Routine inspection (multi-day)·June 14, 2023

Licensing Program Analyst (LPA) David España conducted an unannounced Annual visit to Belmont Village Westwood. Upon arrival at the facility, LPA conducted a risk assessment at the front desk. LPA verified that the facility has an approved mitigation plan report. LPA was properly screened for Covid-19 symptoms and temperature was checked. LPA met with Executive Director, Chris Schroeder. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance. Facility is licensed for 180 non-ambulatory, 60 bedridden and a hospice waiver for 20. Facility is approved for delayed egress. The facility currently has 181 residents and 7 residents on hospice. The facility does not handle any of the residents’ money. LPA toured the physical plant, toured a vacate unit and reviewed medication. The facility consists of 176 units of which 31 of those units have 2 bedrooms and 2 bathrooms. All other units have one bed and one bathroom. Facility also has a lobby area, 3 dining rooms and a bistro, kitchen, salon, theater, gym, several recreational spaces and patios. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew. The water temperature in vacant room measured within range between105-120F. Common areas were clean and clear of hazards; doorways were free of obstructions. All exit doors in the memory care unit have auditory alarms. Resident Files: LPA reviewed files for randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed. Medications: Were properly labeled and stored in the Wellness centers located on the third and fifth floors. A medication cart was also observed on the second floor in the memory care unit. Medication cart was locked during visit. Staff Files: LPA reviewed files for randomly selected staff. While reviewing the staff records LPA observed several staff whose were missing the following records: LIC508; LIC503; LIC501; LIC9052. LPA also informed Mr. Schroeder that the staff records identified shall be located within the personnel records at all times. Staff schedule appears sufficient to meet the needs of the residents. Staff training is current, including first aid training. Medications are only handled by Med Tech. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies (i.e., Technical Assistance) were issued today. Exit interview was held. A copy of the report was provided to Executive Director, Chris Schroeder.