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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608467
Report Date: 12/23/2021
Date Signed: 12/23/2021 12:18:51 PM

Document Has Been Signed on 12/23/2021 12:18 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:
12/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Adriana SaisTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced case management visit regarding the serious incident report that occurred 09/11/2021. At 11:00am LPA meet with Adriana Sais Director of Resident Services and explained the purpose of this visit.


Upon meeting Adrianna LPA was informed that a staff member contacted the facility on 12/22/21 to notify of her positive test. Community Care Licensing had not yet been notified of the positive test, but the facility have notified California Department of Health of the positive Covid-19 employees. Mass testing for staff began on 12/22/21 and residents will began on 12/23/21.

LPA requested and obtained documents relevant to the incident at 11:20am.

Based on documents obtained LPA has determined that further investigation is required at this time.

Exit interview conducted. Copy of this report issued.
Naira Margaryan
LaQueena Lacy
DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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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