197608467-3-30-2022-31-AS-NMAN-CEA26T-20220509170737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608467
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:24:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2022 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20220323080447

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: 82	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Adriana Sais		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Toilet in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility on 03/30/2022 at 11:15am to conduct an initial 10 compliant visit. LPA Lacy met with Adriana Sais and explained the purpose of the visit. Physical Plant tour was conducted between 11:22am – 11:36am.

It is alleged that the toilet is broken, and the resident cannot use it. To investigate the above allegation LPA conducted interviews with staff and residents at approximately 11:38am – 1:42pm. LPA requested copies of document relevant to the investigation at 11:36am. LPA spoke with eight (8) out of eighty-two (82) residents. Based on interviews seven (7) out of (8) resident would notify the front desk or S2 (Building Engineer) if any repairs needed to be done. Five (5) out of (8) residents feel that S2 responds to repair request quickly and in a timely manner. Three (3) out of (8) residents have not needed or had any repairs to their apartment. LPA observed nine (9) random rooms, all bathroom toilets were observed to be operational and functioning. During the investigation, S2 confirmed that a service request for room 311 was put in, S2 responded to the service request conducted an inspection and observed no malfunctions.
Contiuned on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20220323080447

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/30/2022

NARRATIVE

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A second request for the toilet was received, S2 inspected the toilet and observe a small amount of water on the floor, S2 contacted Homex Plumbing Rooter INC. LPA conducted a record review of Homex Plumbing Rooter INC, which S2 stated “was for the work performed on room 311's, toilet”. The work performed was for an easy turn emergency shutoff valve, and commercial pull/rest toilet. Based on interviews, observations, and record review, although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited, exit interview conducted, copy of report and appeal rights issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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