<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200721
Report Date: 10/08/2024
Date Signed: 10/08/2024 12:54:33 PM


Document Has Been Signed on 10/08/2024 12:54 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: 184DATE:
10/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Jesus Gonzalez, Executive Director TIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/08/24 around 10:35 AM Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management. LPA met with Executive Director (ED) Jesus Gonzalez and explained the purpose of the visit.

On 09/03/24, LPA L. Holmes received a call from LPA L. Fontanilla requesting COVID-19 status for Belmont Village Albany as a result of a UIR report presented to licensing. LPA L. Holmes requested that ED confirm the number of Staff & Residents that were COVID-19 positive and advised that both should be reported to CCLD as the facility becomes aware of the positive results. Through email, LPA was advised by ED that there were positive COVID-19 cases dated from 08/23/24 - 09/02/24 along with a spreadsheet. During the visit, ED provided LPA with a facsimile and Unusual/Incident Reports (UIRs). LPA advised ED of the regulatory guidelines for reporting infectious diseases within 24 hours.

Based on information obtained a deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.



Exit interview conducted, appeal rights, and copy of this report provided to Executive Director (ED) Jesus Gonzalez.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
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


Document Has Been Signed on 10/08/2024 12:54 PM - 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: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2024
Section Cited
CCR
87211(a)(2)

1
2
3
4
5
6
7
Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports…(2) Occurrences…epidemic outbreaks…major accidents which threaten the welfare, safety or health of residents, personnel or visitors…within 24 hours either by telephone or facsimile…
1
2
3
4
5
6
7
ED agreed to conduct in-service staff retraining on reporting per the regulation and submit proof of completed certifications to CCLD by POC.
8
9
10
11
12
13
14
- This requirement is not met as evidence by:
Based on investigation, licensee did not comply with the section cited above by notifying CCLD of the incident within 24 hours which poses a potential health and safety risk to the persons in care.

8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2