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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609518
Report Date: 04/27/2021
Date Signed: 04/27/2021 04:15:19 PM

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: 104DATE:
04/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Nancy NelsonTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management - Incident visit at the facility today to follow up on an incident pertaining to Resident #1 (R1). The LPA met with Executive Director Nancy Nelson and explained the reason for the visit. On 4/9/2021, the LPA received a call from the Executive Director, whom reported an elopement. On 4/8/2021 at approximately 7:20am, R1 was noted to be absent from their assisted living apartment. The facility contacted R1’s responsible party and local law enforcement. At 9:40am, R1 was found uphill outside of the community, approximately half a block away from the building. R1 was observed to have sustained scratches to their legs. Per interviews and records review, the length of time in which R1 was away from the community was between 2-3 hours. R1 was taken to the hospital and admitted for examination. R1 returned to the community on 4/13/2021.

Prior to the on-site visit, the LPA obtained copies of R1’s physician’s report, R1's appraisal dated 3/1/2021, and the appraisal completed after the incident dated 4/16/2021. During today’s visit, the LPA spoke with the Executive Director, reviewed documents, and observed the location in which R1 was found.

Based on interviews and records review, R1’s physician’s report dated 3/12/21 confirmed that R1 is not able to leave the facility unassisted. Interviews confirmed that although the community has twenty-four-hour concierge service, it is assumed that R1 left the facility through the front door, unbeknownst to staff. The facility is not equipped with Wanderguard, yet there are alarms on the door to alert staff. Although the doors were secure at that time, it is assumed that R1 left the building when another staff person came on shift. Since the incident, R1 has been reassessed and is now residing in the secured Memory Care Unit.

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, today's reports and appeal rights were reviewed and issued via email. Signatures were obtained.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2021
Section Cited

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Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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Based on interview and records review, the licensee did not comply with the section cited above, as the facility failed to ensure that R1 did not leave the facility unassisted per the physician report, which poses an immediate 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: 04/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2021
LIC809 (FAS) - (06/04)
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