079201442-3-4-2026-15-AS-BFOG-DSA4TJ-20260317192313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201442
Report Date: 03/04/2026
Date Signed: 03/04/2026 05:12:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/27/2026 and conducted by Evaluator Alona Gomez

COMPLAINT CONTROL NUMBER: 15-AS-20260227115032

FACILITY NAME:	BELMONT VILLAGE SAN RAMON		FACILITY NUMBER:	079201442
ADMINISTRATOR:	COONS, JENNIFER		FACILITY TYPE:	740
ADDRESS:	1000 WALNUT DRIVE		TELEPHONE:	(925) 242-1000
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	176	CENSUS: 154	DATE:	03/04/2026
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Executive Director (ED) Jennifer Coons		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Facility mismanaging residents medications
Facility not keeping accurate medication records/log

INVESTIGATION FINDINGS:

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On 03/4/2026 at 12:00 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct the initial 10-day visit and deliver findings for the above allegations. LPA explained the purpose of the visit with Executive Director (ED) Jennifer Coons.

LPA conducted interviews with staff, inspected med carts , reviewed records, and toured memory care.

Report continues on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20260227115032

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELMONT VILLAGE SAN RAMON	FACILITY NUMBER: 079201442
	VISIT DATE: 03/04/2026

NARRATIVE

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On the allegation "Facility mismanaging residents medications" and "Facility not keeping accurate medication records/log" LPA observed that the medications for R1, and R2 are being mismanaged. LPA observed medication counts for R1 were off. LPA observed a prescription for R1 that stated for them to take 1 tablet daily had a half tab and staff where unable to explain why. ED states that R1 used to manage their own medication however when the facility took over the proper procedure may not have been done to ensure that the counts were correct. LPA also observed several duplicate medications for R1 that were being used simultaneously when the excess should have been stored in over-flow. LPA also observed that at approximately 1:00pm that R2 had not been administered any of their morning medications. LPA also observed that the proper documentation was not done in the E-MAR as to why the medications were not administered. Through interviews with staff LPA found that they were not familiar with how to properly document medication refusals/ late administration or familiar with medication administration procedures. ED states that they had already identified that staff needed additional training and that it is scheduled for March 9-11 2026. Therefore the allegations "Facility mismanaging residents medications" and "Facility not keeping accurate medication records/log" are Substantiated.

***Civil Penalties assessed for $250 for repeat violation in 12 month period***

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20260227115032

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BELMONT VILLAGE SAN RAMON	FACILITY NUMBER: 079201442
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/18/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...for the provision of adequate services. This requirement was not met as evidence by:	1 2 3 4 5 6 7	By POC facility agrees to have all med-techs retrained and recertified and notify CCLD. Civil Penalty Assesed
	8 9 10 11 12 13 14	Based on interview and record review staff did not know how to provide proper medication assistance which attributed to medication mismanagment for R1 and R2 which poses a potential health and personal rights risk to residents in care	8 9 10 11 12 13 14
Type B 03/18/2026 Section Cited CCR 87465(c)(3)	1 2 3 4 5 6 7	(c) If the resident's physician has stated... all of the following requirements are met:(3 )A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.	1 2 3 4 5 6 7	By POC facility agrees to have all med-techs retrained and recertified and notify CCLD.
	8 9 10 11 12 13 14	Based on interview and record review staff did not properly document the PRN history for R2 which poses a potential health and personal rights risk to residents in care	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026

LIC9099 (FAS) - (06/04)

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