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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608291
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:44:52 PM


Document Has Been Signed on 05/23/2024 04:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:BELMONT VILLAGE WESTWOODFACILITY NUMBER:
197608291
ADMINISTRATOR:SCHROEDER, CHRISFACILITY TYPE:
740
ADDRESS:10475 WILSHIRE BLVDTELEPHONE:
(310) 475-7501
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY:240CENSUS: 174DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Chris Schroeder/Executive DirectorTIME COMPLETED:
04:45 PM
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On 5/23/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Chris Schroeder /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (240) which (180) non-ambulatory and (60) bedridden. Approved hospice waiver for (20). Approved for delayed egress.

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.



LPA Iniguez and the Executive Director toured the physical plant. There is a body of water but there is fence and gated no obstructions on the premises. LPA inspected a total of (10) bedrooms and (10) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 108.5°F to 112.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BELMONT VILLAGE WESTWOOD
FACILITY NUMBER: 197608291
VISIT DATE: 05/23/2024
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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drill was conducted on 4/25/24. Last date fire department came to inspect smoke detectors, carbon monoxide and sprinkler system was: 3/29/24. Delayed egress checked by LPA.

A review of (10) residents' service files and (10) staff personnel files was maintained in order. LPA reviewed (10) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA later. Facility Annual Fess current.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Chris Schroeder / Executive Director.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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