197608466-6-11-2025-29-AS-QHUH-DHJU5D-20250611151633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 06/11/2025
Date Signed: 06/11/2025 03:19:01 PM

Document Has Been Signed on 06/11/2025 03:19 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BELMONT VILLAGE ENCINO		FACILITY NUMBER:	197608466
ADMINISTRATOR/ DIRECTOR:	ABIGAIL TRAXLER		FACILITY TYPE:	740
ADDRESS:	15451 VENTURA BLVD		TELEPHONE:	(818) 788-8870
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY: 150	TOTAL ENROLLED CHILDREN: 0	CENSUS: 108	DATE:	06/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:55 AM
MET WITH:	Abigail Traxler - Executive Director		TIME VISIT/ INSPECTION COMPLETED:	03:30 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) Quoc Huynh arrived unannounced at 8:55AM for a required one-year visit. The LPA met with Resident Care Services Director (RCSD) Cortney Barber and explained the reason for the visit. Entrance interview conducted. Executive Director (ED) Abigail Traxler arrived at 10:33AM. At 9:45AM, the LPA and RCSD toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a five-story building. The following was observed: RESIDENT ROOMS: The LPA observed randomly selected rooms on the first, second, third, and fourth floors and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident restrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 104.5 degrees F and 133.5 degrees F, which is not within the required range of 105 degrees F and 120 degrees F. Additionally, the LPA observed two (2) out of six (6) resident restroom sinks to be clogged and slow to drain during the visit. One (1) resident stated their sink had been clogged “for quite some time” and submitted a work order in addition to notifying staff. RCSD and ED immediately notified the building engineer to repair the sinks’ drainage. Report Continued on LIC 809-C

Kristin Heffernan	TELEPHONE: (818) 593-4493
Quoc Huynh	TELEPHONE: (323) 313-4746
	DATE: 06/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 06/11/2025 03:19 PM - It Cannot Be Edited

Created By: Quoc Huynh On 06/11/2025 at 02:35 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 6 resident restroom sinks hot water measured between 104.4 degrees F and 133.5 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2025
	Plan of Correction
1 2 3 4	Executive Director contacted the building engineer to adjust the facility's water boiler/heater. Executive Director will send CCLD proof of adjusted hot water temperatures by POC Due Date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (818) 593-4493

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (323) 313-4746

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/11/2025 03:19 PM - It Cannot Be Edited

Created By: Quoc Huynh On 06/11/2025 at 02:36 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 6 resident restroom sinks were clogged and slow to drain which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2025
	Plan of Correction
1 2 3 4	Executive Director contacted the building engineer who contacted a third party plumber to visit the facility on 06/11/2025 to clear the pipes. Executive Director will send proof to CCLD of draining sinks and plumber confirmation by POC Due Date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (818) 593-4493

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (323) 313-4746

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 06/11/2025

NARRATIVE

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COMMON AREAS: The facility has five (5) total floors: basement/parking garage, first floor, second floor, third floor, and fourth floor. The basement provided general parking, contained emergency food and water, and general storage as well as extra facility supplies/emergency supplies. On the first floor, there was the concierge desk, the great room, common restrooms, bistro, bistro patio, staff lockers, dining room, courtyard, kitchen, and memory care unit. The memory care unit contained resident units, common restrooms, a courtyard, laundry room, and office. On the second floor, there was a wellness center, resident units, town hall room, activity room, balcony, and common restrooms. On the third floor, there was a beauty salon, resident units, discovery room, gym, card room, laundry room, and common restrooms. On the fourth floor, there was a laundry room, resident units, terrace rooftop, office, and common restrooms. LPA Huynh observed common areas to be clean, clear of obstructions/hazards, and furniture was in good condition with patios/courtyards providing shade for residents. Required postings were found in the hallway on the first floor. There were no bodies of water observed during today’s visit. There were fire extinguishers throughout the facility, which were serviced on 09/11/2024.

KITCHEN: The main kitchen is located on the first floor, attached to the main dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries which occurs every Wednesday and produce deliveries occurs every Monday, Thursday, and Saturday. There was a sufficient supply of perishable and non-perishable food. The LPA observed the walk-in refrigerator and freezer; food appeared to be of good quality and labeled with expiration dates. Kitchen sinks had signage of tap water delivering above 125 degrees F.

MEDICATION: Medication review began at 11:00AM. The LPA reviewed medications for five (5) residents. Medications are maintained locked inaccessible to residents in the Wellness Center located on the second floor. Resident medications reviewed were documented and stored in compliance with regulation at this time.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Quoc Huynh	TELEPHONE: (323) 313-4746
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 06/11/2025

NARRATIVE

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RECORDS: Resident records were reviewed at 11:38AM. LPA Huynh reviewed five (5) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. Resident records reviewed were in order at this time. The LPA reviewed six (6) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate training. Staff files reviewed were in compliance with regulation at this time.

INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills as required, with the last drill documented on 05/29/2025. Fire alarm system is tested annually with the last inspection on 05/15/2025 by Absolute Fire Inspection, Inc. with a follow up inspection to be determined.

Four (4) residents and six (6) staff were interviewed. No complaints noted.

LPA Huynh obtained the following documents: LIC 500 Personnel Report, Resident Census/Roster, Emergency Disaster Plan, Infection Control Plan, and Dementia Plan of Operation.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (Refer to LIC 809-D).

Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Quoc Huynh	TELEPHONE: (323) 313-4746
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025

LIC809 (FAS) - (06/04)

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