197608466-12-13-2021-29-AS-SURA-C9NTZU-20211213141054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 12/13/2021
Date Signed: 12/13/2021 02:12:34 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 ENCINO		FACILITY NUMBER:	197608466
ADMINISTRATOR:	DRACHENBERG, CYNTIA		FACILITY TYPE:	740
ADDRESS:	15451 VENTURA BLVD		TELEPHONE:	(818) 788-8870
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY:	150	CENSUS: 115	DATE:	12/13/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Cyntia Drachenberg		TIME COMPLETED:	12:00 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	On 12/13/2021, Licensing Program Analyst (LPA) Sandra Urena conducted a case management visit to issue the final report regarding an alleged incident. At 11:45 a.m. the LPA met with the Administrator, Cyntia Drachenberg, and explained the reason for the visit. On 10/08/21, Belmont Village Encino self-reported an incident that involved a staff member, staff #1 (S1). The report stated that they were informed of an incident that occurred outside the Belmont Village Encino facility regarding S1. The self-report was sent to the Community Care Licensing Division (CCLD) via an Unusual Incident/Injury Report (LIC 624). The report stated that they received word that S1 attempted to rape a homeless woman outside the facility. On 10/12/21, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection regarding the alleged incident which occurred outside of S1’s working hours at the facility. S1 was put on a leave of absence effective 10/08/2021. The LPA met with Administrator, Cyntia Drachenberg at 3:53 p.m. and conducted an interview. The administrator stated there have been no unusual incidents or complaints pertaining to S1. The administrator said that S1 was recently promoted as a staff assistant, that S1 was never a caregiver and S1’s only contact with residents was when they worked as a receptionist at the front desk. S1 was well liked by everyone, including the residents. No immediate health and safety concerns were observed during the inspection by the LPA. The LPA also reviewed records at 4:08 PM and obtained copies of pertinent documents. The administrator stated that the resident families and staff have been notified of the arrest of S1. No one has come forward to disclose that they experienced or witnessed any inappropriate behavior from S1.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

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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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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO	FACILITY NUMBER: 197608466
	VISIT DATE: 12/13/2021

NARRATIVE

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On 10/12/21, the Woodland Hills North Adult and Senior Care Regional Office referred this case to the Community Care Licensing (CCL) Investigations Branch (IB). On 10/13/2021, (IB) Investigator, Dennis Douglas, Badge #118, was assigned to investigate the incident and whether or not S1 may have had any inappropriate contact with facility residents.

On 10/21/2021, IB Investigator Douglas submitted a formal request for the LAPD Investigative Report to LAPD Records. On 10/19/21, IB Investigator Douglas conducted a visit to the Van Nuys Police Station to gather additional information on S1. During the visit, IB Investigator Douglas interviewed the lead detectives assigned to this case, LAPD Detectives Leslie Brenner, and Detective Whetsel. IB Investigator Douglas was informed by both detectives, Brenner and Whetsel, that the alleged incident occurred at approximately 3:00 a.m. on 9/15/2021, but S1 was not arrested at that time because S1 left the scene before police arrived. However, the incident was captured by surveillance cameras. The surveillance footage was broadcasted on the local news channels and S1 was ultimately identified, arrested, and taken into custody in October of 2021 by the Los Angeles Police Department (LAPD). In addition, as part of the investigation, the investigator reviewed the LAPD Investigative Report, the incident report, along with the facility file.

On 10/22/21 and 11/02/21, several facility residents and staff were interviewed by the IB Investigator Douglas, none of whom disclosed experiencing or observing any inappropriate interaction or behavior by S1 while S1 was at the facility. It is still uncertain if any residents may or may not have experienced any inappropriate behavior by S1. S1 has not returned to the facility. The administrator stated that S1 was immediately placed on a Leave of Absence, and S1’s employment was terminated following S1’s arrest.

On 11/09/2021, IB Investigator Dennis Douglas contacted the Los Angeles District County District Attorney’s Office and was advised that a “preliminary for rest” for S1 was scheduled for 11/29/2021.

Based on the interviews with staff, residents, and the LAPD detectives, the investigatory leads, records, and information obtained and reviewed, the IB Investigator findings of the incident is Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

LIC809 (FAS) - (06/04)

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