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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 06/15/2021
Date Signed: 06/15/2021 01:26:15 PM

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: 107DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Cyntia DranchenbergTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Ashley Morgan and Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 8:30am. LPAs met with Administrator Cyntia Drachenberg who arrived at around 9:15am and the LPAs explained the reason for the visit.

At 9:45 am: LPAs were given a tour by Administrator and Building Manager. LPAs toured 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.

At 10:05am: The LPAs observed the kitchen area which is not accessible to residents of the facility. Temperature of refrigerator was observed to be at 40 degrees. Appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. A variety of food was observed.

At 10:08 am LPAs toured the first floor (Memory Care Unit #1), which houses approximately 29 residents with memory care needs. The second floor (Memory Care Unit #2) houses approximately 18 residents with memory care needs.

Outdoor Space: LPAs observed patio areas where residents can meet with family members. The outdoor areas area equipped with furniture for resident use.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point with an automated system for symptom screening, temperature checks, and a sanitation station. LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is adequate. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. Signatures obtained. A copy of report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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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