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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608467
Report Date: 07/01/2024
Date Signed: 07/01/2024 05:33:28 PM


Document Has Been Signed on 07/01/2024 05:33 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:JANELLE TOPETEFACILITY TYPE:
740
ADDRESS:2051 N HIGHLAND AVETELEPHONE:
(323) 874-7711
CITY:LOS ANGELESSTATE: CAZIP CODE:
90068
CAPACITY:150CENSUS: 89DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Janelle TopeteTIME COMPLETED:
05:30 PM
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On 07/01/24, 9:45 AM, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced inspection of the Facility. LPA met with Administrator, Janelle Topete.

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, there are four (4) residents receiving hospice care services, and no bedridden residents.

At 10:15 AM, LPA and the Administrator 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, with 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. (Dining room) Emergency exit routes are clear of obstructions. 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 and 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 73.0°F., within the required range. Administrator's Certificate is valid with expiration: 10/5/2024.

The facility maintains an approved Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 6/12/2024.

[LIC 809C-Continued]
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE HOLLYWOOD
FACILITY NUMBER: 197608467
VISIT DATE: 07/01/2024
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Resident records: Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.

Staff records: Staff files were reviewed. Criminal record clearances, Health Screening, Employee Rights records were present, and Staff are associated to this facility. Staff records appear to be complete and current.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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