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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 09/01/2022
Date Signed: 09/01/2022 04:10:27 PM

Document Has Been Signed on 09/01/2022 04:10 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:DINA DAVISFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 158CENSUS: 103DATE:
09/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Collette PhillipsTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - POC visit at the facility. LPA met with staff Colleen Papp - Interim Executive Director. Interim ED called and spoke with Ann Wood - Senior Vice President of Operations via telephone who initially authorized Regional Vice President of Resident Care, Sharlene Gephart to sign and review documents. However, Memory Program Director, Collette Philipp, was ultimately authorized to review and sign the reports.

During the inspection on 8/29/2022, the facility was issued a citation for not having Interim ED, Colleen Papp associated to the facility. The Plan of correction date given to submit the paperwork necessary to associate Interim ED was 8/30/2022. However, the plan of correction was not met as Interim ED has not been associated to the facility as of today. Additionally, LPA met with Regional Vice President of Resident Care; however, information gathered during the inspection revealed staff who was originally designated to sign off the report is also not associated to the facility. Interviews with staff revealed that Staff has been working at the facility since Tuesday, 8/30/2022.

Civil penalties are being assessed today in the amount of $200, $100 X 2 days for Interim ED not being associated to the facility and $200, $100 X 2 days is also being assessed due to Regional VP of Resident Care not being associated to the facility either. Civil penalties will continue to accrue until proof of correction has been received by CCL. Total amount of civil penalties assessed today is $400.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted. Appeal Rights discussed. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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 09/01/2022 04:10 PM - It Cannot Be Edited


Created By: Martha Arroyo On 09/01/2022 at 03:21 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: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2022
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance. (e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c) or...
This requirement is not met as evidenced by:
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Licensee has agreed to send paperwork needed to associate S1 and S2 to the facility by 9/02/2022.
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Based on interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1 and S2 were associated prior to allowing S1 and S2 to work, which poses an immediate safety risk to persons in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
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