565802433-6-25-2022-29-AS-MARO-CFQSHJ-20220625135337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 06/25/2022
Date Signed: 06/25/2022 01:54:15 PM

Document Has Been Signed on 06/25/2022 01:54 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 THOUSAND OAKS		FACILITY NUMBER:	565802433
ADMINISTRATOR:	DINA DAVIS		FACILITY TYPE:	740
ADDRESS:	3680 N MOORPARK RD		TELEPHONE:	(805) 496-9301
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	158	CENSUS: 105	DATE:	06/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Roger Alaba		TIME COMPLETED:	01:55 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	Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. This annual has a specific emphasis on infection control practices and procedures. The last annual conducted at this facility was on 05/08/2019. The LPA met with Staff, Roger Alaba and was explained the reason for today's visit. Entrance interview conducted. At 9:51 a.m., the LPA along with staff began a physical plant tour to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility's dining room and kitchen were observed. The kitchen area was inspected for cleanliness, food handling, and storage practice. The LPA observed facility had a sufficient supply of perishable and non-perishable food and food was stored at appropriate temperatures. All knives and sharps are locked inaccessible to residents. The facility has four (4) levels, including two (2) memory care neighborhoods. A random selection of four (4) resident bedrooms were observed. The LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a nightstand, and sufficient lighting. The LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. The water temperature was tested on each of the four floor levels. Level one bathroom measured 114.8 degrees Fahrenheit, second level bathroom measured at 113.5 degrees Fahrenheit, third level bathroom measured 118 degrees Fahrenheit, and the fourth level bathroom measured at 111.2 degrees Fahrenheit. Fire extinguishers were observed on each floor to be fully charged and last serviced on 05/2022. At 9:52 a.m., the LPA observed a housekeeping cart with cleaning supplies and toxins in the memory care unit on level two (2) accessible to residents in care. Staff was called to remove housekeeping cart and place in a secure location inaccessible to residents in care. The LPA observed the Medication to be locked and inaccessible to residents. ...Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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 THOUSAND OAKS	FACILITY NUMBER: 565802433
	VISIT DATE: 06/25/2022

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
26
27
28
29
30
31
32

...Continued from LIC 809...

During today’s visit, the LPA spoke with the Staff regarding the facility’s infection control practices. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE). The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility has one more round of testing before they are cleared from their recent Covid-19 Outbreak on 4/28/2022. Staff were observed wearing face coverings during time of visit. All staff has been fully vaccinated. No staffing concerns, the facility is currently using agency to cover staff shortages when needed.

Pursuant to Title 22, California Code of Regulations, the following deficiencies will be cited (refer to LIC 9099-D)

Exit interview conducted. Appeal Rights discussed. A copy of this report was sent via email to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 06/25/2022 01:54 PM - It Cannot Be Edited

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 THOUSAND OAKS	FACILITY NUMBER: 565802433
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above as cleaning supplies and toxic substances were observed on an unattended housekeeping cart accessible to residents, which poses an immediate health risk to persons in care.
	POC Due Date: 07/01/2022
	Plan of Correction
1 2 3 4	Staff placed items and housekeeping cart in an inaccessible location during facility visit. Staff stated that they will provide documentaton of staff training regarding regulation 87309(a) to CCL by 7/01/2022.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3