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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 10/24/2019
Date Signed: 10/24/2019 05:59:55 PM


Document Has Been Signed on 10/24/2019 05:59 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., STE. 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: 137DATE:
10/24/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cyntia DrachenbergTIME COMPLETED:
03:15 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) Cassandra Harris made an unannounced Case Management-Incident visit to this facility. LPA met with Administrator and explained the reason for the visit. This visit is a follow-up visit for the investigation that was initiated on 6/25/19 by LPA Smith.

An incident report was received regarding an incident that occurred on 6/12/19. Resident #1 (R1) was found on the floor in their room next to the bed at approximately 5:30pm. R1 had swelling on the left eye and nose and complained of pain. Emergency services were called and R1 was sent to the hospital by ambulance. R1 returned to the facility on 6/14/19. This was R1's second fall that day (6/12/19) as R1 was found on the floor by their bed at approximately 11am and complained of pain to their head. R1 was sent to hospital by ambulance due to that incident also.

At the initial visit on 6/25/19, LPA Smith conducted an interview with the administrator regarding the incidents, went to R1's room and observed R1 resting in bed, took a brief tour of the memory care unit on the second floor, and obtained copies of pertinent information from R1's facility file. Investigations Branch (IB) Investigators Eddie Hector and Harminderjit Sandhu conducted an investigation into the incident. Supervising Investigator Donald Arvidson completed the investigation. Investigators visited the facility, obtained medical records, reviewed records, and interviewed staff and resident.

Based on Investigators’ interviews, R1 had a behavior of trying to get out of bed without assistance which is why a bed alarm was installed on R1’s bed. R1 requires two staff members to transfer them from the bed to the wheelchair. A hoyer lift can also be used for transfers when R1 is not able to stand. As a result of the falls on 6/12/19, facility increased the frequency of their checks on R1 and installed half rails on R1’s bed.

Based on Investigators’ review of records, R1 sustained an orbital floor fracture from the second fall on 6/12/19.
SUPERVISOR'S NAME: Jill NakataTELEPHONE: (818) 596-4377
LICENSING EVALUATOR NAME: Cassandra HarrisTELEPHONE: (818) 324-2650
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2019
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 3


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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE ENCINO
FACILITY NUMBER: 197608466
VISIT DATE: 10/24/2019
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
26
27
28
29
30
31
32
Based on R1’s physician’s report dated 3/25/19, R1 has dementia, an unsteady gait, and walks with assistive devices. The physician’s report also notes several times that R1 is a high fall risk. R1’s facility notes documented that R1 had two assisted falls within 5 days of the incidents on 6/12/19. Bruises to R1’s legs were noted after one of the falls. Based on R1’s facility assessment dated 5/2/19, R1 needs transfers with two staff members or a hoyer lift. The assessment states that R1 uses a wheelchair for mobility.

During a tour of R1’s bedroom on 9/6/19, Investigator Sandhu noted that the only way R1 can get out of the bedroom is to go through the roommate’s room.

Based on the information obtained, deficiencies will be cited. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D). An immediate civil penalty of $500 is also assessed during today’s visit.

The administrator was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).

Exit Interview Conducted / Appeal Rights Discussed / Copy of Report Issued
SUPERVISOR'S NAME: Jill NakataTELEPHONE: (818) 596-4377
LICENSING EVALUATOR NAME: Cassandra HarrisTELEPHONE: (818) 324-2650
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/24/2019 05:59 PM - It Cannot Be Edited

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., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: BELMONT VILLAGE ENCINO
FACILITY NUMBER: 197608466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/28/2019
Section Cited
CCR
87466

1
2
3
4
5
6
7
87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator states that an in-service training will be provided to all memory care staff on the second floor on how to properly observe residents and how to document and communicate changes of condition. Sign-in sheets and training topics will be submitted.
8
9
10
11
12
13
14
Based on interview and record review, licensee failed to observe and provide appropriate assistance to R1 after multiple falls which posed an immediate safety risk to resident in care.
8
9
10
11
12
13
14
An immediate civil penalty of $500 is assessed.
Request Denied
Type B
11/01/2019
Section Cited
CCR87307(a)(2)(C)

1
2
3
4
5
6
7
87307(a)(2)(C) Personal Accommodations and Services Living accommodations and grounds shall be related to the facility's function...The following provisions shall apply: Resident bedrooms shall be provided which meet, at a minimum, the following requirements: No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
1
2
3
4
5
6
7
Administrator states that she will consult with corporate office on available options to be compliant with regulations regarding room 245. Administrator will contact LPA with corporate office decision regarding plan of correction by the due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on observation, licensee failed to ensure that no resident rooms were used as a passageway to another room (room 245) which poses a potential personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jill NakataTELEPHONE: (818) 596-4377
LICENSING EVALUATOR NAME: Cassandra HarrisTELEPHONE: (818) 324-2650
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3