198601646-10-14-2023-11-AS-EDAT-CWM3JS-20231014181800

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601646
Report Date: 10/14/2023
Date Signed: 10/14/2023 06:18:10 PM

Document Has Been Signed on 10/14/2023 06:18 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:	BALBIN, RALPH		FACILITY TYPE:	740
ADDRESS:	5701 CRESTRIDGE RD		TELEPHONE:	(310) 377-9977
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	150	CENSUS: 125	DATE:	10/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Ralph Balbin		TIME COMPLETED:	04:21 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	On 10/14/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Executive Director Ralph Balbin. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to serve (150) non-ambulatory elderly residents of which (30) may be bedridden ages 60 and above. The facility is approved for (20) hospice residents. Currently, the facility has (16) hospice residents. The facility is a three-story structure located in a residential neighborhood. It consists of the following: (27) resident bedrooms in the Neighborhood and (114) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, a lobby, a living room, (3) lounge areas, a dining room, a kitchen, a bistro, a Memory Care Unit. housekeeping/janitorial storage closets, (3) administrative offices, (2) laundry rooms, an activity room, a Wellness room, an engineering office, a beauty salon, an activity area, front and rear patio area, a gated pool, and outdoor storage sheds. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #135, #138, #245, #253, #322 and #330. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.7 – 115.4 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. (Evaluation Report continues LIC 809-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

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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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: 10/14/2023

NARRATIVE

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Fire extinguishers were fully charged, and smoke detectors and carbon monoxide were operable in each resident's room. The facility conducted an emergency fire and earthquake drills on 09/20/23. The facility has certificate of liability insurance effective 10/01/23 - 10/01/24. The facility is current on annual (CCL) license fees.

A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#6 (S1-S6) personnel files were in maintained in place. LPA conducted (5) residents and (3) staff interviews.

Deficiency:
During staff file review between 12:30pm - 2:30pm, the following required items were not in the files:

(3) out of (6) staff #2, #4, #5 care staff did not have have current CPR/First aid on file.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Ralph Balbin, and a copy of the report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/30/2023 03:49 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/30/2023 03:12 PM

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General - All RCFE staff...shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review), the licensee did not comply with the section cited above. LPA identified staff #2, #4 and #5 did not a valid or current CPR/First Aid on file. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/11/2023
	Plan of Correction
1 2 3 4	The licensee is to obtain current first aid certificates for staff #2, #4, #5 and will create a plan to ensure that ensure that caregiver staff who assist residents with personal activities of daily living receive annual first aid training. Proof of correction will be submitted to CCL via email at ernand.dabuet@dss.ca.gov. The administrator may ask for an extension if more time is needed via email. *This report serves as an amendment to clarify the Deficient Practice Statement. It does not supersedes the inspection citation reflected on report created on 10/14/23. _.

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC809 (FAS) - (06/04)

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