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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200721
Report Date: 12/28/2021
Date Signed: 12/28/2021 02:19:11 PM

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:MOROS, MICHELLEFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 78DATE:
12/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Michelle Moros, Executive DirectorTIME COMPLETED:
02:30 PM
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On 12/28/2021 Licensing Program Analyst (LPA) L. Holmes and Licensing Program Manager (LPM ) Y. Flores-Larios arrived unannounced to conduct a case management visit. At 1:10 PM, LPA and LPM met with Michelle Moros, Executive Director and explained the reason for visit in response to an incident report received on 12-08-2021 where R1 was absence without leave (AWOL).

LPA conducted interview with Executive Director and toured the memory care unit "The Neighborhood" located on the second floor. On 11-25-2021 a LVN was conducting usual rounds, LVN noticed that R1 was not in her room. Facility staff immediately searched the facility and surrounding areas, R1's family was notified, and Albany Police Department was notified as well. R1 was located and returned unharmed. Facility suspects that R1 left through the front door as other resident's families were entering and exiting with residents from outings for Thanksgiving. Facility has implemented procedures in the event of an influx of visitors.

No deficiencies are being cited on this visit. Exit interview conducted and a copy of this report provided
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
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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