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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608291
Report Date: 06/08/2021
Date Signed: 06/08/2021 02:21:00 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: 170DATE:
06/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Executive Director, James ArpTIME COMPLETED:
10:06 AM
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Licensing Program Analyst (LPA) Troy Agard conducted an unannounced visit to Belmont Village Westwood. The purpose of today’s visit was to conduct an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA conducted a risk assessment at the front desk. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA was properly screened for Covid-19 symptoms and temperature was checked. LPA met with Executive Director James Arp and was later joined by Director of Resident Care, Ann Zavela. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff.


Facility is licensed for 180 non-ambulatory, 60 bedridden and a hospice waiver for 20. Facility is approved for delayed egress. The facility currently has 170 residents and 14 residents on hospice. The facility does not handle any of the residents’ money. LPA Agard toured the physical plant, toured a vacate unit and reviewed medication. The facility consists of 176 units of which 31 of those units have 2 bedrooms and 2 bathrooms. All other units have one bed and one bathroom. Facility also has a lobby area, 3 dining rooms and a bistro, kitchen, salon, theater, gym, several recreational spaces and patios. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew. The water temperature in vacant room measured out of range but was corrected during visit. Common areas were clean and clear of hazards; doorways were free of obstructions. All exit doors in the memory care unit have auditory alarms. The facility’s designated visitation area is on the patios in addition to the resident’s bedroom. LPA observed staff, residents, and visitors maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BELMONT VILLAGE WESTWOOD
FACILITY NUMBER: 197608291
VISIT DATE: 06/08/2021
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Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguishers were fully charged. First Aid kit was available. Outside grounds were toured and the facility has a swimming pool that is surrounded by a locked gate. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises.

No deficiencies cited during today’s visit.

Exit interview conducted and a copy of the report was provided to Executive Director, James Arp.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC809 (FAS) - (06/04)
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