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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608291
Report Date: 08/30/2024
Date Signed: 08/30/2024 10:31:15 AM


Document Has Been Signed on 08/30/2024 10:31 AM - 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:
08/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Chris Schroeder/Executive DirectorTIME COMPLETED:
10:30 AM
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On 8/30/24, Licensing Program Analysts (LPAs) Alfonso Iniguez and Yolanda Rosser conducted an unannounced Case Management visit at the community named above. The LPAs met with Chris Schroeder, the executive Director, and explained the reason for the visit.

On 8/28/2024, the El Segundo Regional Office received reports of a male dressed as a service worker entering community care facilities in the Westwood area.

The Executive Director stated that they conducted staff training for all facility staff regarding this event; also, the Executive Director said that they asked the fire marshal if we could locked at any external doors, but the fire marshal has yet to answer. In addition, he said that when visitors and vendors come into the facility, they must sign in before coming into the community. Also, the executive Director stated that the community has a security guard at nighttime from 10:30 PM to 7:00 AM.

The Executive Director stated that on the day of the event, there were sufficient staff at the facility. In addition, no stolen items were reported from the resident's rooms. The Executive Director stated that some residents decided not to lock their doors, but the facility will bring this topic to the next resident council meeting.

During this visit LPAs conducted the following:

-A health and safety check of the facility.

-Copies of the staff roster and resident’s roster.

- images of the intruder of the day he went inside facility.

-Copies of Staff in-service training

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
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: 08/30/2024
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During this visit LPAs conducted the following:

-A health and safety check of the facility.

-Copies of the staff roster and resident’s roster.

-LPAs observed video recording of the day when the intruder went inside facility.

-Copies of Staff in-service training

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: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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