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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608467
Report Date: 06/17/2022
Date Signed: 06/17/2022 03:18:36 PM


Document Has Been Signed on 06/17/2022 03:18 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:BELMONT VILLAGE HOLLYWOODFACILITY NUMBER:
197608467
ADMINISTRATOR:YOUNG, ALLYSON LFACILITY TYPE:
740
ADDRESS:2051 N HIGHLAND AVETELEPHONE:
(323) 874-7711
CITY:LOS ANGELESSTATE: CAZIP CODE:
90068
CAPACITY:150CENSUS: 78DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Adriana SaisTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPAs) LaQueena Lacy & Gary Tan arrived at the facility at approximately 10:35am on 06/17/2022 to conduct a One (1) year Required Infection Control visit. LPAs meet with Adriana Sais and explained the purpose of this visit.

The facility has an approved mitigation plan on file. A tour of the physical plant was conducted at 10:54am and the following was observed:

The facility has a fire clearance for one hundred twenty-five (125) non ambulatory and twenty-five (25) bedridden with a hospice waiver for fifteen (15), and a dedicated Memory Care Unit equipped with approved delayed egress doors. The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE screening station is located at the receptionist desk upon entry equipped with sufficient PPE readily accessible, accushield thermometer and electronic sign in sheet, hand sanitizer, gloves, mask, at the time of visit. The facility maintains a temperature at 71 degrees Fahrenheit. The facility has fire extinguishers located throughout the facility to have a service tag dated 10/21/2021. The facility has four (4) floors, the 4th floor is currently occupying positive covid-19 residents, this area was observed to have the appropriate signage with PPE stations and trash cans located outside of the isolation rooms. The second floor is vacant and would be utilized for quarantining positive residents if necessary.
Kitchen: At 11:04am LPAs observed the kitchen to be clean and free from obstruction. Appliances observed
to be in good repair and functional. Sharps are stored inaccessible to residents which they do not have access to the kitchen. Refrigerated and frozen foods were stored at proper temperatures with sufficient amount of perishable and non-perishable food properly stored. LPAs observed the refrigerators and freezers to be stocked with a variety food.

Continued on LIC809C.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE HOLLYWOOD
FACILITY NUMBER: 197608467
VISIT DATE: 06/17/2022
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Bedrooms: At 11:21am LPAs were able to observe twelve (12) random rooms from the remaining floors that
are not occupying positive covid-19 residents. All bedrooms observed to be appropriately furnished with
sufficient lighting. LPAs observed appropriate bed linen and comforters on all beds. All bedrooms observed
to be clean and clear from obstruction.
Bathroom: At 11:21am LPAs observed (12) bathrooms located in the bedrooms. LPAs observed appropriate
grab bars located in the shower and around the toilet. Non-skid mats are in the shower. The water temperature measured in range of 106.7 between 119.1 degrees Fahrenheit. Bathrooms are stocked and equipped with soap and paper towels. Hand towels are not shared.
Medications: LPAs observed the Wellness Center at 11:46am located on the 3rd floor where the medication room is located observed to be storing medication in drawers with locks and cabinets. The medication drawers are locked and inaccessible to residents. The medication refrigerator is in another office located inside of the medication room to have a closed door and inaccessible to residents. The facility has two (02) first aid kits located in the medication room. LPAs observed (02) cabinets to be storing extra first aid supplies the second to be storing medications baskets filled with residents’ medications. There is also a bathroom located in the medication room not currently being used.
Laundry Room: At 11:56am LPAs observed the laundry rooms located on each floor, observed to be clean and free from obstruction. These areas are accessible to residents to do their own laundry.
Living, dining room and common areas: At 12:07pm LPAs observed these areas to be appropriately
furnished with tables and chairs and adequate lighting to be neat and clean. The facility has a theater, a gym, a center for learning observed to be neat and clean and free from obstruction. LPAs observed multiple outdoor patio areas and the surrounding grounds of the facility which was clean and clear from debris and obstruction. These areas are equipped with owing and tables with chairs for seating and additional tables and chairs for lounging. At 12:37pm LPAs observed a Fire Department Fire Protection Equipment Performance Report with a retest dated 02/21/2021 with a passed result, the fire alarm system was tested and observed to be working, it is hard wired and interconnected throughout facility. The facility has fire sprinklers throughout the facility. The facility has a basement where the parking lot is located as well as an area fenced off that is storing PPE, incontinent supplies, wheelchairs, files, etc. which is inaccessible to residents. No bodies of water observed or located on the premises.

No deficiencies cited, exit interview conducted, and a copy of report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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