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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201442
Report Date: 01/09/2025
Date Signed: 01/09/2025 02:37:19 PM

Document Has Been Signed on 01/09/2025 02:37 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:
01/09/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Executive Director, Jennifer Coons TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 1/09/2025 at 1:45PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a second announced pre-licensing visit. LPA met with Executive Director, Jennifer Coons. The facility currently has no residents.

LPA inspected the issues that were noted during the first pre-licensing visit. All issues are corrected and observed. Random hot water temperatures were measured and were between 111.7 and 113.8 degrees Fahrenheit

No Issues were noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Administrator and a copy of this report provided.

COMP III waived

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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