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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601003
Report Date: 01/29/2024
Date Signed: 01/29/2024 11:55:08 AM

Document Has Been Signed on 01/29/2024 11:55 AM - 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: 5DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Rodrigo and Loreta KhoTIME COMPLETED:
12:15 PM
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On January 29, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Administrators, Rodrigo and Loreta Kho and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. No accessible bodies of water or fire safety hazards observed. The indoor and outdoor passageways were free from obstruction. There was one client present at the facility, the other 4 clients were at their day programs.

LPA observed two shared rooms with beds 6ft apart from each other and one private room with all required furnishings. Two bathrooms were observed to be clean and free from odor. Water temperature throughout the facility measured between 112-116 degrees F. LPA observed 2 days for perishables and 7 days non-perishables. Emergency drills are logged and done every three months.

A comfortable temperature of 69 degrees F is maintained and lighting is sufficient for comfort. Toxins and medication were locked and inaccessible to residents. Carbon monoxide detectors and smoke alarms monitors are working properly.

LPA reviewed 3 resident records and 2 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No deficiencies were found during this visit. LPA reviewed report with administrators and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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