<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608468
Report Date: 07/21/2025
Date Signed: 07/21/2025 01:35:31 PM

Document Has Been Signed on 07/21/2025 01:35 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: 117DATE:
07/21/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Mary Jane Rodriguez-Executive Director TIME VISIT/
INSPECTION COMPLETED:
01:30 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) Nadia Shahbazian conducted an unannounced continuation of the required One Year inspection, dated 07/17/2025. LPA met with Executive Director, Mary Jane Rodriguez and explained the reason for the visit. Current census is 117 residents, 90 residents residing in the Assisted Living portion of the facility and 27 residents in the Memory Care unit.

During today's visit, LPA toured the first floor Memory Care area with the Executive Director. The tour of the other second, third and fourth floors was conducted on 07/17/2025.



Bedrooms: LPAs toured multiple resident bedrooms on all four floors, randomly. Except for three shared apartments in the Memory Care area, all bedrooms are private. The bedrooms were inspected and observed to maintain required furnishings and sufficient lightings. Administrator mentioned that some of the residents have brought their own furniture, based on their own taste. LPA inspected the bedroom walls, floors, furniture and bed linens for cleanliness. All bedrooms were observed to be clean, sanitary and clear of obstructions. In room numbers 119, 201, 311 and 408, LPAs pulled the assistance cord; caregiver responded within 2-3 minutes.

Bathrooms: There are nine (9) public restrooms, scattered on the four floors of the facility, which are designated for residents', visitors' and staff use. All bedrooms have their own private bathrooms. All the bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, non-slip mats). Hot water temperature measured between 105.9° F. and 117.6° F; within the required range. At bathroom# 123 and 408, LPA pulled the assistance cord; caregivers responded within 2 minutes.

Continued on 809-C

Eva Miller
Nadia Shahbazian
DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2025
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
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)
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: 07/21/2025
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
First-Aid Kit/Medications: Facility has a Wellness Center, where all the medical charts, supplies, medicine destruction bins are kept, All medications were observed to be locked in medicine cabinets on the first and third floors. LPA observed several complete first-aid kits with all required supplies and the first aid manual in the Wellness Center, in facility vans and multiple locations throughout the facility.

Resident Files: A review of ten resident records was conducted to ensure compliance of licensing required forms. The records included but were not limited to: Admission agreement, consent forms, emergency information, medical assessments and medication records.

Staff Files: LPA observed staff files kept in locked cabinets in the Administration Office. Ten staff files were reviewed to ensure all forms and training certificates are up to date.

Staff Rooms/Offices: Facility has one staff break room and several offices, including Human Resources, Administration, Sales, Maintenance Office and Wellness Center.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report provided to Executive Director.

SUPERVISOR'S NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3