197608467-6-23-2021-31-AS-JGTN-C49M6V-20210623092035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608467
Report Date: 06/22/2021
Date Signed: 06/23/2021 09:21:47 AM

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 HOLLYWOOD		FACILITY NUMBER:	197608467
ADMINISTRATOR:	YOUNG, ALLYSON L		FACILITY TYPE:	740
ADDRESS:	2051 N HIGHLAND AVE		TELEPHONE:	(323) 874-7711
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90068
CAPACITY:	150	CENSUS: 74	DATE:	06/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Adriana Sais - Director for Resident Services		TIME COMPLETED:	03:16 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 Analysts (LPAs) Gary Tan, LaQueena Lacy and Licensing Program Manager (LPM) Naira Margaryan met with Director for Resident Services Adriana Sais and Nurse Liaison Zara Karchatrian for a One (1) Year Required - Infection Control visit for this facility. LPAs explained the reason for the visit. A tour of the physical plant was conducted at 9:32 AM and the following was noted: There is only one entrance being utilized at the facility, the front main entrance door. There are required poster posted at the main door. Screening area is located immediately upon entrance on the receptionist area. All visitors/resident and staff are required to sign in using an automated sign in machine, which automatically record the visit. Hand sanitizer, gloves and masks available upon request to the receptionist. LPAs and LPM was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. The facility had submitted and approved Mitigation plan. There are hand sanitizing stations all over the facility. There are signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in common bathrooms, elevators and all over the common areas of the facility. The facility have a designated visitors' area in the front entrance yard. The facility has sufficient stock of PPE in the storage room. (continued to LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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 6

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 HOLLYWOOD	FACILITY NUMBER: 197608467
	VISIT DATE: 06/22/2021

NARRATIVE

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(continued from LIC 809)

Residents' bedrooms on the first, second, third and fourth floors were inspected. Common areas, including the activity rooms, auditorium, center for learning, fitness center, library, dining rooms and reception were observed to be clean and were properly furnished. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen, glass shards however was observed on the floor of the patio area adjacent to the kitchen. There were no pesticides or poisons observed near any food areas. Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. The medications were locked in seven (7) medication carts parked in the first and second floors near the Wellness Room. Random resident rooms were inspected and observed with all the required furnishings and grab bars and nonskid surfaces in the bathrooms, room numbers 101, 123, 222, 420 and 413 grab bars were observed to be loose. Dresser on Room no. 101 was observed to be broken. Hot water temperature in random resident bathrooms were checked. Non-hospice Resident in room no. 338 was observed to have full bed rails and another non-hospice Resident on room no. 225 was also observed to have half bed rails and no written physician's order on file until today. The hot water temperature range from 102.5°F to 126.2°F. Biohazard room located beside the Wellness Room was observed to be unlocked during the visit. LPAs observed fire extinguishers throughout the facility hallways on both floors, all extinguishers were last serviced on 09/21/20. First aid kit was in the medication cart located on the second floor. The facility's smoke alarms are hard wired and the facility is equipped with sprinkler system. Emergency pull cord were tested on random residents' room and observed to be operational. Care staff response however, took approximately twelve (12) minutes to arrive in the room.

Citation issued, appeal rights discussed and given. Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

Page: 2 of 6

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 HOLLYWOOD	FACILITY NUMBER: 197608467
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Cleared during visit.
	POC Due Date: 06/22/2021
	Plan of Correction
1 2 3 4	The maintenance manager immediately adjusted the hot water temperature and were last measured at 109.6°F, 109.7°F and 111.7°F on three (3) different floors

Type A

Section Cited

CCR

87309(a)(1)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation during the physical plant tour, the licensee did not comply with the section cited above poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2021
	Plan of Correction
1 2 3 4	Resident care director immediately locked the the biohazard room. Cleared during visit.

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

Page: 3 of 6

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 HOLLYWOOD	FACILITY NUMBER: 197608467
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation during physical plant tour Resident on room 338 has full bed rails, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/24/2021
	Plan of Correction
1 2 3 4	Resident Care director already received a physician order to put the resident on half bed rail. The director agreed to check all residents using bed rails and will submit to CCL copies of physician order for all residents using bed rails.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

Page: 4 of 6

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 HOLLYWOOD	FACILITY NUMBER: 197608467
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation during the physical plant tour, grab bars in the some room and dresser in room 101 was broken, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/29/2021
	Plan of Correction
1 2 3 4	Resident care director agreed to fix all the loose grab bars and repair the dresser on room 101 and will submit a proof of the repair on or before the POC date.

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation during physical plant tour, resident on room 225 has half bed rail without doctor's order, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/29/2021
	Plan of Correction
1 2 3 4	Resident Care director agreed to obtain a doctor's order for the resident and submit a copy of the order to CCL on or before the POC date.

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

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