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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603231
Report Date: 04/21/2021
Date Signed: 04/21/2021 04:35:05 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:ASHLEY MARCELLUSFACILITY TYPE:
740
ADDRESS:3535 MANCHESTER AVETELEPHONE:
(760) 436-8900
CITY:CARDIFF BY THE SEASTATE: CAZIP CODE:
92007
CAPACITY:175CENSUS: 134DATE:
04/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:42 PM
MET WITH:Operations Specialist, Mary Jane RodriguezTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management virtual visit, due to the COVID-19 pandemic. LPA identified herself and stated the purpose of the visit to Operations Specialist, Mary Jane Rodriguez and Director of Residential Care, Deeanna Lyons.

The facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing on February 26, 2021. The incident report stated that on February 22, 2021, R1 reported to a family member that they sustained an injury.

On today’s date, LPA toured the facility, requested copies of facility records and interviewed staff. No deficiencies were cited at this time.

An exit interview was conducted with Operations Specialist Mary Jane Rodriguez and Director of Residential Care, Deeanna Lyons. A copy of this report, LIC811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail to Operations Specialist Mary Jane Rodriguez. An electronic read receipt verifies receipt of these documents.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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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