197608466-5-13-2022-29-AS-SURA-CEDPM6-20220513112547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 05/12/2022
Date Signed: 05/13/2022 11:26:44 AM

Document Has Been Signed on 05/13/2022 11:26 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BELMONT VILLAGE ENCINO		FACILITY NUMBER:	197608466
ADMINISTRATOR:	DRACHENBERG, CYNTIA		FACILITY TYPE:	740
ADDRESS:	15451 VENTURA BLVD		TELEPHONE:	(818) 788-8870
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY:	150	CENSUS: 109	DATE:	05/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ralph Balbin		TIME COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required
annual visit at 9:37 a.m. This annual inspection had an emphasis on infection control practices and procedures. The LPA met with Executive Director (ED), Ralph Balbin, and explained the reason for the visit.

At 10:08 a.m., the LPA, the ED, the Building Manager, and the Director of Resident Care Services toured the physical plant areas inside and outside to ensure there are no health and safety hazards and to ensure facility is in compliance with Title 22 Regulations.

Kitchen: At 10:15 a.m., the LPA observed the kitchen area, which is not accessible to residents of the facility. Temperature of refrigerator was observed to be at 40 degrees, and freezer below 0 degrees. Appliances were in operable condition. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. The menu was posted, and snacks and beverages are available for residents.

Common Areas: The facility has four floors. At 10:40 a.m., the LPA and staff toured the four floors of the facility. Each floor has a laundry area, janitor room, and residents’ common spaces. The first floor has a Bistro, main dining area, entertainment area, kitchen, outdoor areas, herb garden, and memory care unit. Second Floor has a small dining area, wellness center, in addition to the residents’ rooms (second memory care unit and assisted living). Third floor has a hair salon, gym, and assisted living residents’ rooms. Fourth floor has an outdoor patio area, and assisted living residents’ rooms.

Bedrooms: The residents’ bedrooms were furnished appropriately with clean linens, appropriate

furnishings and sufficient lighting.

Restrooms: Restrooms are clean, sanitary and in operating condition. The common bathrooms were observed with appropriate signs and stocked with paper towels. Hand washing signs were posted in the common and private bathrooms.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 05/12/2022

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Upon entry to the facility, there is a central entry point for symptom screening and temperature checks for residents, staff, and visitors. Staff were observed wearing appropriate face coverings throughout the visit. In addition, the LPA observed hands-free hand sanitizer interspersed throughout the common grounds. There were no obstructions and/or tripping hazards throughout the facility. Planned activities are offered for each day of the week. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair.

Outdoor Space: At 11:30 a.m., the LPA, the ED and staff toured the courtyards; the LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The facility has an outdoor area designated for gardening activities for residents. Parking is available for residents and visitors.

Infection Control: During today’s visit, the LPA spoke with the Executive Director regarding the community's infection control practices. The LPA observed appropriate signs in all common areas that promoted hand hygiene, masking protocol, physical distancing, and cough/sneeze etiquette. The community has an adequate supply of Personal Protection Equipment (PPE) and is able to obtain additional supplies. The community's cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. If needed, the facility has the capacity to designate isolation zones if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The community's policies and procedures pertaining to infection control were adequate. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements.

No deficiencies cited. Exit interview conducted with Executive Director, Ralph Balbin. Signatures obtained. A copy of report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC809 (FAS) - (06/04)

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