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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197608467
Report Date:
08/04/2021
Date Signed:
08/04/2021 02:35:36 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., 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:
08/04/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:20 PM
MET WITH:
Adrianna Sais
TIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit to deliver an immediate exclusion order to the facility on behalf of the Monterey Park Adult and Senior Care Office to this facility. LPA met with Adrianna Sais (Resident Services Director) and went over the Immediate Exclusion Order.
Exit Interview conducted.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/04/2021
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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