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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601003
Report Date: 01/11/2022
Date Signed: 02/10/2022 02:48:28 PM

Document Has Been Signed on 02/10/2022 02:48 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BELMONT HOMESFACILITY NUMBER:
415601003
ADMINISTRATOR:KHO, RODRIGO & KHO, LORETAFACILITY TYPE:
735
ADDRESS:1060 HILLER STTELEPHONE:
(650) 544-4802
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 6CENSUS: 5DATE:
01/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Loreta NgoTIME COMPLETED:
02:30 PM
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On January 11, 2022, Licensing Program Analyst (LPA) Komal Charitra attempted an unannounced annual infection control inspection. LPA arrived to the facility and rang the doorbell but there was no answer. LPA knocked multiple times but no one opened the door.

On February 10, 2022, LPA Charitra conducted an unannounced annual inspection. Upon arrival, LPA did not observe signage on the front door. LPA was greeted by the Administrator, Loreta Ngo and Rodrigo Ngo joined shortly thereafter. LPA explained the purpose of the visit. LPA was screened at the entry point and the administrator was able to provide screening log documentation for residents and visitors.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are present: entry procedures, daily monitoring for residents, and 30-day PPE supply. LPA advised Administrators to start documenting staff's temperatures and to post more signage throughout the facility and on front door.

LPA observed two bathrooms; both are equipped liquid soap, paper towels, and trash cans with lids. During the facility tour, LPA observed 5 residents that were in their day program virtually.

There are a total of 5 bedrooms in the facility, two of which are shared rooms with beds 3 feet apart from head-to-toe and the other three used as private rooms.

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SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BELMONT HOMES
FACILITY NUMBER: 415601003
VISIT DATE: 01/11/2022
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Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed.

LPA also requests the following documents to be sent to CCLD by 2/17/22:
  • LIC500 Personnel Summary
  • LIC308 Administration Organization
  • LIC400 Resident Cash Resources
  • LIC402 Surety Bond
  • Administrative Certificate

Report is reviewed with administrators and a copy is provided. No citations issued.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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