Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a Case Management – Other visit, with the aims of discussing the community’s current COVID-19 outbreak. This visit was conducted in conjunction with Registered Nurse (RN) Jolene Thoreson from the Los Angeles Department of Public Health. Parties met with Executive Director Nancy Nelson and explained the reason for the visit.

This visit was regarding ongoing concerns related to the current Coronavirus (COVID-19) Outbreak for this community, and the facility staff’s failure to follow reporting requirements. Community Care Licensing (CCL) received an email on 01/22/2023, indicating the presence of COVID-19 in the community. Per communication with local public health, the outbreak for this community was opened on 01/31/2023. A Health Officer Order was also issued to this community and details regarding outbreak requirements were discussed. A site visit was conducted by local public health on 02/02/2023 and during the visit, parties discussed infection control policies and procedures. A discussion was had regarding reporting requirements as set forth by the local health department in managing communicable disease outbreaks.

At the start of an outbreak, facilities are required to complete and submit a line list and must complete the COVID-19 Public Health Email Update daily, Monday through Friday. The community is required to also update the line list as new positives arise. The above-mentioned requirements have been communicated to facility staff in person, over the phone, and via email. In discussion with Belmont Calabasas management and the local health department, the staff have not submitted the daily update report to local health department on a daily basis as requested. At times, the daily update has insufficient information and /or is not completely filled out. In addition, several requests have been made regarding the requirements for a completed and regularly updated line list. However, it has reportedly taken several days for the community to send updates to public health, versus sending the daily update as discussed.