197608466-5-28-2026-29-AS-QHUH-DUHTUH-20260528150221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 05/28/2026
Date Signed: 05/28/2026 03:02:37 PM

Document Has Been Signed on 05/28/2026 03:02 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		CENSUS: 117	DATE:	05/28/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:29 PM
MET WITH:	Lance Shenk - Executive Director		TIME VISIT/ INSPECTION 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) Quoc Huynh conducted an unannounced Case Management to deliver findings for a self-reported sexual assault. The LPA arrived at 12:29PM and met with Executive Director (ED) Lance Shenk. Entrance interview conducted. On 01/27/2026, the Department received a notification of an alleged staff on resident sexual assault that reportedly occurred a week prior. On 01/28/2026, the LPA conducted an initial visit. Beginning at 9:43AM, the LPA conducted a physical plant tour and reviewed and obtained pertinent documents. Between 02/04/2026 and 05/15/2026, the Department interviewed the ED, Resident #1 (R1), family, and staff. During today’s visit, the LPA and ED conducted a physical plant tour at 12:40PM, and no immediate concerns were observed. The following was then determined: It was reported that Staff #1 (S1) solicited R1 to leave the facility over the course of multiple days, transported R1 to S1’s home, and sexually assaulted R1. It was further revealed that R1 initially disclosed the assault to Staff #2 (S2) and Staff #3 (S3) on 01/25/2026 and 01/27/2026. However, neither staff reported the allegation to the facility’s On Duty Nurse nor the ED at that time. S2 and S3 stated they believed they were required to report directly to the ED in-person and therefore did not report the alleged abuse immediately. R1 also reported the allegation to the On Duty Nurse on 01/27/2026, at which time the On Duty Nurse immediately notified the ED. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

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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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: 05/28/2026

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Interviews with the ED at that time, Abigail Traxler, and R1’s family indicated their belief that the allegation may be unfounded due to R1’s declining condition. The ED reported that an internal investigation was conducted, including a review of facility video footage covering all entrances and exits. The internal investigation determined that R1 did not leave the premises during the alleged time frame. R1’s family also reported that between 2018-2019, R1 underwent an irreversible surgical procedure that makes sexual activity impossible. The family further expressed no concerns regarding the facility staff or the care and services provided.

An interview with R1 was attempted but unsuccessful due to R1’s diagnosis and decline in condition. R1’s Wandering Potential Assessment dated 06/17/2025 indicated that R1 was independently mobile and cognitively impaired with poor decision-making skills. Record review further revealed that prior to the allegation, R1 experienced a fall on 01/11/2026, during which they hit their head, were hospitalized, and an arachnoid cyst was discovered. During the investigation, R1 was again hospitalized and diagnosed with acute metabolic encephalopathy, described as “a rapid-onset, reversible, or treatable global brain dysfunction causing confusion, altered consciousness, or delirium resulting from systemic diseases rather than direct brain injury.” Thus, leaving R1 no longer verbal.

S1 denied the allegation against them and stated R1’s decline in condition may have attributed to the allegation. S1 reported no inappropriate behavior initiated on their end and that R1 often inquired about S1’s personal life and touched their arm. S1 stated that they were no longer comfortable providing services to R1 which they reported to management and removed R1 from S1’s care.

At this time, no further investigation is required regarding the sexual assault allegation.

Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D).

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

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/28/2026 03:02 PM - It Cannot Be Edited

Created By: Quoc Huynh On 05/28/2026 at 01:51 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: 05/28/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/29/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(a) Facility personnel shall at all times be… competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by:	1 2 3 4 5 6 7	A staff in-service training was conducted on 05/22/2026 regarding mandated reporting. The Licensee will conduct the training with absent staff at the time and provide proof by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the above cited section in 2 staff did not follow mandated reporting requirements which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC809 (FAS) - (06/04)

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