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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 01/28/2026
Date Signed: 01/28/2026 03:21:47 PM

Document Has Been Signed on 01/28/2026 03:21 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:		MARK RANNOFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 158CENSUS: 115DATE:
01/28/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Mark Ranno -Executive Director (ED)
Karen Pasten, Director of Resident Care		TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Incident visit to follow up on a self-reported incident which took place on 01/16/2026. Upon arrival at 9:45 a.m. LPA was greeted by the front desk receptionist and explained the reason for the visit. LPA met with Executive Director (ED) Mark Ranno and Director of Resident Care Karen Pasten and the reason for the visit was explained. Entrance interview conducted.

On 01/16/2026 it was reported that Resident #1 (R1) exited the community through the front door at approx. 1:30 p.m. and proceed to walk down the side walk with their walker. A bystander observed R1 and proceed to drive into the community to inquired about R1. Upon identification of R1 staff responded and R1 was returned to the community. No injuries or incidents occurred. Physician and Power of Attorney (POA) informed and consented to have R1 placed on Wander Guard.

During today's visit, LPA and the staff toured the physical plant area inside and out to ensure there were no immediate health and safety concerns. Starting at 10:10 a.m. and throughout the visit LPA conducted three (3) in person staff interviews, at 11:12 a.m. attempted to conduct a telephonic interview with POA of R1, file and record review for R1 and obtained copies of pertinent documents relevant to the incident.

Staff interviews revealed that R1 is well-known within the community and regularly participates in community events and activities. R1 is social, self-aware, and independent. Prior to the incident, R1 had no history of elopement or wandering and had not exhibited any concerning behaviors or indicators suggesting a risk of elopement or wandering. Staff state that on the day of the incident R1 stated they were going to go for a walk around the community but decided to leave the community and cross the street. A bystander drove into the community spoke to concierge staff. Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2026
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: 01/28/2026
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(PAGE 2) Report Continued from LIC 809...

Concierge staff immediately informed management and ran out to look for R1. R1 was returned to the community with no injuries or incidents. Upon return R1 was assessed by the on duty nurse and noted to be at baseline, alert and oriented to person, place, time and situation. Staff noted that R1 stated they were going for a walk, knew where they were going and how to return. Staff communicated with R1 regarding the the potential risk and hazard of leaving the community unassisted. R1 vocalized remorse to staff stating they did not like the fact that they worried the staff however were unaware that they could not leave unassisted. On the day of the incident R1's Physician and Power of Attorney (POA) were informed and consented to have R1 placed on Wander Guard.

Staff state the facility utilizes a photo list to identify which residents are permitted to leave the facility unassisted and which are not. If a resident who is not allowed to leave unassisted wishes to go for a walk or exit the community, staff will either arrange for a staff to accompany the resident or redirect them as needed. Residents in the memory care are never permitted to leave without supervision. When these residents express a desire to leave, staff redirect them, often incorporating physical therapy or other activities to support engagement. All residents whether or not they wear a Wander Guard device are accompanied when leaving the premises. Only a select few residents, evaluated and approved by their Physician, are permitted to leave independently.

File and record review confirms that there have been no other incidents involving elopement or wandering for R1. Wandering potential assessment dated 03/24/2025 indicate R1 as a zero (0) no risk for wandering. An updated assessment was conducted on 01/16/2026 with the implementation of Wander Guard. R1's service plan dated 09/01/2025 is listed as no assistance with redirection or guidance. Service plan dated 01/16/2026 is listed as requires interventions with redirection or guidance, Wander risk device left wrist placement, check on each shift, ensure on.

No deficiencies were cited at this time. Exit interview conducted. Report was reviewed and a copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC809 (FAS) - (06/04)
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