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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608468
Report Date: 07/24/2024
Date Signed: 07/24/2024 12:04:31 PM


Document Has Been Signed on 07/24/2024 12:04 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:RODRIGUEZ, MARY JANEFACILITY TYPE:
740
ADDRESS:455 E ANGELENO AVETELEPHONE:
(818) 972-2405
CITY:BURBANKSTATE: CAZIP CODE:
91501
CAPACITY:160CENSUS: 120DATE:
07/24/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Director of Resident Care Services, Diana Gevorgyan TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted unannounced case management Annual Continuation visit to the facility. LPA met with Executive Director, Mary Jane Rodriguez and Director of Resident Care Services (DRCS), Diana Gevorgyan and explained the reason for the visit. LPA met the assistant administrator and informed that this visit was conducted to complete Required 1 year inspection initiated on 06/23/2024.


During this visit at 9:45a.m. LPA and DRCS toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility. At approximately 10:20a.m. LPA reviewed staff files and they were complete and staff had criminal record clearance and association to the facility. All required documents were appropriately signed and dated.


Exit interview was conducted. A copy of this report was provided to the Executive Director.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-EttimaTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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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