Belmont Village Burbank.

Licensing Program Analyst (LPA) Leslie Ngo- Castaneda conducted a Case Management visit to hand deliver an “Order To Licensee/Facility Of Immediate Exclusion From Facility", of Staff #1 (S1) to the Licensee/Facility. LPA met with Exective Director Mary Jane Rodriguez and explained the purpose of the visit. It was determined by the Department that a complaint of conduct inimical, of a resident was substantiated against S1, thus, necessitating the “Order To Licensee/Facility Of Immediate Exclusion From Facility". S1 will also receive copies of the “Order To Licensee/Facility Of Immediate Exclusion From Facility” for the facilities with which S1 is associated with. The LPA hand delivered the "Order to Licensee/Facility of Immediate Exclusion from the Facility" in regards to S1 to executive director. Executive Director accepted and read the letter and confirmed he/she understood. A copy of the "Order to Individual for Immediate Exclusion From All Facilities” was hand delivered to S1 during todays visit. No immediate health or safety issues observed. Exit interview conducted. A copy of the report was provided.

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced continuation of the required One Year inspection, dated 07/17/2025. LPA met with Executive Director, Mary Jane Rodriguez and explained the reason for the visit. Current census is 117 residents, 90 residents residing in the Assisted Living portion of the facility and 27 residents in the Memory Care unit. During today's visit, LPA toured the first floor Memory Care area with the Executive Director. The tour of the other second, third and fourth floors was conducted on 07/17/2025. Bedrooms: LPAs toured multiple resident bedrooms on all four floors, randomly. Except for three shared apartments in the Memory Care area, all bedrooms are private. The bedrooms were inspected and observed to maintain required furnishings and sufficient lightings. Administrator mentioned that some of the residents have brought their own furniture, based on their own taste. LPA inspected the bedroom walls, floors, furniture and bed linens for cleanliness. All bedrooms were observed to be clean, sanitary and clear of obstructions. In room numbers 119, 201, 311 and 408, LPAs pulled the assistance cord; caregiver responded within 2-3 minutes. Bathrooms: There are nine (9) public restrooms, scattered on the four floors of the facility, which are designated for residents', visitors' and staff use. All bedrooms have their own private bathrooms. All the bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, non-slip mats). Hot water temperature measured between 105.9° F. and 117.6° F; within the required range. At bathroom# 123 and 408, LPA pulled the assistance cord; caregivers responded within 2 minutes. Continued on 809-C 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 26 27 28 29 30 31 32 First-Aid Kit/Medications: Facility has a Wellness Center, where all the medical charts, supplies, medicine destruction bins are kept, All medications were observed to be locked in medicine cabinets on the first and third floors. LPA observed several complete first-aid kits with all required supplies and the first aid manual in the Wellness Center, in facility vans and multiple locations throughout the facility. Resident Files : A review of ten resident records was conducted to ensure compliance of licensing required forms. The records included but were not limited to: Admission agreement, consent forms, emergency information, medical assessments and medication records. Staff Files : LPA observed staff files kept in locked cabinets in the Administration Office. Ten staff files were reviewed to ensure all forms and training certificates are up to date. Staff Rooms/Offices : Facility has one staff break room and several offices, including Human Resources, Administration, Sales, Maintenance Office and Wellness Center. Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit Interview Conducted / A Copy of the Report provided to Executive Director.

Licensing Program Analysts (LPA) Nadia Shahbazian and Michael Cava, conducted an unannounced Required One year inspection. LPAs met with Executive Director, Mary Jane Rodriguez and explained the reason for the visit. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools. The facility is licensed to serve a capacity of one hundred sixty (160) Non-Ambulatory residents, ages 60 and above, of whom thirty (30) may be bedridden. There are currently 118 residents, 91 residents residing in the assisted living portion of the facility and 27 residents in the memory care unit. At 11:20 am, LPAs conducted a tour of the physical plant with the Executive Director and observed the following: Facility consists of four floors. Screening/Reception area is located immediately upon entrance. Required postings were displayed at the reception area. The main door is the primary entry/exit access. In addition, the facility has four (4) exit doors on each floor. Facility provides dementia care; LPAs observed delayed egress doors in the memory care unit. Physical plant was inspected for cleanliness; LPAs observed the facility as clean, sanitary, and appropriately furnished. Fire Detection/Protection system is present in the facility. Multiple dual smoke/carbon monoxide alarms are installed, hardwired, and interconnected throughout the facility. Multiple fire extinguishers were observed throughout the facility, on each floor. All fire extinguishers were serviced on 11/07/2024. Evacuation chair were observed atop stairwell on the fourth floor. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility. Last emergency/disaster evacuation drill was conducted on 06/28/2025 and the last fire/earthquake drill was conducted on 06/28/2025. Last fire inspection was performed by Burbank Fire Department on 10/30/2024. Continued on 809-C 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 26 27 28 29 30 31 32 Kitchen: Facility has an industrial kitchen, which was observed to be clean, sanitary, and inaccessible to residents. The kitchen is equipped with three (3) refrigerators, walk in freezer, dishwasher, stove, two (2) grills, ovens, microwave, steamer, ice maker, coffee makers and ice cream freezer. LPAs observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days. Food was properly labeled and stored. Sharps are stored in the kitchen; inaccessible to residents. Detergents and chemicals were locked in a storage room in the kitchen. Common Areas: Building is a four story structure. First floor has a lobby, two dining rooms, bistro, computer area for residents, a great room, two patios. There is a fitness center, activity rooms and offices on the second floor. The third floor has activity rooms such as "Center for Learning" and "Circle of Friends". There is a library, movie theatre, gaming area and hair salon on the fourth floor. There are sitting and activity areas on each floor, two elevators and three balconies on second, third and fourth floors. Common area walls, carpets and furnishings were observed to be clean and in good condition. No obstructions or hazards were observed. Surrounding Grounds: The passageways and entrance to the home was clear of obstruction. Facility has two shaded outdoor patios with tables and sufficient seating for the residents. Outdoor furniture was observed to be in good condition. LPA also observed raised bed gardening area, where residents had planted herbs and flowers. There are no bodies of water in the facility. Laundry: Facility has one (1) laundry room on each floor with total of three (3) washers and four (4) dryers. LPAs observed all the machines in functional capacity. Laundry detergents, cleaning toxins are connected to the washers and electronically dispensed. Due to time constraints, LPAs were unable to complete today's annual inspection. LPAs will complete the inspection at a later date. Exit interview was conducted, and copy of the report was given to facility Administrator.

