<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 07/13/2022
Date Signed: 07/15/2022 02:46:26 PM


Document Has Been Signed on 07/15/2022 02:46 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
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: 108DATE:
07/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ralph BalbinTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sandra Urena arrived at 11:00 a.m. unannounced to conduct a joint Case Management- Incident visit in lieu of COVID-19 Positive outbreak at the above facility. In attendance included Nurse Olivia Manzo, Public Health Nursing Supervisor(PHNS). The purpose of the visit had a specific emphasis on infection control practices. The LPA, and the PHNS met with Executive Director (ED), Ralph Balbin, and Ivan Saa, Director of Resident Care Services (DRCS).

Upon entry, the facility has a central entry point for signing in, symptom screening, and temperature checks. The facility has appropriate signs in the common spaces to promote proper hand hygiene, physical distancing, and symptom reporting. Staff and residents were observed wearing masks throughout the common spaces. Hand sanitizer was available throughout the common spaces for resident and staff use.



The LPA, the PHNS, ED, and the DRCS conducted a tour of the facility from 11:05 a.m. to 12:20 p.m.
During today's visit, a discussion was held regarding the current status of COVID-19 positive residents and staff, testing, communication to staff and families, symptom screening, and adjusted procedures around visitation and excursions. The community is not experiencing any issues with staffing or obtaining Personal Protection Equipment (PPE) at this time. Cleaning and disinfectant protocol is adequate.

No health and safety hazards noted during today's visit. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1