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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 10/05/2020
Date Signed: 10/05/2020 03:50:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELMONT VILLAGE ENCINOFACILITY NUMBER:
197608466
ADMINISTRATOR:DRACHENBERG, CYNTIAFACILITY TYPE:
740
ADDRESS:15451 VENTURA BLVDTELEPHONE:
(818) 788-8870
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY:150CENSUS: 103DATE:
10/05/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Cyntia DrachenbergTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Eva Miller initiated a Case Management Visit in response to an incident that was reported on 9/25/20 involving the death of a Staff member. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s Case Management Visit was conducted virtually with the use of "FaceTime" with Administrators Cyntia Drachenberg.

A tour of the facility dining area and kitchen was conducted. LPA observed commonplace hazards to be expected in a commercial kitchen. The facility kitchen is kept inaccessible to LPA observed no visible hazards to the health and safety of residents in care. Pertinent documents were previously submitted.

Copy of Licensing Report provided to the Administrator for signature and return.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva MillerTELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020
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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