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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 04/13/2023
Date Signed: 04/13/2023 11:39:36 AM


Document Has Been Signed on 04/13/2023 11:39 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:NANCY D NELSONFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:158CENSUS: 112DATE:
04/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Cyntia DrachenbergTIME COMPLETED:
11:45 AM
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 04/09/2023. Upon arrival, LPA met with Executive Director (ED), Cyntia Drachenberg and the reason for the visit was explained. Entrance Interview.

04/11/2023, the Department received an unusual incident report (LIC 624) regarding Resident #1 (R1). On 04/09/2023, at approximately 12:26am, while doing routine checks, caregiver noted R1 was not in their apartment, which prompted an immediate search for R1. R1 was later found by the parking lot entrance at approximately 12:50am. R1 was fully assessed by staff and had no injuries noted from the elopement.

On 04/11/2023, at 11:03am, LPA Arroyo spoke with the ED regarding the incident of elopement for R1. ED stated R1 is part of the “circle of friends program” in the 4th floor which is considered part of the assisted living area. ED stated R1’s responsible party was notified the same night, arrived at the facility, and spent the night at the facility alongside R1. As of 04/09/2023, R1 has been transferred to the Memory Care unit where they will have 24-hour supervision. Additionally, ED reported to LPA that a new agreement and physician’s report was requested and is currently being reviewed. Furthermore, upon review of R1’s Physician’s Report dated 03/21/2023, it is noted that R1 is not able to leave the facility unassisted and indicates R1's primary diagnosis to be dementia.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency was cited (refer to LIC 809-D). This is a repeat citation and a civil penalty of $250 will be assessed today (see LIC421).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
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 04/13/2023 11:39 AM - 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: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2023
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.

Proof of Correction has been met.
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 was 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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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