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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608291
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:38:54 PM

Document Has Been Signed on 11/21/2024 01:38 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/
DIRECTOR:		SCHROEDER, CHRISFACILITY TYPE:
740
ADDRESS:10475 WILSHIRE BLVDTELEPHONE:
(310) 475-7501
CITY:LOS ANGELESSTATE: CAZIP CODE:
90024
CAPACITY: 240TOTAL ENROLLED CHILDREN: 0CENSUS: 177DATE:
11/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Chris Schroeded/Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On November 21,2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit. LPA met with Chris Schroeder /Executive Director and the purpose of the visit was explained.

On 11/7/24, El Segundo Regional Office eceived an LIC 624 regarding (R#1) pushing down (R#2) in the dining room, causing (R#2) to fall on the floor. Facility staff promptly assisted (R2) and separated (R1) from the table. Facility staff assessed and contacted the PCP and families of (R1) and (R2).

On 11/21/24, Licensing Program Analyst-LPA Alfonso Iniguez reviewed (R1)’s Physicians Report for Residential Care Facilities for the Elderly or LIC 602A dated 5/15/2024. LPA observed that it is marked on the form that (R1) does not have aggressive behavior. In addition, the Executive Director stated that this is the first time (R1) exhibited that kind of behavior. Also, ED stated that a new LIC 602A will be done for (R1).

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

An exit interview was conducted, and a copy of this Case Management report was provided to Chris Schoeder / Executive Director.

Eva M AlvarezTELEPHONE: (323) 629-7047
Alfonso IniguezTELEPHONE: 323-981-1755
DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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