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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609518
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:26:32 AM


Document Has Been Signed on 08/29/2024 11:26 AM - 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: 139DATE:
08/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nancy NelsonTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240214112429). LPA met with Executive Director Nancy Nelson and explained the reason for the visit.

During the Department’s investigation of complaint # 29-AS-20240214112429, the following deficiencies were observed:

A review of the facility notes revealed that on several dates (11/10/2021, 12/22/2022, 02/25/2022, 02/08/2023, 03/28/2023, and 04/04/2023) Resident #1 (R1) had unwitnessed falls which required visits to the Emergency Room. There were no incident reports submitted to Community Care Licensing (CCL) for the dates noted.

On 07/30/2023, after an unwitnessed fall in the bathroom, R1 suffered facial swelling on the right side and a skin tear to chin and was admitted to the hospital. R1 was placed on Affinity hospice and discharged back to the facility. The facility did not submit a hospice notification to CCL.

Citations issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/29/2024 11:26 AM - 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: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87211(1)(B)

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(a) Each licensee shall furnish to the licensing agency...(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.This requirement is not met as evidenced by:
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The licensee will submit a plan describing how you will ensure reporting requirements are followed. Submit proof to CCL via email by 09/06/2024
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Based on records review, the licensee did not comply with the section cited above. Licensee did not submit incident reports for R1’s numerous unwitnessed falls which required hospital visits, which posed a potential health and safety risk to residents in care.
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Type B
09/06/2024
Section Cited
CCR87632(d)(2)

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The licensee shall notify the Department in writing within five working days... name and date of admission to the facility and the name and address of the hospice.This requirement is not met as evidenced by:
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The licensee will submit a plan describing how you will ensure the Department receives hospice notifications. Submit proof to CCL via email by COB 09/06/2024
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Based on records review, the licensee did not comply with the section cited above. Licensee did not submit hospice notification to CCL when R1 was placed on hospice 07/30/2023, which posed 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2