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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200721
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:29:59 PM


Document Has Been Signed on 07/03/2024 04:29 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:BLACKWELL,CAROLFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 180DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Erik Holzherr, Assistant Executive DirectorTIME COMPLETED:
04:45 PM
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On 07/03/2024 around 12:30 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA met with Erik Holzherr, Assistant Executive Director (AED) and explained the purpose of the visit. The facility’s fire clearance was approved for 225 non-ambulatory, 50 may be bedridden and 20 are approved for hospice waivers.

Upon entry and during the visit, residents were lounging in the facility including but not limited to the common areas, bistro, and courtyard area. The facility has a central medication room that remains locked. First Aid kits are stored throughout the facility. Smoke/carbon monoxide detectors are combined with sprinkler system. Fire extinguisher was last serviced on 05/16/2024. Fire drills are performed monthly and an annual evacuation is performed in conjunction with the local police department. Lunch was served while at the facility. Residents reside in individual apartments and the hot water temperature was a comfortable temperature with the censored faucet in the residents' shared bathroom. There was adequate lighting throughout the facility. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 06/2024.

LPA reviewed ten (10) resident records and 5 staff records. LPA also reviewed a sample of residents' clinical files.

Exit interview conducted and copy of this report reviewed with Erik Holzherr, Assistant Executive Director.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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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