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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200721
Report Date: 02/27/2024
Date Signed: 02/27/2024 11:46:07 AM


Document Has Been Signed on 02/27/2024 11:46 AM - 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:BLACKWELL,CAROLFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 186DATE:
02/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jesus Gonzalez, Executive DirectorTIME COMPLETED:
11:55 AM
NARRATIVE
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On 2/27/2024, at 10:00am Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/14/2024. LPA met with Executive Director, Jesus Gonzalez and explained the purpose of the visit.

The incident report received stated that Resident 1 (R1) was observed walking back into the community through the front door by the concierge. Record review of R1's physician's report dated 3/21/2023, indicated that R1 is not able to leave the facility unassisted. Staff 2 (S2) stated that staff checked cameras and did not catch her leaving, but there are exits where a PIN code is not needed and staff assume R1 left through rear door. LPA obtained a copy of the staff roster, resident roster, Resident 1 (R1) physician's report and progress notes for the month of February during the visit.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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 02/27/2024 11:46 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2024
Section Cited
CCR
87705(c)(4)

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87705 (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s... safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidence by:
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Execuive Director implemented a plan to have a private companion for R1 starting 2/29/2024. Deficiency cleared.
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Based on LPAs interviews and record review the Licensee did not comply with the section cited above in supporting R1's needs, which poses a potential health and safety risk to residents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
LIC809 (FAS) - (06/04)
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