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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200721
Report Date: 07/20/2023
Date Signed: 07/20/2023 03:34:32 PM


Document Has Been Signed on 07/20/2023 03:34 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BELMONT VILLAGE ALBANYFACILITY NUMBER:
019200721
ADMINISTRATOR:MOROS, MICHELLEFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 184DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Tamra Marie Tsanos, Executive DirectorTIME COMPLETED:
04:00 PM
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On 07/20/2023 at 09:40 AM, Licensing Program Analyst (LPA) L. Holmes and Associate Governmental Program Analyst (AGPA) L. Francisco conducted an unannounced annual inspection. LPA/AGPA met with Tamra Marie Tsanos, Executive Director (ED) and explained the purpose of the visit. LPA L. Holmes toured the facility with (ED) who currently holds a certificate (#6049144740) that expires on 05/07/24. The facility’s fire clearance was approved for two hundred twenty-five (225) non-ambulatory residents; fifty (50) may be bedridden.

Upon arrival, LPA observed one (1) staff attending the receptionist desk, and two families visiting in the facility's common area. LPA, ED, and two (2) staff members toured the facility, including but not limited to, common areas, wellness center, library, bathrooms, kitchen, dining room(s), medication room/nursing station, front area and courtyard(s). The facility consists of individual apartments housed by the residents and has a monitored unit for memory care (The neighborhood). All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at 71 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature was measured at 111.2 degrees (F). All shared restrooms, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing signs, paper towels, and soap observed at all hand washing stations. Linen and hygiene products are available for all residents. PPE, sanitizer, and paper goods remain sufficient.

...continued on LIC9099C.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BELMONT VILLAGE ALBANY
FACILITY NUMBER: 019200721
VISIT DATE: 07/20/2023
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...continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and serviced 04/06/23. Emergency Disaster Plan is updated. Safety drills were last conducted 06/2023 and are rotational between AM and PM schedules monthly.

AGPA reviewed five (5) staff records, and all staff have criminal record clearances. Five (5) residents records were reviewed and are complete.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided to ED.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2