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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601003
Report Date: 11/21/2022
Date Signed: 01/19/2023 12:06:58 PM

Document Has Been Signed on 01/19/2023 12:06 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
SF COASTAL AC/SC, 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) 832-1052
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 6CENSUS: 2DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Licensees, Rodrigo and Loreta KhoTIME COMPLETED:
12:11 PM
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On January 19, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA met with Licensees/Administrators, Rodrigo and Loreta Kho and explained the purpose of the visit. LPA was screened at entry point and Licensees were able to provide LPA screening log documentation for staff, visitors, and residents.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a double story home with 6 bedrooms and 2 full bathrooms. During the visit, LPA observed 2 residents present. According to the Licensee, the other 3 residents are at their day program. LPA toured the facility and observed 3 resident rooms; 2 of which were shared rooms with beds 6ft apart from each-other and the other room being a private room. 3 rooms were observed to be staff rooms, 2 on the first story and 1 on the second story. Bathrooms were observed to be equipped with liquid soap, paper-towels, hand-washing signs, and a trash can with a fitted lid. Non-skid mats were present in the showers.

LPA observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA toured the kitchen and observed it to be clean and in good repair. Medications, toxins, and sharps were locked and stored appropriately and inaccessible to residents. LPA observed 2 day perishable and 7 day non-perishable. Extra food supply was present. Washer and dryer was observed to be in good repair. First aid kit was observed to be completed. 30 day PPE supply was present. COVID-19 signage was posted throughout the facility. Overall the facility was clean and in good repair.

Infection control practices are observed: entry procedures, daily monitoring log for staff, residents and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies.

LPA requests the following forms to be submitted to CCL by 1/26/2023:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610D Emergency Disaster Plan
-Administrator Certificate
-LIC400 Resident Cash Resources
-A copy of surety bond

No citations will be issued during this visit. Report is reviewed with Licensees and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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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