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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609518
Report Date: 03/06/2023
Date Signed: 03/06/2023 02:27:26 PM


Document Has Been Signed on 03/06/2023 02:27 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:BELMONT VILLAGE CALABASASFACILITY NUMBER:
197609518
ADMINISTRATOR:NELSON, NANCYFACILITY TYPE:
740
ADDRESS:24141 VENTURA BLVDTELEPHONE:
(818) 222-2600
CITY:CALABASASSTATE: CAZIP CODE:
91302
CAPACITY:165CENSUS: 127DATE:
03/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Nancy NelsonTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a Case Management – Other visit, with the aims of discussing the community’s current COVID-19 outbreak. This visit was conducted in conjunction with Registered Nurse (RN) Jolene Thoreson from the Los Angeles Department of Public Health. Parties met with Executive Director Nancy Nelson and explained the reason for the visit.

This visit was regarding ongoing concerns related to the current Coronavirus (COVID-19) Outbreak for this community, and the facility staff’s failure to follow reporting requirements. Community Care Licensing (CCL) received an email on 01/22/2023, indicating the presence of COVID-19 in the community. Per communication with local public health, the outbreak for this community was opened on 01/31/2023. A Health Officer Order was also issued to this community and details regarding outbreak requirements were discussed. A site visit was conducted by local public health on 02/02/2023 and during the visit, parties discussed infection control policies and procedures. A discussion was had regarding reporting requirements as set forth by the local health department in managing communicable disease outbreaks.

At the start of an outbreak, facilities are required to complete and submit a line list and must complete the COVID-19 Public Health Email Update daily, Monday through Friday. The community is required to also update the line list as new positives arise. The above-mentioned requirements have been communicated to facility staff in person, over the phone, and via email. In discussion with Belmont Calabasas management and the local health department, the staff have not submitted the daily update report to local health department on a daily basis as requested. At times, the daily update has insufficient information and /or is not completely filled out. In addition, several requests have been made regarding the requirements for a completed and regularly updated line list. However, it has reportedly taken several days for the community to send updates to public health, versus sending the daily update as discussed.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE CALABASAS
FACILITY NUMBER: 197609518
VISIT DATE: 03/06/2023
NARRATIVE
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On 02/09/2023, the LPA sent an email to the management team of this community, reiterating the importance of timely reporting for both CCL and the local health department.

PIN 23-04-CCLD, which was released 02/27/2023, indicates that licensees are no longer required to report individual positive cases of COVID-19. However, licensees are still required to report outbreaks, including COVID-19 outbreaks. This community has been considered under an outbreak since 1/31/2023 under the local public health department; as a result, they are required to follow local public health department guidance.

At this time, the community is not abiding by reporting requirements as set forth by the local health department.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted. A copy of the report, along with appeal rights, were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/06/2023 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2023
Section Cited

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87211(a)(2) Reporting Requirements. Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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The Executive Director agreed to do the following:
1. Review reporting requirements as communicated by local public health. Submit a statement of understanding, indicating how the facility will maintain voluntary compliance. Submit statement no later than 3/8/2023.
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This requirement is not met as evidenced by:
Based on interview, the licensee did not comply with the section cited above as the facility is not following reporting requirements to the local public health department, which poses an potential health, safety and personal rights risk to persons 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: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
LIC809 (FAS) - (06/04)
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