197609518-3-20-2024-29-AS-EPEI-D3K236-20240320170148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609518
Report Date: 03/20/2024
Date Signed: 03/20/2024 05:02:32 PM

Document Has Been Signed on 03/20/2024 05:02 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 CALABASAS		FACILITY NUMBER:	197609518
ADMINISTRATOR:	NELSON, NANCY		FACILITY TYPE:	740
ADDRESS:	24141 VENTURA BLVD		TELEPHONE:	(818) 222-2600
CITY:	CALABASAS	STATE: CA	ZIP CODE:	91302
CAPACITY:	165	CENSUS: 127	DATE:	03/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Nancy Nelson, Executive Director		TIME COMPLETED:	05:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Emily Peraldi and Licensing Program Manager (LPM) Kristin Heffernan arrived at the facility unannounced to conduct a required annual visit. At 9:50 a.m., the LPA was greeted by staff. At 9:58 a.m., the LPA met with the Executive Director (ED), Nancy Nelson and explained the reason for the visit. Between 10:57 a.m. and 12:46 p.m., the LPA and LPM along with the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The facility is a three (3) story building. Resident rooms are located throughout three floors. The neighborhood (memory care unit) is located on the first (1st) floor; Circle of Friends units and assisted living units are located on the second (2nd) and third (3rd) floor. Common spaces on the first floor include the reception area/lobby, bistro, dining room, and fitness room. The remaining floors each have their common spaces for activities, and all have appropriate furniture. All activity rooms and common spaces appeared clean and in good repair. A theater and salon are located on the third floor. Activity schedules are posted throughout the facility. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 04/05/2023. Fire alarm/sprinkler system was tested on 02/19/2024. Kitchen: Dining is located on the first floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. Residents do not have access to the kitchen; dangerous items are stored inaccessible to residents. The menu was available for viewing and the facility offers daily specials and a standard selection at every meal. Snacks and beverages are available for residents. Continued on LIC 809C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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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Document Has Been Signed on 03/20/2024 05:02 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS	FACILITY NUMBER: 197609518
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in water temperature was tested throughout the visit including resident unit restroom and common areas, and water measured between 107.4– 121.0 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2024
	Plan of Correction
1 2 3 4	The ED stated that the facility staff will adjust water temperature within required range and send proof to the LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/20/2024 05:02 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS	FACILITY NUMBER: 197609518
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)

87465(h)(6) Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on an observation and record review, the licensee did not comply with the section cited above, as the records, CSMDR were not updated or were missing for six (6) out of six (6)resident medications which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	The Director of Resident Care Services, Kelly Penrose, stated that facility staff will receive medication training and look for the missing CSMDR by due date and moving forward will ensure that CSMDR are completed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE CALABASAS	FACILITY NUMBER: 197609518
	VISIT DATE: 03/20/2024

NARRATIVE

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Resident Units: The LPA, LPM and ED toured fourteen (14) randomly selected resident rooms throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting.

Restrooms: The LPA, LPM and ED observed restrooms in fourteen (14) resident units and common area restrooms. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces in the bathing unit. The water temperature was tested throughout the visit including resident unit restrooms and common areas, and water measured between 107.4– 121.0 degrees Fahrenheit. The ED stated that the water temperature is going to be adjusted.

Outside areas: There are multiple outdoor patios equipped with furniture for resident use as well as covered areas for resident use. The in-ground pool was appropriately fenced per regulation. Parking is available for residents and visitors.

Starting at 1:59 p.m., the LPA and LPM conducted a review of medication, medication records, policy and procedures with medication technician. Audit for six (6) residents revealed that facility staff did not accurately record medications or had missing information on the Centrally Stored Medication and Destruction Record (CSMDR) for all six (6) residents’ medications reviewed. Three (3) out of six (6) residents’ medications reviewed, (Resident #1, Resident #2, Resident #3) did not have completed, or up-to-date CSMDR. The remaining three (3) out of six (6) residents’ medications reviewed, (Resident #4, Resident #5 and Resident #6) did not have CSMDR present during the medication review. The Director of Resident Care Services, Kelly Penrose, stated that facility staff will receive medication training and look for the missing CSMDR.

Documentation: The LPA obtained a copy of the liability insurance, resident roster, and staff roster, Infection Control Plan, Emergency and Disaster Plan.
Throughout the visit, LPA Peraldi interviewed four (4) residents.

Due to time constraints, the LPA will return at a later date to complete the annual.
Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were cited (refer to LIC 809-D).
Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC809 (FAS) - (06/04)

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