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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609518
Report Date: 12/31/2020
Date Signed: 12/31/2020 12:23:06 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/24/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20201224111059
FACILITY NAME:BELMONT VILLAGE CALABASASFACILITY NUMBER:
197609518
ADMINISTRATOR:NELSON, NANCYFACILITY TYPE:
740
ADDRESS:24141 VENTURA BLVDTELEPHONE:
(818) 222-2600
CITY:CALABASASSTATE: ZIP CODE:
91302
CAPACITY:165CENSUS: 111DATE:
12/31/2020
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Nancy NelsonTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Unlawful Eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Nancy Nelson.

It was alleged that the facility issued an unlawful eviction to Resident #1 (R1). A review of the eviction notice and speaking with the Executive Director confirmed that the eviction was based off a violation of general polices as stated in the Admissions Agreement. However, this was not explicitly stated in the eviction notice; rather, it was summarized that R1’s needs could not be met as a result of the alleged violations. The circumstances and events mentioned in the eviction do not speak to the facility’s inability to meet R1’s needs. As such, there is sufficient evidence to support the claim that the facility issued an unlawful eviction. This allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9009-D). Exit interview conducted. Appeal rights provided. A copy of this report was emailed for signature.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20201224111059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS
FACILITY NUMBER: 197609518
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2021
Section Cited
CCR
87224(a)(34
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Eviction Procedures. The licensee may evict a resident for one or more of the reasons ... (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted... and the licensee.. believes that the facility is not appropriate for the resident.
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The Executive Director has agreed to do the following:
1. Rescind the initial eviction issued to R1 and provide a valid eviction notice to R1. The community will provide the LPA with a copy of the notice prior to issuing it to R1 for approval.
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This requirement is not met as evidenced by: Based on interview and documentation, the licensee did not comply with the section cited above, the circumstances documented in the notice did not correlate to an inability to meet R1's needs, which poses a potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
LIC9099 (FAS) - (06/04)
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