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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206861
Report Date: 09/16/2021
Date Signed: 09/22/2021 02:51:18 PM

Document Has Been Signed on 09/22/2021 02:51 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BELMAR VILLAFACILITY NUMBER:
107206861
ADMINISTRATOR:HRIPSIME MAKARYANFACILITY TYPE:
740
ADDRESS:2020 NORTH WEBER AVENUETELEPHONE:
(559) 486-5977
CITY:FRESNOSTATE: CAZIP CODE:
93705
CAPACITY: 100CENSUS: 67DATE:
09/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Hripsime (Kristina) MakaryanTIME COMPLETED:
11:01 AM
NARRATIVE
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Today, LPA L. Xiong was at the above facility to follow up on an incident occurred on 9/12/21 involving resident R1 AWOL from the facility. I met with K. Makaryan, Administrator and informed her the purpose of the visit. During the visit, I reviewed and obtained copies of records relevant to the case.

The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of residents in care.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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 09/22/2021 02:51 PM - It Cannot Be Edited


Created By: Les Xiong On 09/22/2021 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BELMAR VILLA
FACILITY NUMBER: 107206861

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
HSC
1569.312(a)

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.

**This requirement is not met as evidenced by: Facility did not provide care and/or supervision to resident R1 and as a result of lack of supervision R1 went AWOL. Staff on duty were not aware that the resident R1 had left the building unassisted.

***This presented an immediate or substantial threat to the physical health, mental health, or safety of the residents in care.
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Licensee shall develop a plan of correction (POC): procedure and/or policy to ensure that all staff monitor the activities of the resident while he under the supervision of facility to ensure adequate care and supervision as defined in Section 1569.2. by POC date.

Meaning in part that facility assumes responsibility for, or provides 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.

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Per Administrator, A policy/procedure was developed and implimented for staff to conduct observation check every 2 hours to ensure staff has knowledge of his location at all times. A copy of the implimented tracking record was provided to LPA during the visit.

No further correction necessary.


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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Les Xiong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021


LIC809 (FAS) - (06/04)
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