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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 11/17/2025
Date Signed: 11/17/2025 02:39:04 PM

Document Has Been Signed on 11/17/2025 02:39 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: 120DATE:
11/17/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Karen Pasten - Director of Resident Care TIME VISIT/
INSPECTION COMPLETED:
02:48 PM
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Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced Case Management visit for the purpose of conducting a full physical plant tour along with reviewing the Stipulation and Waiver; Order adopted by the Department on 09/18/2025. The LPA met with Karen Pasten, Director of Resident Care (DRC) and explained the reason for the visit.
The LPA, alongside Karen Pasten, reviewed and discussed the contents of the Stipulation and Waiver; and Order adopted by the Department on 09/18/2025: 2. REVOCATION: STAYED WITH PROBATION: Respondents, Belmont Village Sabre Springs and Belmont Village Thousand Oaks licenses are revoked upon the Department's adoption of this Stipulation as its Order. The revocation of the licenses shall be STAYED for eighteen months during which time Respondents shall be granted probationary licenses subject to the following limitations and conditions: TERMS OF LICENSE PROBATION: 09/18/2025 - 03/18/2027
A. Respondents shall operate the facility in substantial compliance with the regulations and statutes governing the operation of a Residential Care Facilities for the Elderly (RCFE).
B. Respondents shall develop and implement the following policies, procedures, and training that Respondents stipulate will be incorporated into Respondents' Plans of Operation. Maintain accurate Medication Administration Records (MARs) for each resident: Include facility-administered and self-administered prescribed and PRN medications. Document medication name, dosage, dates, times, administering staff, missed doses, refusals, and offsite status. Record side effects, errors, and drug reactions on the back of MAR or in nurses' notes. Verify staff training and certification prior to medication administration. Conduct resident evaluations every six months or upon significant change in condition.
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: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2025
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: 11/17/2025
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(PAGE 2) REPORT CONTINUED FROM LIC 809...
Ensure medical and behavioral care meets resident needs. Perform quarterly audits of at least 10% of resident files: Review MARs, Physician Reports, Care Plans, admission records, appraisals, incident reports, staff notes, and personal info. Rotate files each quarter and make audit results available to the Department. Perform quarterly audits of at least 10% of employee files: Confirm training, health info, certifications, and personal info are current. Monitor and log call response times: Address excessive delays and provide logs to the Department upon request. Install Wander Guard or similar system within 60 days of effective date. Conduct quarterly elopement in-service training. Maintain an organizational chart of job positions within 60 days of effective date.
The Department received the 60 days requested Wander Guard system and organizational chart on 10/09/2025.
C. Within 90 days of the effective date of the Stipulation, Respondents shall contract with a telehealth medical provider who can provide telehealth consultation and/or care services to a facility resident who has consented to receive, or will consent to receive in the future, such telehealth services if the resident's personal care physician is unable or fails to respond in a timely manner to a request for care consultation or care.
The Department received the 90 days requested telehealth contract on 10/09/2025.
D. Respondents shall implement and maintain a consulting arrangement with a medical director to provide guidance and instruction on resident care issues, as needed.
E. Each direct care staff actively employed, which is defined as all employees except those who are on a leave of absence and on-call employees who are not actively picking up shifts, will undergo annual training on all of the following topics. In addition, quarterly in-service training will be conducted on one of the following topics- Pressure Injuries; Restricted & Prohibited Conditions; Reappraisal and Observation of Residents; and Use of Belmont's in-house system (Sensys Mobile) for reporting changes of condition and documenting support services completed, as set forth in Paragraph 3.E.iv.: Document all care provided by medical professionals and facility staff in resident files. Accurately update pre-admission appraisals as needed. Observe and document changes in residents’ conditions. Notify physicians and responsible parties of significant changes; call 911 if necessary. Implement and maintain the in-house system for compliance tracking. Maintain records of training attendance: Quarterly for first 18 months, then annually. Include new hires during probationary period. Make records available to the Department.
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: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: 11/17/2025
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(PAGE 3) REPORT CONTINUED FROM LIC 809-C Page 2...
F. Within 30 days following the effective date of the Stipulation, Respondents will develop a documentation and reporting system ("System") for fully complying with the regulations referenced in paragraphs 2(8) and 2(E) above. The protocols underlying the System will be written and provided to the Department within 30 days of the effective date of this Stipulation.
The Department received the 30 day requested plan for documentation and reporting system on 10/09/2025.
G. The facility Director of Resident Care Services or designee will observe and monitor skin conditions to ensure skin conditions are being properly addressed, that the resident care plan is updated as needed, and that follow-up with the resident's licensed medical provider is done as needed. The Director of Resident Care Services or designee will report to the Area Director of Clinical Services observations of pressure injuries that progress to Stage 3 and/or are covered in eschar and/or are considered unstageable to the Area Director of Clinical Services.
H. If Respondents choose to care for a resident with a prohibited health condition, Respondents shall comply with Title 22, California Code of Regulation sections 87616 and 87209, prior to doing so; and, if an exception is granted, Respondents shall address the prohibited health condition in the resident's care plan.
