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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200721
Report Date: 12/12/2024
Date Signed: 12/12/2024 03:25:25 PM

Document Has Been Signed on 12/12/2024 03:25 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/
DIRECTOR:		JESUS GONZALEZ CAMARILLOFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY: 225TOTAL ENROLLED CHILDREN: 0CENSUS: 186DATE:
12/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH: Jesus Gonzalez, Executive Director (ED)TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 12/12/24 around 10:40 AM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management for complaint #15-AS-20240716140724 received on 07/16/2024. LPA Jesus Gonzalez, Executive Director (ED) and explained the purpose of the visit.

During the investigation of the above complaint, LPA interviewed ED, Staff (S1, S2, S3, S4, S5) Witnesses (W1, W2, W3, W4), obtained a resident roster, and requested the following for Resident #1 (R1): current Physician's Report, Admission Agreement, ID/Emergency Contact information, hospice care plan, care notes, incident reports, hospice notification, facility's regulations and documentation regarding Stage 3 and 4 pressure wounds, emails and/or written communications to R1's family regarding pressure wound injuries.

-On 07/23/24, LPA requested R1’s Initiation of Hospice notification and Physician’s Report (LIC602) from S1. LPA requested the reports be provided to the Community Care Licensing Department (CCLD) by 07/30/2024 for preliminary review. The records weren’t provided to LPA during the investigation.

-On 07/23/24, LPA requested R1’s Unusual Incident Reports (UIRs) from S1. R1 was transported to Alta Bates Medical Center in Berkeley for emergency services to treat a stage 3 to 4 pressure wound. Notification of deviation of R1’s hospice care plan on 07/14/24 was not provided to CCLD.

Continued on LIC809C...
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Lisha HolmesTELEPHONE: 510-286-4201
DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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 4
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: 12/12/2024
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...continued from LIC809.

-W1 and S5 confirmed that Private PALs were not available throughout the entire duration of R1’s admission agreement. The licensee did not provide any written notice (30 or 60 days) for the change in services noted below on pages 5, 10 and 30. Records and interviews revealed that W1 hired a private caregiver from 12/2022 to 07/2024 to aid in the care of R1.

Page 5 II. Personal Assistance and Care “… Appendix A. We may change the scope and pricing of the services and our discretion upon sixty (60) days’ written notice to you.

Page 10 C. Private PALs and Services from Home Health Agencies “To accommodate additional resident needs and preferences, we offer private care-giving and companion services for an additional fee as set forth in Appendix B”

Page 30. B. Termination by Us. (1) Upon (30) Days’ Notice. We may terminate this Agreement upon (30) days’ written and verbal notice to you and your personal representative if any of the following events occur: d. If, after admission, we determine that you have a need not previously identified and a reappraisal has been conducted pursuant to Section 87463 of Title 22 of the California Code of Regulations, and we and the person who performs the reappraisal believe that the community is no longer appropriate for you.

Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. 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. A copy of this report and appeal rights were provided to ED.


SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/12/2024 03:25 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: 12/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents...(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services...or within five working days of admitting a resident already receiving hospice care services. The notice ...include...name...date of admission... name and address of the hospice.-This requirement was not met as evidenced by:

Deficient Practice Statement
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POC Due Date: 12/19/2024
Plan of Correction
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ED agreed to provide in-service training to all staff that are involved in decision making & procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Lisha HolmesTELEPHONE: 510-286-4201

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024

LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/12/2024 03:25 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: 12/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.-This requirement was not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 12/19/2024
Plan of Correction
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ED agreed to provide in-service training to all staff that are involved in decision making & procedures on the cited regulation. Submit a list of attendees signatures as proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Lisha HolmesTELEPHONE: 510-286-4201

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024

LIC809 (FAS) - (06/04)
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