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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603231
Report Date: 08/13/2021
Date Signed: 08/13/2021 01:55:58 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: 139DATE:
08/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ashley Marcellus, Executive DirectorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Carmen Lopez, and Licensing Program Manager (LPM), Denise Powell, conducted a Case Management visit, to follow-up on a related concern observed during a complaint investigation. LPA and LPM identified themselves and were granted entry by Diana Atempa, Receptionist. LPA and LPM met with Ashley Marcellus, Executive Director, and disclosed the purpose of today’s visit.

On March 2, 2020, an outside source reported that staff did not administer medications as prescribed. Review of staff interviews and multiple resident records pertinent to the concerns were conducted. Based on information received a Technical Assistance Advisory is being provided to the facility regarding administration of medications.

An exit interview was conducted with Ashley Marcellus, Executive Director, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to Executive Director via electronic mail. An electronic read receipt confirms the documents were received.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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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