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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603231
Report Date: 08/12/2022
Date Signed: 08/19/2022 04:45:42 PM


Document Has Been Signed on 08/19/2022 04:45 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, 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: 150DATE:
08/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Executive Director Ashley Marcellus and Elizabeth Smith, Director of Resident Care Services TIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced annual required licensing inspection. LPA was granted entry by Executive Director Ashley Marcellus after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Ashley and Director of Resident Care Services Elizabeth Smith, including the following sections: Person in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility has Plans for Infection Control and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety.

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs were provided to be posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and encouraged for residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility in in compliance with and has implemented infection control practices as outlined in its LIC 808.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Ashley and Elizabeth. A copy of this report, along with the Licensee Rights (9058 01/16) was printed and provided to Ashley at the facility.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022
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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