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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200721
Report Date: 08/20/2024
Date Signed: 08/20/2024 06:16:00 PM


Document Has Been Signed on 08/20/2024 06:16 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: 171DATE:
08/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Jesus Gonzalez, Executive Director
Carol Blackwell, Director of Resident Care Services
Erik Holzherr, Assistant Executive Director		TIME COMPLETED:
06:30 PM
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On 08/20/24 around 02:25 PM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to conduct a case management for the recent diagnoses and relocation of Resident #1 (R1). LPA met with Jesus Gonzalez, Executive Director (ED) and Carol Blackwell, Director of Resident Care Services (S2). LPA explained the purpose of the visit.

W1 email the following information to CCLD. R1 is a resident at Belmont Village Albany (BVA) and was admitted to the Highland Hospital in Oakland, CA after a fall at BVA during the night on 08/05/24. R1 has a severe fracture to the femur and hip area, and given his age, has decided not to receive treatment to repair the injury. R1 is expected to be completely bed-bound and receiving only pain and comfort medications. He is currently in a short-term skilled nursing facility (SNF), Richmond Post Acute. R1 require 24-7 care for his remaining time; R1 also has multiple other health conditions. The Unusual Incident/Injury Report (UIR) states that the incident occurred on 08/06/24 around 10:40 PM.

W1 stated that in order to waive the 30-day termination notice requirement in the agreement, BVA is requiring a "health condition relocation order" from the Department of Social Services. Per Title 22 Division 6 Chapter 8 Article 11 Health-Related Services and Conditions, 87637 Health Condition Relocation Order is not initiated by R1 or W1 and the onus is on the licensee to follow the regulations.

Given R1's current health condition and situation, LPAand ED discussed the options available to R1 and W1; R1 is currently at a SNF. ED stated that the 30-day notice had been activated by W1 and that he/she is willing to work with W1. LPA confirmed with Erik Holzherr, Assistant Executive Director (AED) that even if R1 is not returning to the facility, W1 would need to make arrangements to remove R1's personal belongings from the unit in order for maintenance to begin renovations and for BVA to retain a possible new resident.
No deficiencies cited.
Exit interview conducted and copy of this report provided to AED.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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