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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:29:21 PM

Document Has Been Signed on 06/14/2023 03:29 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 OAKSFACILITY NUMBER:
565802433
ADMINISTRATOR:NANCY D NELSONFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 158CENSUS: 111DATE:
06/14/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cyntia Drachenberg-Executive DirectorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPA’s) Elsie Campos and Ashley Morgan arrived at the facility unannounced to conduct a continuation to a required annual visit at 9:30 a.m. The LPA’s were greeted by staff and informed them of the reason for the visit. This is an annual continuation, which began on 05/14/2023.

RECORDS: Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The following was noted: 1 out of 5 staff records (S4) were missing Tuberculosis results, 2 out 5 staff records (S1, S4) were missing first aid certification at the time of record review. LPAs were unable to verify required training hours for 4 out of 5 staff (S1, S2, S3, S4).

MEDICATIONS: Medications review began at 12:00 p.m., medications are centrally stored and locked in the Wellness Center. The LPA’s audited five (5) resident files. The following is observed: medications are labeled and checked for expiration dates. For 1 out of 5 residents (Resident #3), the facility did not have the as-needed (PRN) medication of Seroquel as prescribed by R3’s physician. In addition, staff assisted R3 with the self-administration of the PRN Ibuprofen and Acetaminophen, yet it was not properly documented as administered in the PRN log. Not all medications are properly documented on the centrally stored medications and destruction record for 1 out of 5 residents (Resident #4).

OTHER: Facility self-reported a medication error that occurred on 5/20/2023 regarding Resident #1 (R1). It was communicated that a medication technician left a medication cart unattended while passing out medications to help a resident that fell. This resulted in R1 taking someone else’s medication. R1 was monitored for change of condition, no side effects reported.

Continued on LIC 809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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 5
Document Has Been Signed on 06/14/2023 03:29 PM - It Cannot Be Edited


Created By: Elsie Campos On 06/14/2023 at 02:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE THOUSAND OAKS
FACILITY NUMBER: 565802433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Other Provisions
87411(c)(1) Personnel Requirements – General. 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
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Based on record review, the licensee did not comply with the section cited above as 2 out 5 staff records (S1, S4) were missing first aid certification at the time of the visit which poses a potential health and safety risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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The Administrator agreed to do the following:
1. Submit the valid first aid certification for S1 and S4 no later than the POC due date
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for 4 out of 5 staff (S1, S2, S3, S4), as required training hours were unable to be verified at the time of the visit which poses a potential health and safety risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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The Licensee agreed to the following:
1. Submit the training for S1, S2, S3, S4 no later than the POC due date.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2023 03:29 PM - It Cannot Be Edited


Created By: Elsie Campos On 06/14/2023 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE THOUSAND OAKS
FACILITY NUMBER: 565802433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465(a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, and medication audit, the licensee did not comply in the section cited above for four out of five residents (R1, R2, R3, R4), due to the observed medication errors, which poses an immediate health and safety risk to residents in care.
POC Due Date: 06/16/2023
Plan of Correction
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The Administrator agreed to do the following:
1. Conduct a medication audit for the four residents to ensure accuracy. Inform CCL when this has taken place, but no later than 6/16/2023. 2. Staff will receive medications training on 6/20/2023. Submit sign in sheet and training materials no later than 6/21/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


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Document Has Been Signed on 06/14/2023 03:29 PM - It Cannot Be Edited


Created By: Elsie Campos On 06/14/2023 at 03:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE THOUSAND OAKS
FACILITY NUMBER: 565802433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)

87411(f) Personnel Requirements – General. All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 1 out 5 staff records (S4) were missing TB results at the time of the visit which poses a potential health and safety risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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The Administrator agreed to do the following:
1. Submit the TB results for S4 no later than 6/23/2023
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


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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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE THOUSAND OAKS
FACILITY NUMBER: 565802433
VISIT DATE: 06/14/2023
NARRATIVE
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Staff was given corrective measures and scheduled for re-training. Facility further reported an incident that occurred between 5/28/23 and 5/30/2023 at which time Resident #2 (R2) was reported to be given incorrect dosages of Ambien. Dosages were administered at 10mg when prescription called for 5mg. R2 was monitored for change of condition, no side effects reported. Staff was given corrective measures and scheduled for re-training. Today, staff indicated that the training is set for 6/20/2023.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, Staff schedule.


The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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