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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601646
Report Date: 06/08/2021
Date Signed: 06/08/2021 12:18:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BELMONT VILLAGE RANCHO PALOS VERDESFACILITY NUMBER:
198601646
ADMINISTRATOR:LAMM OBERG, RUTHFACILITY TYPE:
740
ADDRESS:5701 CRESTRIDGE RDTELEPHONE:
(310) 377-9977
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:150CENSUS: 104DATE:
06/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:ADMINISTRATOR MIKI LAMMTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Calderon was met by Administrator Miki Lamm and the purpose of today’s visit was explained. The facility is licensed to serve 150 elderly 59 and older.

There are currently 104 elder residents in care. There are 98 non-ambulatory and 6 ambulatory clients of which 66 residents are in the Memory Care Unit. The facility is a 3-story structure with 130 bedrooms and 8 common bathrooms, multimedia rooms, commercial kitchen, patios and a pool.

LPA Calderon and staff toured the physical plant. There is a large 4-foot pool that is gated with a passcode to enter the pool area. 10 client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA Calderon observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were not accessible to clients. Smoke detectors and Carbon Monoxide were operable.

During the visit, LPA Calderon observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES
FACILITY NUMBER: 198601646
VISIT DATE: 06/08/2021
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies under California code of regulation title 22, division 6, chapter 8.

Exit interview held and a copy of the report was provided to Administrator Miki Lamm.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC809 (FAS) - (06/04)
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