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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609518
Report Date: 01/13/2023
Date Signed: 01/13/2023 03:17:15 PM


Document Has Been Signed on 01/13/2023 03:17 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: 115DATE:
01/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Nancy NelsonTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. The LPA met with Nancy Nelson and informed them of the reason for the visit. The LPA toured the physical plant to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

Common Areas: Units designated for assisted living residents are on all three floors and there is a separate unit on the first floor designated for memory care residents. There was hands-free hand sanitizer interspersed throughout the common grounds. The LPA toured all three floors and common spaces in both the assisted living and memory care unit. Activity rooms and common spaces were clean and in good repair. No obstructions and/or tripping hazards observed. Fire extinguishers were charged and last serviced 4/2022. Staff were observed interacting with residents during activities. Kitchen: The facility offers a standard and alternative menu. Snacks and beverages are available for residents in the Bistro. The dining area and kitchen appeared clean and in good repair. Outside areas: The LPA toured the courtyards, where there was appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors. The in-ground pool was appropriately fenced per regulation. Restrooms: Restrooms were stocked with soap and paper towels and signs were posted that promoted good hand hygiene. Water temperature was tested on all floors and the temperature ranged between 110 - 116 degrees Fahrenheit.

Infection Control: Visitors continue to sign in at the front desk and are required to wear a mask. Staff were wearing face coverings. The community has an adequate supply of Personal Protection Equipment (PPE). The cleaning protocol was sufficient. This facility has records of staff and resident vaccinations. The community can designate isolation zones if there is a confirmed case of COVID-19. The facility has managed COVID-19 cases and the facility complied with requirements set forth by the health department and licensing. Staff are up to date regarding guidelines around visitation and vaccine requirements. The community's policies and procedures pertaining to infection control were adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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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