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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603231
Report Date: 08/12/2020
Date Signed: 08/12/2020 12:45:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BELMONT VILLAGE CARDIFFFACILITY NUMBER:
374603231
ADMINISTRATOR:SHERYL JOHNSTONFACILITY TYPE:
740
ADDRESS:3535 MANCHESTER AVETELEPHONE:
(760) 436-8900
CITY:CARDIFF BY THE SEASTATE: CAZIP CODE:
92007
CAPACITY:175CENSUS: 136DATE:
08/12/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Executive Director, Sheryl JohnstonTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA), Natasha Persaud, contacted the facility via telephone to conduct a Case Management Visit- Other regarding a Criminal Record Exemption. The visit is being conducted virtually via telephone due to COVID-19. LPA identified herself and explained the purpose of the call to Executive Director, Sheryl Johnston.

During the call, visual conference with the Executive Director, LPA explained Staff #1 (S1) required a Criminal Record Exemption. Caregiver Background Check Bureau (CBCB) issued a notice dated 05/27/20 regarding an Exemption Approval. On 06/19/20, CBCB issued another notice regarding Exemption Transfer Request Received and requested additional information. On 07/13/20, CBCB issued an additional notice regarding Transfer Case Closure, notifying the facility the requested information was not received and S1 was must be immediately removed. Community Care Licensing was not made aware of these notices until 08/11/20. The facility was contacted on 08/11/20 inquiring about S1. CCL was made aware S1 was present at the facility on 08/11/20. The Executive Director, was made aware S1 cannot be on the premises. According to Executive Director, S1 was removed from the facility on 08/11/20. The Executive Director understands and agrees S1 will not return prior to an approved exemption. No deficiencies were issued.

An exit interview was conducted with Executive Director, Sheryl Johnston, via virtual visit, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Executive Director via electronic mail. An electronic read receipt confirmation was requested to be sent by the Executive Director upon receipt of the documents. [See LIC 811 Confidential Names List to identify Staff #1]
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020
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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