I. Respondents shall submit an updated Plan of Operation that demonstrates policies and procedures that will remain in effect during the probationary period in compliance with the terms outlined in paragraph 2, sections A through H, above, to the Department within 30 days of the effective date of this Stipulation for review by the Department. The Department shall review and approve or request modifications to the Plan of Operation within 20 days of receipt of the Plan of Operation. Proof of quarterly audits will be available to the Department upon request, and any revisions to the Plan of Operation shall be submitted to the Department on an ongoing basis.
The Department received the 30 day requested updated Plan of Operation 10/09/2025.
J. During the period of probation, the Department, in its sole discretion, may conduct unannounced site visits for the purpose of determining whether there is full compliance with the regulations and statutes governing the operation of a RCFE.
K. Respondent Belmont Village Sabre Springs does not contest its prior payment of the $10,000.00 civil penalty.
L. Respondent Belmont Village Thousand Oaks does not contest its prior payment of the $15,000.00 civil penalty. Report continued on LIC809-C PAGE 4...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: 11/17/2025
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(PAGE 4) REPORT CONTINUED FROM LIC 809-C Page 3...
3. FUTURE APPLICATION FOR A LICENSE, REGISTRATION, CERTIFICATION OR APPROVAL: A. Licensure, Certification, or Approval: Respondents agree they shall not apply for, receive, or hold any license to operate any facility licensed by the Department of Social Services as defined in sections 1502(a), 1506(c), 1568, 1568.01, 1569.2, 1596. 78, 1596. 750, and 1796.37 of the Health and Safety Code and California Code of Regulations, title 22, section 102352(f)(1)), other than the probationary licenses granted herein... B. Application Denial: Respondents agree that future applications may be denied based on this agreement’s findings, but they retain the right to a hearing if they file a timely appeal or Notice of Defense.
4. TOLLING OF PROBATIONARY PERIOD: The probationary period pauses when the facility isn’t operating and extends accordingly. If a revocation petition is filed, probation continues until the Department issues a final decision.
5. COMPLETION OF PROBATION: If Respondents meet the Stipulation terms, their license conditions will expire after 18 months, and licenses will be fully restored, except for items in the Plan of Operation. Each Belmont Village location will be evaluated separately.
6. VIOLATION OF STIPULATION TERM: Respondents agree that serious violations of probation terms may lead to license revocation, subject to a hearing. If found responsible, the license will be revoked, and notice may be served by certified mail.
7. DEPARTMENT'S AUTHORITY: The Department may delay disciplinary action without waiving its right to act later. If a revocation is filed during probation, the probation period extends until a final decision is issued.
8. MONITORING FEE: Each Respondent must pay a probation monitoring fee equal to the annual license fee during probation.
9. WAIVER OF HEARING RIGHTS: The parties waive their rights to a hearing, presenting evidence, cross-examining witnesses, and further discovery.
10. WAIVER OF APPEAL/MODIFICATION RIGHTS: Respondents waive all rights to challenge, appeal, or seek changes to this action, Stipulation, or its implementing Order.
11. WAIVER OF CLAIMS: The parties waive all legal claims related to this matter, except for civil penalties, monitoring fees, and audit-related actions involving payment adjustments.
12. PUBLIC RECORD: This Stipulation is a public record and accessible under the Public Records Act.
13. SIGNATURES: A fax, digital, or scanned signature binds the signer once all parties and the Order are executed.
14. COUNTERPARTS: This Stipulation may be executed in counterparts. Report continued on LIC809-C PAGE 5...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: 11/17/2025
NARRATIVE
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(PAGE 5) REPORT CONTINUED FROM LIC 809-C Page 4...
15. EFFECTIVE DATE: This Stipulation is effective on the date on which the Department's Order adopting it is executed.
16. NO ORAL MODIFICATION: The Stipulation is the full agreement on the Sixth Amended Accusation and can only be changed in writing signed by all parties.
17. SEVERABLE TERMS: If any part of the Stipulation is found invalid, the rest remains effective and enforceable.
During todays visit starting at 10:32 a.m. LPA and DRC 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 10:32 a.m., 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.
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 10:40 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.
Bedrooms: Starting at 10:50 a.m. The LPA observed ten (10) randomly selected resident bedrooms, of which five (5) were in memory care and five (5) 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 106.9 – 114.6 degrees Fahrenheit all within the required range. Report continued on LIC809-C PAGE 6...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: 11/17/2025
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(PAGE 6) REPORT CONTINUED FROM LIC 809-C Page 5...
Records: Starting at 12:12 p.m. LPA reviewed facility records. The following were reviewed for, but not limited to, the following: compliance binder, Wander guard / alert system, Organizational chart, contract with Telehealth medical provider and alarm tracking chart every 20+ minutes. All files in order at the time of the visit.

No deficiencies were cited during today’s visit. Exit interview conducted. A copy of the report reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
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