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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608467
Report Date: 03/09/2022
Date Signed: 03/09/2022 07:19:25 PM


Document Has Been Signed on 03/09/2022 07:19 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: 84DATE:
03/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Adriana SaisTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaQueena Lacy conducted a subsequent Case Management visit, LPA arrived at the facility at 11:00am on 03/09/2022, regarding incident that occurred on 09/11/2021. LPA meet with Adriana Sais and explained the purpose of the visit. LPA conducted a physical plant tour at 11:12am.

Woodland Hills South Adult and Senior Care Regional Office (WHASCRO) received an incident report involving the facility resident #1 (R1). Per Incident report on 09/11/2021, The nurse had given R1 an additional dose of a prescribed medication.

On 12/23/2021 at 11:20am, LPA obtained documents relevant to the investigation. LPA conducted interviews with ED on 09/20/2021, and staff and R1 on 03/09/2022 between 11:51am and 2:24pm. Per ED, the nurse that administered the additional dose resigned from the position on 09/18/2021. ED admitted and Interviews confirmed that S1 administered an additional dose of a prescribed medication, and did not use the facility Accuflow computer system, that would tell staff exactly what medications are to be dispensed. During the investigation, upon record review of R1's facility file, medical records, and other relevant documents, R1 is to take the prescribed medication, one (1) tablet by mouth daily. R1 did not experience any complications due to the additional medication, and R1 was monitored on an hourly basis.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit. See LIC 809-D.



Exit interview conducted, copy of report and appeal rights issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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Document Has Been Signed on 03/09/2022 07:19 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2022
Section Cited

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87465(c)(2)Incidental Medical and Dental Care.If the resident's physician has stated in writing... facility staff designated by the licensee shall be permitted to assist the resident...Once ordered by the physician the medication is given according to the
physician's directions.This requirement is not met as evidenced by:
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Based on interviews and record review
the Licensee did not ensure that Staff follow procedures when dispensing medications. This poses an immediate health and safety hazard to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
LIC809 (FAS) - (06/04)
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