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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:56:08 AM


Document Has Been Signed on 09/20/2022 11:56 AM - 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: 113DATE:
09/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Collette Philipp (Memory Program Director)TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management - Other inspection at the facility today with the purpose of following up on a confirmation of removal and Decision and Order (D&O) ordered on 8/24/22 for staff #1 (S1). LPA met with Customer Service Specialist, Cindy Carrillo and Memory Program Director, Collette Philipp. Entrance interview.

The reason for today's inspection is to confirm Staff #1 (S1) who is an excluded individual does not work at this facility. Review of the current staff schedule and an interview with the Human Resources Generalist confirmed S1 does not work at the facility. S1 shows in the system as a flex worker meaning S1 was hired and associated, but never started working at the facility as S1’s name is not on the terminated list for the facility either. The LPA advised the Customer Service Specialist and Human Resources Generalist to submit in writing a request to disassociate S1 from this facility as S1 does not work here or remove and disassociate S1 through Guardian.

During the inspection, the LPA reviewed the D&O, and ensured Management understands that S1 is prohibited from being a licensee, owning a beneficial ownership interest of 10 percent or more in a licensed facility, or being an Administrator, Officer, Director, Member, or Manager of a licensee or entity controlling a licensee, and, further, from employment in, presence in, and contact with clients of, any facility licensed by the Department or certified by a licensed foster family agency, or any resource family home, for the remainder of S1's life, unless and until S1 successfully petitions for reinstatement pursuant to Government Code section 11522. Management is aware that the effective date of the D&O is 9/6/22.

Exit interview conducted. No citations issued. A copy of the report was provided via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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