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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 05/24/2023
Date Signed: 05/24/2023 04:25:01 PM


Document Has Been Signed on 05/24/2023 04:25 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:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cyntia Drachenberg-Executive DirectorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPA’s) Elsie Campos, Ashley Smith and Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 10:10 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Activities Program Coordinator Alejandra Martinez met with the LPA’s. Administrator Cyntia Drachenberg arrived thereafter.

The LPA’s and the Activities Program Director began the tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPAs began the inspection in the kitchen/food service area at 10:55 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:00 a.m., the LPAs and Chef Manager Fabian Munoz observed a variety of breads near the entrance to the kitchen to be expired. Expired breads found were hot dog bread expiration date May 1st, 2023, Bagels expiration date May 15th, 2023, hamburger bread expiration date May 21st, 2023, wheat and white sandwich bread expiration date May 22nd, 2023. The Chef Manager stated that the bread vendor usually checks for expired breads and replaces them accordingly and did not check themselves as bread was delivered yesterday 5/23/2023 and that they would ensure to check in the future. In addition, the LPA’s observed multiple boxes of grits with the expiration date of April 18, 2021.

COMMON AREAS: Units designated for assisted living residents are on all four floors and there is a separate unit on the second floor designated for memory care residents. There was hands-free hand sanitizer interspersed throughout the common grounds. The LPA’s toured all four floors and common spaces in both the assisted living and memory care unit. Activity rooms and common spaces were clean and in good repair. No obstructions and/or tripping hazards observed. At 11:16 a.m., the LPA’s observed an unlocked housekeeping closet on the first floor, which had accessible cleaning supplies.**Continued on LIC 809-C**

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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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Document Has Been Signed on 05/24/2023 04:25 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: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above scissors were found in room 220, shaving razors were found in room 211 and gardening supplies were found in the outdoor courtyards which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/25/2023
Plan of Correction
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The Licensee agreed to the following:
1. To secure accessible items.
2. Conduct an audit of all rooms in memory care to ensure that all sharps and dangerous items are secured. Submit proof of correction to CCL no later than 5/25/2023 by end of day.
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2023 04:25 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: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as 2 resident bathrooms room 407 and 416 were unkempt which poses a potential health and safety risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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The Licensee agreed to the following:
1. Conduct housekeeping of resident bathrooms for rooms 407 and 416. Inform CCL when this is completed but no later than 5/26/2023.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as expired bread, expired ensure and expired grits were observed which poses a potential health and safety risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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The Licnsee agreed to the following:
1. Audit all food items for expiration dates and discard of any expired food items. Inform CCL of when this has been completed but no later than the end of day on 5/26/2023.
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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: 05/24/2023
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In addition, the LPA’s observed unsecured detergent and cleaning supplies in unlocked cabinets in laundry rooms on all four floors. At 11:28 a.m., the LPA’s observed expired Ensure in the cabinet in the art studio, and additional expired Ensure in the small refrigerator by the Wellness Center on the 3rd floor. Fire extinguishers were charged and last serviced 3/2023. Staff were observed interacting with residents during activities.

OUTDOOR AREA: The LPA toured the courtyards, where there was appropriate outdoor furniture, with a covered shaded area for residents. The LPA’s observed the gazebo benches on the 2nd floor to have a nail sticking up which could potentially hurt a resident and soiled chair that appeared to have been taken outside of facility. The LPA’s additionally observed gardening tools accessible to residents on the 2nd and 1st floor outdoor courtyards. Gardening tools observed were a small metal hand rake and small metal hand shovel accessible to residents. Parking is available for residents and visitors.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. LPAs observed a random selection of rooms on all floors. Memory care bedroom 220 was observed to have accessible scissors found in top dresser drawer, Memory care bedrooms 220 and 229 were observed with unlocked cabinets in the bathrooms which housed personal care items. LPA’s conducted water temperature checks between 11:20 a.m. through 12:20 p.m., and the hot water measured ranged between 105 degrees F to 114.8 degrees F. Restrooms were fully stocked with paper towels and soap. LPAs observed a random selection of resident bathrooms on all floors. Bedroom number 229 was observed to have a bathroom vanity with a burnt-out light bulb. Bathroom in room 407 was observed unkempt with toilet paper residue on the floor and a soiled toilet and bathroom in room 416 was observed to have a soiled toilet.

RECORDS: Residents’ records review began at 1:30 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. LPA’s spoke to residents throughout today’s visit.

Due to time constraints, the LPA’s will return at a later date to complete the inspection.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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