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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608468
Report Date: 10/13/2022
Date Signed: 10/13/2022 04:06:39 PM

Document Has Been Signed on 10/13/2022 04:06 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
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: 131DATE:
10/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Mary Jane Rodriguez TIME COMPLETED:
04:27 PM
NARRATIVE
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LPA Lopez in the course of investigating allegation of compliant dated 09/21/2022 which included tour and inspection of food preparation and food storage facilities, LPA Lopez and Chef Manager observed items of food that had expired: Food items included the following:

Peach filling - Expired 12/17/2021
Apple Filling - Expired 05/26/2021
Potato mix - Expired 09/17/2022
Smokey Ham flavored base 01/17/2022
Juice Lime - Expired 09/20/22
Grapefruit sosmert - Expired 09/18/2022
Golden Mated Spray x5 - Expired 07/08/201
Grape Juice lot 14 FL oz x9 Expired 4/16/2022
Jello Mix x3 Expired 03/18/2022, 07/08/0221,
Milk Chocolate Mouse 03/25/2022
11 Flan dessert mix - Expired.04/08/22
Knoor Syrup x2 Expired - 03/11/2020
Oreo Medium Cookie Pies Expired 09/06/020
Golden Girl Baking powder - Expired 01/19/2020
Gelatin 32 envelopes - Expired 04/29/2021
Decorating icing - Expired 02/26/2021
Ground cinnamon - Expired 07/31/2022
Cake Decorations - Expired 07/07/2021
Lyons Cherry filling 10lbs - Expired 05/26/2022, 11/29/2021
Chocolate Icing - Expired 05/10/2021
Muffins X7 packs - Expired 09/22/2022
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BELMONT VILLAGE BURBANK
FACILITY NUMBER: 197608468
VISIT DATE: 10/13/2022
NARRATIVE
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Hamburger Buns - Expired 09/22/2022
Chese Steak buns - Expired 09/13/2022

LPA Lopez asked chef Manager to dispose of all expired food and LPA witness the disposal of all expired food.

Deficiencies cited see 809D.

Exit interview conducted with administrator and copy of report will be email due to printer issues.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/13/2022 04:06 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/13/2022 at 03:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2022
Section Cited
CCR
87555(b)(9)

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87555(b)(9) General Food Service Requirements. Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service

This requirement is not met as evidenced by:
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Chef Manager disposed of all the expired food and LPA wintness all the food thrown into trash cans. Administrator will have all staff in food service attend training in stroring, and preparing food and send proof to LPA by POC date. Also, make sure food is checked everyday and rotated to prevent expired food to be strored at facility.
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Based on observation, the licensee did not comply with the section cited above as LPA and Chef Manger observed many itmes with expired dates. (List on 809 report)
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
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