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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603231
Report Date: 12/17/2021
Date Signed: 12/17/2021 01:17:15 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: 143DATE:
12/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Ashley MarcellusTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Ramon Serrano and County of San Diego Public Health Nurses Jennifer West and Elizar Perez conducted an on-site HAI assessment visit. LPA Serrano and team identified themselves and discussed the purpose of the visit with Executive Director (ED) Ashley Marcellus.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols as well as the use of personal protective equipment (PPE). During today's visit, LPA Serrano and Nurses Jennifer and Elizar conducted a walk-though of the facility. A debriefing was conducted with ED Ashley Marcellus and Director of Resident Care Services Deeanna Lyons at the conclusion of the visit.

No deficiencies were cited during today's visit. An exit interview was conducted with ED Ashley Marcellus and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to ED via electronic mail. An electronic receipt of confirmation was requested to be sent by the ED upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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