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted unannounced case management Annual Continuation visit to the facility. LPA met with Executive Director, Mary Jane Rodriguez and Director of Resident Care Services (DRCS), Diana Gevorgyan and explained the reason for the visit. LPA met the assistant administrator and informed that this visit was conducted to complete Required 1 year inspection initiated on 06/23/2024. During this visit at 9:45a.m. LPA and DRCS toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility. At approximately 10:20a.m. LPA reviewed staff files and they were complete and staff had criminal record clearance and association to the facility. All required documents were appropriately signed and dated. Exit interview was conducted. A copy of this report was provided to the Executive Director.

Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection visit at this facility today. LPA met with Mr. Aaron and explained the reason for the visit. Executive Director, Mary Jane Rodriguez and Director of Resident Care Services, Diana Gevorgyan later joined in the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. The facility is licensed to serve for a capacity of one hundred sixty (160) Non-Ambulatory residents, of which thirty (30) may be bedridden ages 60 and above. There are ninety-seven (97) residents residing in the assisted living portion of the facility and twenty eight (28) residents in the memory care unit. Belmont Village Burbank has an approved Dementia Care Plan in their plan of operation and accepts residents with dementia. Facility is approved for Delay Egress. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The first level consists of a dining room, kitchen, memory care unit, bistro, mail room, wellness center and multiple recreation and lounge rooms. The second floor consists of offices, resident apartments and a gym (Center for Life Enhancement). The third floor consists of resident apartments and a Center for Learning (Circle of Friends Program). The fourth floor consists of a movie theater, salon and resident apartments. The facility maintains a comfortable temperature at 74°F. There are carbon monoxide detector installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 10/18/2023. The fire extinguishers and carbon monoxide detectors were observed to be fully charged and in compliance. The facility is equipped with emergency pull alarm and sprinkler system. Facility emergency disaster plan was reviewed. Facility disaster drill was last conducted on 06/20/2024. A fire inspection by the Burbank Fire Department was last performed on 04/26/2024. 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 26 27 28 29 30 31 32 There is only one entrance being utilized at the facility, all required posters were posted at the entrance. The facility has central air and heating accommodations. During today's visit, in addition to the physical plant inspection LPA reviewed the physician's reports for Residents #1 through #3. A tour of the physical plant was conducted and the following was noted: Kitchen: The kitchen appliances and fixtures were functional. Food supplies was sufficient amount for two (2) days of perishable and seven (7) days of non-perishable was stored in covered containers at the appropriate temperatures. Knives and sharp objects were observed to be locked and inaccessible to residents. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to residents. Walls, ceiling, and floor is in good repair, ample supply of dishes, cups, glasses and utensils for the current census. Dining area: The dining area was observed to be neat, clean and in proper order. Walls, ceiling, tables, chairs and floor is in good repair. Laundry rooms: There are laundry rooms located on each floor of the building. All toxins such as laundry detergents, cleaning agents were observed to be inaccessible to the residents in laundry rooms. Medication: Medications are centrally stored in the locked medication stations located on floors one and three. The medications were observed to be locked and inaccessible to residents. There are multiple complete first aid kits in the facility. Medication and Medication Records were properly labeled and review for proper documentation. Facility uses the AccuFlo medication program. Bedrooms: LPA randomly selected resident’s apartments on each floor. Resident bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting. Hygiene for residents was observed and hallways/passageways are lit. There were enough clean linen available in the closets. Each resident’s apartment has their own restroom. 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 26 27 28 29 30 31 32 Bathrooms: LPA randomly selected resident’s bathrooms on each floor. The bathrooms were observed to be clean properly supplied, functional fixtures and appropriate grab bars in showers and toilets. The hot water temperature measure range was between 111.3 – 117.3 degrees Fahrenheit within Title 22 Regulations. Common Areas : LPA observed common areas on every floor. All furnishings are in good repair, lighting is good, walls, ceiling and floors are also in good repair. Surrounding Grounds : The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. All passageways were observed to be clear from obstruction. The outdoor area was enclosed, and no bodies of water were observed. Resident Files : LPA conducted a file review of three (3) randomly selected resident records to ensure compliance of licensing forms. Residents’ files appear to be complete and updated. Due to time constraints, LPA had to terminate the visit and will return on a later date to complete the Required - 1 Year inspection by reviewing staff files, resident record, interview residents and staff. An exit interview was conducted. A copy of this report was provided to the Executive Director.