197608468-6-23-2024-31-AS-AAEA-D6J34R-20240623175535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608468
Report Date: 06/23/2024
Date Signed: 06/23/2024 05:57:33 PM

Document Has Been Signed on 06/23/2024 05:57 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BELMONT VILLAGE BURBANK		FACILITY NUMBER:	197608468
ADMINISTRATOR:	RODRIGUEZ, MARY JANE		FACILITY TYPE:	740
ADDRESS:	455 E ANGELENO AVE		TELEPHONE:	(818) 972-2405
CITY:	BURBANK	STATE: CA	ZIP CODE:	91501
CAPACITY:	160	CENSUS: 125	DATE:	06/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Activity Program Coordinator, David Aaron		TIME COMPLETED:	06:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection visit at this facility today. LPA met with Mr. Aaron and explained the reason for the visit. Executive Director, Mary Jane Rodriguez and Director of Resident Care Services, Diana Gevorgyan later joined in the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. 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. There are ninety-seven (97) residents residing in the assisted living portion of the facility and twenty eight (28) 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 is in compliance with 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 (Circle of Friends Program). The fourth floor consists of a movie theater, salon and resident apartments. The facility maintains a comfortable temperature at 74°F. There are carbon monoxide detector installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 10/18/2023. The fire extinguishers and carbon monoxide detectors were observed to be fully charged and in compliance. The facility is equipped with emergency pull alarm and sprinkler system. Facility emergency disaster plan was reviewed. Facility disaster drill was last conducted on 06/20/2024. A fire inspection by the Burbank Fire Department was last performed on 04/26/2024.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BELMONT VILLAGE BURBANK	FACILITY NUMBER: 197608468
	VISIT DATE: 06/23/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. The facility has central air and heating accommodations. During today's visit, in addition to the physical plant inspection LPA reviewed the physician's reports for Residents #1 through #3.

A tour of the physical plant was conducted and the following was noted:

Kitchen: The kitchen appliances and fixtures were functional. Food supplies was sufficient amount for two (2) days of perishable and seven (7) days of non-perishable was stored in covered containers at the appropriate temperatures. Knives and sharp objects were observed to be locked and inaccessible to residents. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to residents. Walls, ceiling, and floor is in good repair, ample supply of dishes, cups, glasses and utensils for the current census.

Dining area: The dining area was observed to be neat, clean and in proper order. Walls, ceiling, tables, chairs and floor is in good repair.

Laundry rooms: There are laundry rooms located on each floor of the building. All toxins such as laundry detergents, cleaning agents were observed to be inaccessible to the residents in laundry rooms.

Medication: Medications are centrally stored in the locked medication stations located on floors one and three. The medications were observed to be locked and inaccessible to residents. There are multiple complete first aid kits in the facility. Medication and Medication Records were properly labeled and review for proper documentation. Facility uses the AccuFlo medication program.

Bedrooms: LPA randomly selected resident’s apartments on each floor. Resident bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting. Hygiene for residents was observed and hallways/passageways are lit. There were enough clean linen available in the closets. Each resident’s apartment has their own restroom.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BELMONT VILLAGE BURBANK	FACILITY NUMBER: 197608468
	VISIT DATE: 06/23/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Bathrooms: LPA randomly selected resident’s bathrooms on each floor. The bathrooms were observed to be clean properly supplied, functional fixtures and appropriate grab bars in showers and toilets. The hot water temperature measure range was between 111.3 – 117.3 degrees Fahrenheit within Title 22 Regulations.

Common Areas: LPA observed common areas on every floor. All furnishings are in good repair, lighting is good, walls, ceiling and floors are also in good repair.

Surrounding Grounds: The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. All passageways were observed to be clear from obstruction. The outdoor area was enclosed, and no bodies of water were observed.

Resident Files: LPA conducted a file review of three (3) randomly selected resident records to ensure compliance of licensing forms. Residents’ files appear to be complete and updated.

Due to time constraints, LPA had to terminate the visit and will return on a later date to complete the Required - 1 Year inspection by reviewing staff files, resident record, interview residents and staff.

An exit interview was conducted. A copy of this report was provided to the Executive Director.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3