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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201442
Report Date: 01/07/2025
Date Signed: 01/07/2025 02:34:07 PM

Document Has Been Signed on 01/07/2025 02:34 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BELMONT VILLAGE SAN RAMONFACILITY NUMBER:
079201442
ADMINISTRATOR/
DIRECTOR:		COONS, JENNIFERFACILITY TYPE:
740
ADDRESS:1000 WALNUT DRIVETELEPHONE:
(925) 242-1000
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 176CENSUS: 0DATE:
01/07/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Executive Director, Jennifer CoonsTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 1/07/2025 at 8:55 AM, Licensing Program Analyst (LPA) A. Gomez arrived announced to conduct a Pre licensing inspection. LPA met with Executive Director, Jennifer Coons and explained the purpose of the visit. The facility currently has no residents.

LPA toured facility with Executive Director including but not limited to 18 bedrooms, 18 bathrooms, kitchen, common areas and courtyards. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Extra linens and hygiene supplies were available. There is sufficient lighting throughout facility. Room temperature was maintained at 72 degrees F and a sample of hot water temperature was measured over at 120 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational and facility has an interconnected sprinkler system. Fire extinguisher was last serviced on 5/13/2024. Facility pool is secured with fence and key fob activated lock from the outside. Kitchen freezer temperature was maintained at -4 degrees F and refrigerator at 38 degrees F.

LPA observed the following:
Hot water temperature is measuring over 120 degrees F

***Facility is not ready to be licensed***

LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application, and license to be granted by CAB analyst.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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