum capacity of 175, age 60 and above, 30 of whom may be bedridden on the first floor only. A hospice care waiver is approved for thirty (30) residents. The facility is equipped with delayed egress and secured perimeter in the dementia unit. During today’s inspection, according to records, there were a total of 129 residents in care. During the visits, LPA, accompanied by Building Engineer Mario Castaneda, toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. LPA privately interviewed multiple staff and residents. LPA also reviewed multiple staff and resident records/files. The files which were reviewed contained the required documents. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained required furniture. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Confidential records and centrally stored medications were kept in locked areas. The facility had at least two days of perishable food and seven days of non-perishable food present. The facility had cooking and dining utensils to facilitate resident meal service. The Walk-In Refrigerator’s temperature was compliant at 40 F, and the Walk-In Freezer’s temperature was complaint at 0 F. The facility’s ambient internal temperature was compliant at 68 F. [CONTINUED ON LIC 809-C] 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 LIC 809] Where tested, hot water temperature at taps (which were used by residents for personal care) were compliant: Bedroom #122 sink was 117.8 F, Bedroom #114 sink was 117.1 F, Bedroom #236 sink was 111.8 F, Bedroom #238 sink was 112.5 F, Bedroom #313 sink was 116.1 F. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents diagnosed with Dementia. A pool was present at the facility with secured entrance and a fence at least 5 feet high, which completely surrounds the pool. Per Wes Lavender, no firearms or ammunition are kept at the facility. Smoke and fire alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. Complete first aid kits were present and readily accessible. Licensee presented proof of current/active business liability insurance. Required licensing postings were observed in visible areas of the facility. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Wes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analysts (LPA) Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and identified themselves to Executive Director Wes Lavender. LPA discussed the purpose of the visit with Executive Director Wes Lavender. During today’s visit, LPA toured the facility with Building Engineer Mario Castaneda and reviewed staff and resident records. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with Wes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to correct/amend a report. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Wesley Lavender. During today's visit, LPA formally amended a prior facility evaluation report and discussed the changes made with the Licensee. Licensee agreed to remove any copies of the prior report they have, substituting/replacing with the amended report. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Lavender, to whom a copy of the amended report, this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Interview with staff did reveal that in January of 2024 Resident 1 (R1) was suspected of having scabies and R1 was treated preventively. Records collected confirmed that R1 was treated for symptoms related to scabies. Interviews with staff also revealed they did receive training to counter the spread of scabies. Interview with outside source confirmed that facility followed public health guidance in eradicating the outbreak. It was also alleged that licensee did not treat for bed bugs. On today’s date, LPA Strong conducted room inspections and did not observe any active bed bugs. Records collected also confirmed that facility has had pest control inspections and records confirmed there was no bed bug activity. Interview with multiple residents did not reveal any corroborating information to prove that facility has pests. Based on LPA's interviews, observations and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Director of Resident Care Services Elizabeth Smith to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

It was alleged staff are not responding to residents call buttons in a timely manner. Interviews revealed the staff are responding to the call button although at times it is taking a little longer due to staff calling out. Interviews revealed that the facility is responding to the call button. Interviews with residents also revealed that some residents press the call button for things that are not very important and that does waste time for the staff to respond to a resident that may really need more assistance. There were no witness statements that confirmed staff are not responding to residents call buttons in a timely manner The complaint allegations are unsubstantiated. An exit interview was conducted with Ashley Marcellus, Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.

Although, records obtained from the facility revealed R1 had sustained nineteen incidents from 3/17/23 to 8/12/23, interviews with staff, R1 and external sources did not reveal any concerns with lack of supervision, nor neglect. It was revealed staff would encourage R1 to call staff when assistance was needed, but R1 would not. R1 would remove R1’s incontinence brief causing the floor to become slippery and as a result, R1 falling when attempting to use the bathroom. During an interview with R1, R1 corroborated R1 often did not use R1’s call pendant to request assistance from staff. R1 did not have any concerns with assistance from staff and indicated staff continued to check in throughout the day and encourage R1 to use R1’s pendant. Based on the evidence gathered throughout the investigation, there was not a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation was Unsubstantiated. An exit interview was conducted with Smith, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.