198601646-6-7-2024-11-AS-AINZ-D5ZTYR-20240607150912

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601646
Report Date: 06/07/2024
Date Signed: 06/07/2024 03:09:46 PM

Document Has Been Signed on 06/07/2024 03:09 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	BELMONT VILLAGE RANCHO PALOS VERDES		FACILITY NUMBER:	198601646
ADMINISTRATOR:	BALBIN, RALPH		FACILITY TYPE:	740
ADDRESS:	5701 CRESTRIDGE RD		TELEPHONE:	(310) 377-9977
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	150	CENSUS: 129	DATE:	06/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Ralph Balbin/Executive Director		TIME COMPLETED:	03:00 PM

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On 6/7/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Ralph Balbin /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (150) elderly adults ages 60 and above, of which (120) can be non-ambulatory and (30) may be bedridden. The facility has an approved hospice waiver for (20). Approved for delayed egress.

The facility is a three-story structure located in a residential neighborhood. It consists of the following: (27) resident bedrooms in the neighborhood and (114) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, a lobby, a living room, (3) lounge areas, a dining room, a kitchen, a bistro, a Memory Care Unit. housekeeping/janitorial storage closets, (3) administrative offices, (2) laundry rooms, an activity room, a Wellness room, an engineering office, a beauty salon, an activity area, front and rear patio area, a gated pool, and outdoor storage sheds.

LPA Iniguez and the Executive Director toured the physical plant. There is gated pool on the premises, and no obstructions were observed. LPA inspected a total of (9) bedrooms and (9) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 113.5°F to 118.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
	VISIT DATE: 06/07/2024

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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills was conducted on 5/16/24.

A review of (8) residents' service files and (6) staff personnel files was maintained in order. LPA reviewed (8) Medication Administration Records (MARs) no discrepancies were found. Delayed egress checked.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-Can of pesticide found on facility’s kitchen food pantry.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ralph Balbin / Executive Director.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/07/2024 03:09 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BELMONT VILLAGE RANCHO PALOS VERDES	FACILITY NUMBER: 198601646
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(25)

General Food Service Requirements

(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) the licensee did not comply with the section cited above in can of pesticide found on kitchen food pantry which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2024
	Plan of Correction
1 2 3 4	Executive Director removed can of pestice while LPA was present. Licensee will ensure toxins should be store in areas separate from food supplies at all times. As plan of correction, licensee will conduct an in-service with all kitchen staff about the importance of keeping toxins separate from food supplies.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

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