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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 06/24/2025
Date Signed: 06/24/2025 05:05:57 PM

Document Has Been Signed on 06/24/2025 05:05 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELMONT VILLAGE THOUSAND OAKSFACILITY NUMBER:
565802433
ADMINISTRATOR/
DIRECTOR:		CYNTIA DRACHENBERGFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 158CENSUS: 102DATE:
06/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Cyntia Dachenberg - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 9:45 a.m. Upon arrival LPA was greeted by the front desk receptionist and explained the reason for the visit. LPA met with Executive Director (ED) Cyntia Dachenberg, and explained the reason for visit was explained. Entrance interview conducted. LPA Mosley and the ED toured 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.
Common Areas: At approx 10:12 am, the LPA began the physical plant tour, the furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 04/04/2025. The LPA observed required postings throughout the common space. The LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA observed an adequate supply of emergency food and water. The last fire inspection was completed on 09/26/2024 and was found to be in compliance with Fire Code Regulations at the time of inspection. Emergency disaster drills conducted quarterly as per regulation; with the last one conducted on 06/04/2025. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. All records were in order.
Interviews: From approx. 10:02 a.m. – 12:20 p.m. LPA conducted random interviews with thirteen (13) residents, ten (10) staff, and one (1) family visitor. Resident interviews revealed that no concerns were noted at the time of the visit. Staff interviews revealed that staff are knowledgeable in their job description, resident rights, different forms of abuse, and reporting procedures. Family visitor interview revealed that no concerns were noted at the time of the visit. Report continued on LIC809-C PAGE 2...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE THOUSAND OAKS
FACILITY NUMBER: 565802433
VISIT DATE: 06/24/2025
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(PAGE 2) REPORT CONTINUED FROM LIC 809...
Infection Control / Emergency disaster planning: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control and emergency planning are satisfactory.
Bedrooms: Starting at 10:16 a.m. The LPA observed fifteen (15) randomly selected resident bedrooms, of which five (5) were in memory care and ten (10) in assisted living which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a sufficient supply of towels and linens.
Restrooms: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water measured between 105.1 – 112.5 degrees Fahrenheit all within the required range.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors.
Kitchen: The LPA inspected the kitchen/food service area at 11:40 a.m. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.
Medication Audit: LPA conducted a medication review on eight (8) randomly selected residents at approx. 12:25 p.m., The medications are centrally stored in the wellness room located on the third floor. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. No errors observed during review.
Records: Resident Records and Personnel records were reviewed starting at approx. 2:45 p.m., Ten (10) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files in order at the time of the visit. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files in order at the time of the visit.
Report continued on LIC809-C PAGE 3...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE THOUSAND OAKS
FACILITY NUMBER: 565802433
VISIT DATE: 06/24/2025
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(PAGE 3) REPORT CONTINUED FROM LIC 809-C PAGE 2...

LPA obtained the following documents – Census, Staff schedule, and updated Limited Liability insurance.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.
Exit interview conducted. Copy of report provided.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC809 (FAS) - (06/04)
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