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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608468
Report Date: 07/15/2025
Date Signed: 07/15/2025 05:05:54 PM

Document Has Been Signed on 07/15/2025 05:05 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 BURBANKFACILITY NUMBER:
197608468
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, MARY JANEFACILITY TYPE:
740
ADDRESS:455 E ANGELENO AVETELEPHONE:
(818) 972-2405
CITY:BURBANKSTATE: CAZIP CODE:
91501
CAPACITY: 160CENSUS: 118DATE:
07/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Mary Jane Rodriguez - Executive Director TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analysts (LPA) Nadia Shahbazian and Michael Cava, conducted an unannounced Required One year inspection. LPAs met with Executive Director, Mary Jane Rodriguez and explained the reason for the visit. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools.

The facility is licensed to serve a capacity of one hundred sixty (160) Non-Ambulatory residents, ages 60 and above, of whom thirty (30) may be bedridden. There are currently 118 residents, 91 residents residing in the assisted living portion of the facility and 27 residents in the memory care unit.

At 11:20 am, LPAs conducted a tour of the physical plant with the Executive Director and observed the following:



Facility consists of four floors. Screening/Reception area is located immediately upon entrance. Required postings were displayed at the reception area. The main door is the primary entry/exit access. In addition, the facility has four (4) exit doors on each floor. Facility provides dementia care; LPAs observed delayed egress doors in the memory care unit. Physical plant was inspected for cleanliness; LPAs observed the facility as clean, sanitary, and appropriately furnished.

Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the facility. Multiple fire extinguishers were observed throughout the facility, on each floor. All fire extinguishers were serviced on 11/07/2024. Evacuation chair were observed atop stairwell on the fourth floor. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Last emergency/disaster evacuation drill was conducted on 06/28/2025 and the last fire/earthquake drill was conducted on 06/28/2025. Last fire inspection was performed by Burbank Fire Department on 10/30/2024.

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NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE BURBANK
FACILITY NUMBER: 197608468
VISIT DATE: 07/15/2025
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Kitchen: Facility has an industrial kitchen, which was observed to be clean, sanitary, and inaccessible to residents. The kitchen is equipped with three (3) refrigerators, walk in freezer, dishwasher, stove, two (2) grills, ovens, microwave, steamer, ice maker, coffee makers and ice cream freezer. LPAs observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days. Food was properly labeled and stored. Sharps are stored in the kitchen; inaccessible to residents. Detergents and chemicals were locked in a storage room in the kitchen.

Common Areas: Building is a four story structure. First floor has a lobby, two dining rooms, bistro, computer area for residents, a great room, two patios. There is a fitness center, activity rooms and offices on the second floor. The third floor has activity rooms such as "Center for Learning" and "Circle of Friends". There is a library, movie theatre, gaming area and hair salon on the fourth floor. There are sitting and activity areas on each floor, two elevators and three balconies on second, third and fourth floors. Common area walls, carpets and furnishings were observed to be clean and in good condition. No obstructions or hazards were observed.

Surrounding Grounds: The passageways and entrance to the home was clear of obstruction. Facility has two shaded outdoor patios with tables and sufficient seating for the residents. Outdoor furniture was observed to be in good condition. LPA also observed raised bed gardening area, where residents had planted herbs and flowers. There are no bodies of water in the facility.

Laundry: Facility has one (1) laundry room on each floor with total of three (3) washers and four (4) dryers. LPAs observed all the machines in functional capacity. Laundry detergents, cleaning toxins are connected to the washers and electronically dispensed.

Due to time constraints, LPAs were unable to complete today's annual inspection. LPAs will complete the inspection at a later date.

Exit interview was conducted, and copy of the report was given to facility Administrator.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC809 (FAS) - (06/04)
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