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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 05/12/2022
Date Signed: 05/13/2022 11:31:24 AM


Document Has Been Signed on 05/13/2022 11:31 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
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: 109DATE:
05/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ralph BalbinTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA), Sandra Urena conducted an unannounced Case Management-Incident visit to obtain additional information surrounding an incident that occurred on 05/07/2022. The LPA met with Executive Director (ED) Ralph Balbin at 1:25 p.m. and explained the reason for the visit.

The reason for today's inspection is to follow up on a self-reported incident received on 05/09/2022. The report pertains to Staff #1(S1), regarding an alleged incident which occurred on 05/07/2022, at around 11:00 a.m. S1 was observed by a Witness(W) striking Resident #1(R1) on the hand, and rubbing R1’s face in a manner that caused R1 discomfort. The LPA interviewed the witness, Staff#2(S2), and Staff#3(3) from 12:05 p.m., to 1:00 p.m. The LPA also reviewed records, and obtained copies of pertinent documents.

No health and safety concerns noted at this time. Further investigation is needed prior to issuing findings.

Exit interview conducted with Executive Director, Ralph Balbin. Signatures obtained. A copy of report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 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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