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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608291
Report Date: 09/11/2020
Date Signed: 09/11/2020 04:12:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BELMONT VILLAGE WESTWOODFACILITY NUMBER:
197608291
ADMINISTRATOR:ARP, JAMESFACILITY TYPE:
740
ADDRESS:10475 WILSHIRE BLVDTELEPHONE:
(310) 475-7501
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY:240CENSUS: 168DATE:
09/11/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:James ArpTIME COMPLETED:
11:02 AM
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On 09/11/2020, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced case management visit to the above facility. Due to the situation surrounding Corona virus (Covid 19), and to implement mitigation measures, today's case management was conducted telephonically.

LPA spoke with James Arp, Administrator and explained the purpose of the visit. The purpose of today’s visit was to gather records regarding an incident/death report submitted on 07/26/2020. LPA Agard requested the following documents be sent on or before Monday, September 14, 2020: Admissions agreement, needs and service (care plan), Medication Administration Records, Contact information for family, physicians report, death certificate and any medical summaries from the hospital regarding resident.

Exit interview conducted with James Arp and a copy of this report was provided via email for signature
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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