197608466-6-27-2023-29-AS-SURA-CT7U7R-20230627152023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 06/27/2023
Date Signed: 06/27/2023 03:21:17 PM

Document Has Been Signed on 06/27/2023 03:21 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 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: 112	DATE:	06/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Abigail Traxler		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required
annual inspection. The LPA met with Executive Director (ED), Abigail Trexler, and explained the reason for the visit.

At 11:32 a.m., the LPA, the ED, and the Building Manager started the toured of 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 11:35 a.m., the LPA observed the kitchen area which is accessible only to staff. Temperature of refrigerator was observed to be at 39 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. Two fire extinguishers were present in the kitchen area; both were serviced on 09/29/2022.

Common Areas: The facility has four floors. At 12:05 p.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, and a Memory Care unit. Second Floor has Memory Care unit, and a small dining area. Third floor has a hair salon, a gym, and assisted living residents’ rooms. Fourth floor has assisted living residents’ rooms, and an outdoor patio area. Fire extinguishers were observed in each floor. Date of last service was 6/01/2023. Egress doors were tested and were found to be in operable condition.

Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 06/27/2023

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

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

Due to time constraints, LPA Urena will return on another date to complete the Annual inspection.

Exit interview was conducted with Executive Director. A copy of the 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: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC809 (FAS) - (06/04)

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