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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:07:08 PM


Document Has Been Signed on 01/26/2023 03:07 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:NANCY D NELSONFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:158CENSUS: 108DATE:
01/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cyntia DrachenbergTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced CASE MANAGEMENT- INCIDENT visit to the above facility to investigate an incident that occurred on 01/16/2023. Upon arrival, LPA met with Executive Director (ED), Cyntia Drachenberg and the reason for the visit was explained. Entrance Interview.

On 01/17/2023, the Department received an unusual incident report (LIC 624) regarding Resident #1 (R1). On 01/16/2023, at approximately 10:30am, Community driver saw R1 walking on the sidewalk outside of the community without an escort. R1 stated they exited through the kitchen door because it was a beautiful day and wanted to take pictures. Community driver was able to redirect R1 back into the facility without resistance.

On 01/18/2023, at 3:31pm, LPA Arroyo spoke with the ED regarding the incident of elopement for Resident #1 (R1). ED stated R1 is part of the “circle of friends program” which is still considered assisted living and not memory care. But nonetheless, R1 is not able to leave the facility unassisted and staff did not see R1 walk outside of the facility. Additionally, a new Physician’s Report (LIC 602) has been requested from R1’s Primary Care Physician (PCP) as R1 may now have mild cognitive impairment (MCI) or dementia. Upon review of R1's records it was revealed that per R1’s Physician’s Report updated on 01/18/2023, R1 is not able to leave the facility unassisted and primary diagnosis states Alzheimer’s Dementia. As of today, R1’s family has made arrangements to move R1 to the dementia unit as they can no longer reside in the assisted living area. Furthermore, ED reported that today, R1 was able to elope from the facility for a second time this month. This morning, R1 walked out of the facility without an escort along with Resident #2 (R2).

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 OAKS
FACILITY NUMBER: 565802433
VISIT DATE: 01/26/2023
NARRATIVE
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Report Continued from LIC 809...

Review of R2’s records revealed R2 has MCI and cannot leave facility unassisted. According to ED, both R1 and R2 have finalized moving into the memory care unit as of today. Based on the information obtained and reviewed, facility staff failed to supervise R1 on 01/16/2023 and R1 and R2 on 1/26/2023 as they eloped from the facility.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted. Appeal Rights discussed. A copy of the report was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/26/2023 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 OAKS
FACILITY NUMBER: 565802433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited

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Basic Services "Care and Supervision" means the facility assumes responsibility for…or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Facility will conduct an in-house service training regarding safety and elopement protocols and submit proof to CCL by 2/03/2023.
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 and R2 were able to elope and walk out of the facility unassisted which poses an immediate health and 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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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