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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 10/12/2021
Date Signed: 10/12/2021 06:47:48 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: 110DATE:
10/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:42 PM
MET WITH:Cyntia DrachenbergTIME COMPLETED:
05:05 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) KaSandra Lopez conducted an unannounced Case Management - Incident inspection. The LPA met with Administrator Cyntia Drachenberg at 3:53 PM.

The reason for today's inspection is to follow up on a self-reported incident report received on 10/11/2021. The report pertains to Staff #1 (S1) regarding an alleged incident which occurred outside of S1's working hours at the facility. S1 was put on leave of absence effective 10/08/2021. An interview was conducted with the Administrator. The LPA also reviewed records at 4:08 PM and obtained copies of pertinent documents.

No immediate health and safety concerns were observed during today's inspection.

Further investigation is needed. A referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB). Exit interview and report reviewed with the Administrator. A copy of the report will be emailed.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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 1