<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 04/20/2023
Date Signed: 04/20/2023 02:35:28 PM


Document Has Been Signed on 04/20/2023 02:35 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: 111DATE:
04/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cyntia DrachenbergTIME COMPLETED:
02:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-NP-20220311163324). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation of complaint # 29-NP-20220311163324, the following deficiency was observed: On 12/31/2021, the facility had a power outage approximately between 9:00am and 7:00pm. Interviews conducted revealed these incidents typically get reported to Community Care Licensing (CCL) and to the persons responsible for the residents. However, the incident was not reported to either CCL or the persons responsible for the residents as resident’s family members walked into the facility on 12/31/2021 and were not aware of the power outage and CCL does not have any record indicating it was reported. Furthermore, the facility was unable to show documentation indicating power outage was reported within 24 hours either by telephone or facsimile as required by the California Code of Regulations.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit Interview. Citation issued. A copy of the report and appeal rights were given to the ED.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
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 2


Document Has Been Signed on 04/20/2023 02:35 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: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited

1
2
3
4
5
6
7
(a) Each licensee shall furnish to the licensing agency (2) Occurrences... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency… This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee will submit a plan detailing how the facility will maintain in compliance of Regulation 87211 and submit to CCL by 04/24/2023.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee failed to comply with the section cited above as the facility did not report the power outage that occurred on 12/31/2021 within 24 hours either by telephone or facsimile to CCL, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2