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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608291
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:55:32 PM


Document Has Been Signed on 06/14/2023 03:55 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



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: 181DATE:
06/14/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:ADMINISTRATOR, CHRIS SCHROEDERTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) David España conducted an unannounced Annual visit to Belmont Village Westwood. Upon arrival at the facility, LPA conducted a risk assessment at the front desk. 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, Chris Schroeder. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance.

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 181 residents and 7 residents on hospice. The facility does not handle any of the residents’ money. LPA 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 within range between105-120F. Common areas were clean and clear of hazards; doorways were free of obstructions. All exit doors in the memory care unit have auditory alarms.



Resident Files: LPA reviewed files for randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed.

Medications: Were properly labeled and stored in the Wellness centers located on the third and fifth floors. A medication cart was also observed on the second floor in the memory care unit. Medication cart was locked during visit.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BELMONT VILLAGE WESTWOOD
FACILITY NUMBER: 197608291
VISIT DATE: 06/14/2023
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Staff Files: LPA reviewed files for randomly selected staff. While reviewing the staff records LPA observed several staff whose were missing the following records: LIC508; LIC503; LIC501; LIC9052. LPA also informed Mr. Schroeder that the staff records identified shall be located within the personnel records at all times. Staff schedule appears sufficient to meet the needs of the residents. Staff training is current, including first aid training. Medications are only handled by Med Tech.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies (i.e., Technical Assistance) were issued today.

Exit interview was held. A copy of the report was provided to Executive Director, Chris Schroeder.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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