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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200721
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:55:48 PM

Document Has Been Signed on 01/15/2025 02:55 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:
01/15/2025
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Jesus Gonzalez, Executive Director (ED) TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 01/15/24 around 01:15 PM L. Holmes, Licensing Program Analyst (LPA) arrived announced to conduct a case management for complaint 15-AS-20241007145119 received on 10/07//2024, and to discuss two (2) reported elopements. LPA met with Jesus Gonzalez, Executive Director (ED) and explained the purpose of the visit.

During the visit LPA and ED discussed Resident #1 (R1's) admission history, and reviewed Safely You footage for the investigation on the of the above complaint. LPA noted findings, ED will forward emails related to the complaint, staff and resident roster.

ED reported on 11/19/24, R2 resides in Assisted Living, (AL) exited an alarmed back door at the facility around 4:30 PM. The concierge and caregiver intercepted R2 after the alarm and camera detection by 04:35PM. R2 has exiting behaviors, MD and Responsible Party (RP) were notified.

Ed reported on 01/04/25, R3 resides in AL, exited through the main entrance of the facility around 2:00 PM. A caregiver intercepted R3 at the bus stop in front of the facility at 2:02 PM. R2 doesn't have exiting behaviors, will be monitored, MD and RP's were notified.

No deficiencies cited, exit interview conducted and a copy of this report was provided to ED.


Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Lisha HolmesTELEPHONE: 510-286-4201
DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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