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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 06/18/2024
Date Signed: 06/18/2024 08:15:44 PM


Document Has Been Signed on 06/18/2024 08:15 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:CYNTIA DRACHENBERGFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:158CENSUS: 106DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Cyntia DachenbergTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Cyntia Drachenberg was contacted and met with LPA. Reason for the visit was stated.

Administrator designated staff to assist LPA with the physical plant tour. Physical plant tour was conducted with staff. Areas inside and outside were toured to ensure that there are no health and safety hazards.

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. The LPA toured all four floors and common spaces in both the assisted living and memory care unit. Memory care delayed egress doors were tested for operational need. Activity rooms and common spaces were clean and in good repair. No obstructions and/or safety hazards observed during the tour. Fire extinguishers were charged and serviced on 04/24/2024.

BEDROOMS: The LPA observed a random selection of resident rooms (on all floors), and rooms were observed furnished appropriately with clean linens, furnishings and sufficient lighting. LPA also conducted interview with random residents during the resident room checks.

RESTROOMS: The LPA observed a random selection of resident restrooms. Restrooms were clean, sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms were stocked with soap and paper towels. Hand washing signs promoting good hand hygiene were observed in the common restrooms.

KITCHEN: Kitchen observed clean and appliances in operable condition. Facility food supply observed sufficient during todays visit (three (3) day perishable and seven (7) day non-perishable food supply).

EXTERIOR: The facility has outdoor seating for residents on the first, second and third floor.

Due to time constraints, the annual inspection will be completed on a follow-up visit.


No deficiencies cited at this time. Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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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