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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608467
Report Date: 10/09/2025
Date Signed: 10/09/2025 02:50:01 PM

Document Has Been Signed on 10/09/2025 02:50 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELMONT VILLAGE HOLLYWOODFACILITY NUMBER:
197608467
ADMINISTRATOR/
DIRECTOR:		JANELLE TOPETEFACILITY TYPE:
740
ADDRESS:2051 N HIGHLAND AVETELEPHONE:
(323) 874-7711
CITY:LOS ANGELESSTATE: CAZIP CODE:
90068
CAPACITY: 150CENSUS: 95DATE:
10/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nathaniel Akyempon- DirectorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 10/09/25, 10:00 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced inspection of the Facility. LPA met with Resident Care Director, Nathaniel Akyempon, and reason for the visit was disclosed. Administrator's Certificate is valid; expiration date: 10/05/2026.

Facility is licensed as a four story complex, maintaining resident bedrooms with private bathrooms, and multiple public bathrooms. Fire clearance approved for (125) non-ambulatory, and an additional twenty-five (25) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, no residents were receiving hospice care services, and no bedridden residents.

At 10:25 am, LPA toured the physical plant and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main doors are the primary entry/exit point, including four (4) emergency exits: Two exits off the northeast and northwest corners of the facility, one exit off the south corner, and one exit off the southeast corner. Screening area is located immediately upon entrance. Visitor sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Facility is separated into Independent/Assisted Living, (second, third, fourth floors) and Memory Care. (First Floor) As the Facility provides dementia care, LPA observed the delayed egress system working properly. Room temperature is comfortable; wall thermostat displays a setting of 74.0°F., within the required range. Required postings are prominently displayed and observed as current.

[Continued on LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE HOLLYWOOD
FACILITY NUMBER: 197608467
VISIT DATE: 10/09/2025
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FIRE SAFETY: Fire detection system is present in the facility. LPA observed multiple smoke and carbon monoxide alarms installed, hardwired, and interconnected. Fire system monitoring is serviced on a monthly basis. Fire alarm system was tested and working properly. Fire drill was last conducted in Sept, 2025. Fire extinguishers were observed on all floors of the Facility. All extinguishers were last serviced on 2/19/2025. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. LPA observed evacuation chairs in facility stairwells.

KITCHEN: At 11:10 am, LPA observed kitchen to be clean, with an adequate supply of perishable and non-perishable foods located in the refrigerator, freezer, and pantry. LPA observed a variety of fresh fruits, vegetables, meats, dry cereals, and desserts. Foods are properly labeled and stored. Knives and sharps are stored in a designated area of the kitchen and inaccessible to residents.

LAUNDRY: LPA observed laundry rooms located all floors for residents to launder their personal clothing; with the exception of the first-floor Memory Care Unit. Laundry areas were clean and clear from obstruction. Facility bed linens, towels, etc. are serviced by contracted laundering vendor.

BEDROOMS: LPA conducted random observations of resident bedrooms (#105, #222, #234, #305, #319, #321, #412, #414, #416) for safety, privacy, and comfort. Bedrooms were inspected and observed to maintain required furnishings and sufficient lighting, bed linens, and blankets. All observed bedrooms were clean, free of odor, and clear of obstruction.



BATHROOMS: were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured between 108.0°F. and 116.0°F.; within the required range.

COMMONS: LPA inspected activity rooms, movie theater, salon, wellness centers, gym, library, dining rooms, and reception areas. Common areas were observed to be clean with adequate furnishings for resident use. Furnishings are in good condition. No obstructions, nor tripping hazards observed.

Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date. Exit interview conducted/Copy of report was provided.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
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