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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200721
Report Date: 08/20/2024
Date Signed: 08/20/2024 06:16:57 PM


Document Has Been Signed on 08/20/2024 06:16 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:BLACKWELL,CAROLFACILITY TYPE:
740
ADDRESS:1100 SAN PABLO AVETELEPHONE:
(510) 525-4554
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:225CENSUS: 171DATE:
08/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Carol Blackwell, Director of Resident Care Services
Erik Holzherr, Assistant Executive Director 		TIME COMPLETED:
06:30 PM
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On 08/20/24 around 02:25 PM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to conduct a case management for an Unusual Incident/Injury Report (UIR) for Resident #1 (R1). LPA met with with Carol Blackwell, Director of Resident Care Services (S2) and Erik Holzherr, Assistant Executive Director (AED). LPA explained the purpose of the visit.

Upon interviewing S2 regarding R1's bowel movements, S2 immediately knew who R1 was and stated that R1 resides in an Independent Living (IL) unit and that the caregivers would not normally keep record of the IL residents' bowel movements. Now that the facility is aware, there will be some follow-up conversations with R1 and R1's spouse to aid with R1's condition.

AED confirmed that the UIR was sent to CCLD and was aware of the incident as Assisted Living (AL) and IL support both sides.

No deficiencies cited.
Exit interview conducted and copy of this report provided to Erik Holzherr, Assistant Executive Director (AED).
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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