198601646-1-6-2023-11-AS-WGIS-CMU2S2-20230106163825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601646
Report Date: 12/19/2022
Date Signed: 01/06/2023 04:38:36 PM

Document Has Been Signed on 01/06/2023 04:38 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BELMONT VILLAGE RANCHO PALOS VERDES		FACILITY NUMBER:	198601646
ADMINISTRATOR:	LAMM OBERG, RUTH		FACILITY TYPE:	740
ADDRESS:	5701 CRESTRIDGE RD		TELEPHONE:	(310) 377-9977
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	150	CENSUS: 107	DATE:	12/19/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Miki Lamm		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management inspection. LPA met with and toured the facility with Miki Lamm. All residents and staff are vaccinated and boosted
Infection Control During the visit, LPA observed the facilities infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked. All staff were wearing masks and 95% of residents outside of their rooms were wearing masks (when asked to put them on some resident responded with no). All staff have completed Fit testing. All resident’s temperatures are checked and logged (once a day) and upon re-entry from an outing. Some outings (community based) have been suspended until further notice.

Isolation Rooms Resident's private rooms were converted into isolation rooms. Outside every isolation room is a isolation cart with all the necessary PPEs. Included in the isolation carts are individual medical equipment (ex. blood pressure cuff), and cleaning products. Inside the isolation rooms, by the door, is a trash can with a lid for doffing PPEs. LPA observed resident's doors, who are isolating, to have an isolation posting on them and to be zoned yellow and red. LPA observed staff donning appropriate PPEs before entering an isolation room.

Common Rooms Each common room has enough space for resident's to maintain a safe distance. Near every common space (dining room entrance, elevator, sitting rooms) there is a hand sanitizing station available for use. LPA observed no infection control postings in common spaces areas.

Visitation All residents who are not in isolation are able to have visitors. Visitors may go to the resident's room or they may go to one of the many patios or sitting areas. Visitors are required to wear a mask and to be screened upon entry.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 12/19/2022

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Postings LPA did not observe the required infection control postings throughout the facility (ex Cough etiquette, reminders to distance, wear a mask). There were isolation signs on doors of residents who are in isolation. In the public restrooms and any location that had a sink had the required hand washing signs posted. There was a sign posted on the entrance door to wear a mask and to not enter if you are experiencing any Covid symptoms. LPA observed

Supply The facility had 30 day supply of PPEs stored and inaccessible to residents in room #239. There are pre-made isolation carts fully stocked and ready for use. LPA observed an ample supply of hand sanitizer and hand soap.

Cleaning LPA observed an ample supply of cleaning products. High surface touch areas are wiped and cleaned multiple times a day. Each isolation cart has cleaning wipes available. Twice a day the inside of the facility is sprayed with Efferent, it disinfects surfaces within 1 minute.

Administrator is still awaiting a copy of the Health Order.

Two Technical advisories: have signs posted throughout the facility to serve as reminders for residents of cough/sneezed etiquitte, maintain distance from others, wash your hands and report all respiratory illnesses.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022

LIC809 (FAS) - (06/04)

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