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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608468
Report Date: 06/07/2022
Date Signed: 03/01/2023 04:08:56 PM


Document Has Been Signed on 03/01/2023 04:08 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/08/2022 09:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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**** This amended report supersedes report dated 06/07/2022. It was created to insert the correct word to correctly identify the deficiency. "non" was added in from of the word perishable on the Deficient Practice Statement for deficiency number 87555(b)(26). Revision did not change any other aspects of the report and all aspects remain the same.

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Lizze Cohn,Drcs, in training, Zara Khatchatrian RN, Micelle Sucillion Sales Director, and explained the purpose of the visit. Administrator Mary Jane Rodriguez arrived later and assisted with the inspection. Administrator certificate expires 8/2/2023 Last fire drill was on May 11/2021

Structure:
The facility is licensed to serve for a capacity of one hundred sixty (160) Non-Ambulatory residents, of which thirty (30) may be bedridden ages 60 and above. The facility has an approved Hospice Waiver on file for fifteen (15) residents. There are currently fourteen (5) Residents on Hospice. There are currently eleven (1) residents who are bedridden. There are one hundred and ten (105) residents residing in the assisted living portion of the facility and twenty seven (24) residents in the memory care unit. Belmont Village Burbank has an approved Dementia Care Plan in their plan of operation and accepts residents with dementia. Facility is approved for Delay Egress.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility follows Title 22 Regulations. The first level consists of a dining room, kitchen, memory care unit, bistro, mail room, wellness center and multiple recreation and lounge rooms. The second floor consists of offices, resident apartments and a gym (Center for Life Enhancement). The third floor consists of resident apartments and a Center for Learning. The fourth floor consists of a movie theater, salon and resident apartments. There are laundry rooms located on each floor of the building. Medications are centrally stored in the locked medication stations located on floors one and three.

LPA toured a random selection of resident rooms on each floor. Resident rooms were furnished appropriately. Each resident room has their own restroom. The bathrooms were observed to be clean and operational w/grab bars. With the exception of room 219. The resident rooms have a signal system located in each restroom and facility phones to call the front desk. The facility has central air and heating accommodations. The hot water temperature was tested throughout the facility and was not measured within Title 22 Regulations.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BELMONT VILLAGE BURBANK
FACILITY NUMBER: 197608468
VISIT DATE: 06/07/2022
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 The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· LPAs was screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does not have one designated isolation room due to each resident having private.
· 12 client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Client rooms were equipped with alcohol-based hand sanitizer.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days was observed but non-perishable foods for 7 days were not observed.

· A posted Emergency Disaster Plan was posted but was at facility.


· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
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Deficiencies cited per Title 22 Health and safety code, See 809D for details.
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Exit interview was conducted with Administrator Mary Jane Rodriguez . A copy of the report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/15/2022 04:20 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/08/2022 07:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: BELMONT VILLAGE BURBANK
FACILITY NUMBER: 197608468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as water temperature in Room 217 measured 122.9 degrees F in bathroom sink. Room 219 water temperature measured 72 degrees F. Room 317 water temperature measured 121.7 in sink and 120.5 in bathroom sink. Town Hall sink water temperature measured 120.9 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2022
Plan of Correction
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Licensee will adjust water temperture and send photos and certify that water temperture is within 105-120 degrees F by POC date.
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA and Food Manger Andrew Zumbado observed lack of 7 day non-perishable food supplies. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2022
Plan of Correction
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Licensse wiil purchase additional non-perishable food for 7 days and send invoice/reciepts as proof to LPA by POC.
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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/07/2022 04:30 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: BELMONT VILLAGE BURBANK
FACILITY NUMBER: 197608468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA and maintance manager oberved 3 screens in disreapir which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Licensee will repair/replacce window screens and send photos as proof to LPA by POC date.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one count as toliet in room 219 was not fllushing and in need of cleaning. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2022
Plan of Correction
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Toliet was repaired and clean at time of visit and no further action is required.
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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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