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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609518
Report Date: 11/15/2023
Date Signed: 11/16/2023 02:57:58 PM


Document Has Been Signed on 11/16/2023 02:57 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 N.ASC, 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: 119DATE:
11/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Nancy NelsomTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management visit regarding an incident which took place on 10/18/2023 involving Resident 1 (R1). LPA met with Executive Director (ED) Nancy Nelson and Resident Care Director (RCD) Zara Khatchatrian, RN, and explained the reason for the visit.

At 10:00 a.m. LPA interviewed the ED and RCD, regarding the incident report they submitted for R1. On 10/18/2023, R1 was not responding to stimuli and staff called 9-1-1. R1 was admitted to the hospital with an initial diagnosis of severe dehydration.

R1 was admitted to the facility in July of 2023. Prior to moving into the facility, R1 was at home with a 24/7 private caregiver. Upon admission to the facility, R1 was eating finger foods but started losing their appetite. Staff encourage residents to eat and drink but R1 would eat and then remove the food from their mouth. R1 also did not like to drink much.

At 10:30 a.m. LPA reviewed R1's facility file. After their stay at the hospital, R1 returned to the facility on 10/21/2023. The discharge paperwork from the hospital stated R1 was admitted for sepsis. R1 returned to the facility from the hospital with redness in a few areas. R1's physician ordered home health. A home health nurse visits three times a week for R1's rash to assess and ensure the redness does not progress further. R1's physician also ordered an appetite stimulant.

At 11:28 LPA toured the memory care unit and met R1. LPA interviewed the Memory Care Coordinator at 11:31 and interviewed a caregiver at 11:35 a.m. The staff encourage residents to drink water, juice, and other beverages they enjoy. Beverages are offered at all meals, snacks, after activities and during medication pass. R1 has been prescribed a pureed diet and is eating well but still does not like to drink fluids. They continue to offer R1 different beverage options and encourage hydration.

Based on the information obtained, it appears R1's needs are being met based on R1's care plan and medical orders. No deficiencies observed. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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