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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200721
Report Date: 04/11/2022
Date Signed: 04/11/2022 03:57:13 PM


Document Has Been Signed on 04/11/2022 03:57 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:MOROS, MICHELLEFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 187DATE:
04/11/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Rachel Kelly, Senior Administrative Specialist and Zachary Striplin, Wellness nurseTIME COMPLETED:
04:20 PM
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On 4/11/2022 Licensing Program Analysts (LPAs) L. Ibo & L. Francisco conducted a health and safety check as a result of department receiving a priority 2 complaint. LPAs met with Rachel Kelly, Assistant Executive Director and Zachary Striplin, Wellness Nurse. Facility has census of 187 during todays visit.

During the health and safety check, LPAs toured the building, LPAs inspected common areas, bathrooms, kitchen and dining. LPAs observed smoke detectors and carbon monoxide detector throughout facility. Water temperature was checked at one common bathroom with a temperature of 106.4 degrees Fahrenheit. Enough food supplies was observed. Facility is maintained at a comfortable temperature for the residents in care. First aid kit was observed to be complete. Fire Extinguisher last service date was December 13, 2021.

Due to facility's current gastrointestinal outbreak, LPAs was not able to visit residents room, however LPAs observed residents at the common area appeared to be well groomed, neat and comfortable. Facility appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies were cited today.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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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