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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 06/27/2023
Date Signed: 06/27/2023 03:17:40 PM


Document Has Been Signed on 06/27/2023 03:17 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: 112DATE:
06/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Abigail TrexlerTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced case management-incident visit. The LPA met with the Executive Director Abigail Traxler, and explained the reason for the visit.

The purpose of today’s visit is to follow up on an incident report received by the Community Care Licensing Division (CCLD) office on 06/26/2023, regarding an intruder who gained entry to the facility via the front double doors, and accessed entry to the fourth floor via the elevator. During today’s visit, the LPA interviewed residents, and the ED between 10:25 a.m. and 11:10 a.m. Additional interviews are pending due to staff who observed the incident were not present at the time of the visit. The LPA obtained and reviewed records pertaining to the incident at 12:35 p.m. Further investigation is needed before delivering the findings.

Exit interview was conducted with the Executive Director. 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: 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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