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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603231
Report Date: 12/30/2020
Date Signed: 12/31/2020 08:39:09 AM

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:ASHLEY MARCELLUSFACILITY TYPE:
740
ADDRESS:3535 MANCHESTER AVETELEPHONE:
(760) 436-8900
CITY:CARDIFF BY THE SEASTATE: CAZIP CODE:
92007
CAPACITY:175CENSUS: 134DATE:
12/30/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mary Jane Rodriguez, interim EDTIME COMPLETED:
03:35 PM
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Licensing Program Manager (LPM) Denise Powell, County of San Diego Nurse Contractors, Robert Montinallo and Melanie Rodriguez; and California Department Public Health (CDPH), Health Facility Evaluator Nurse (HFEN), Michelle House with the HAI Program, conducted an on-site visit. LPM and team identified themselves and discussed the purpose of the visit with interim Executive Director (ED) Mary Jane Rodriguez. Administrator Ashley Marcellus participated in discussions via telephone.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment (PPE). During today's visit, the team interviewed Administrator and other facility staff and conducted a walk-though of the facility, including Memory Care areas. A debriefing was conducted at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with the Administrator and other facility staff and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided via electronic mail. An electronic receipt of confirmation was requested to be sent by the facility representative upon receipt of the documents.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Denise PowellTELEPHONE: 619-301-9770
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
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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