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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601003
Report Date: 01/22/2025
Date Signed: 01/22/2025 01:15:30 PM

Document Has Been Signed on 01/22/2025 01:15 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BELMONT HOMESFACILITY NUMBER:
415601003
ADMINISTRATOR/
DIRECTOR:
KHO, RODRIGO & KHO, LORETAFACILITY TYPE:
735
ADDRESS:1060 HILLER STTELEPHONE:
(650) 832-1052
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 6CENSUS: 5DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Licensee/Administrators, Loreta And Rodrigo Kho TIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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On January 22, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Licensee/Administrator, Loreta And Rodrigo 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. This is a one story facility; there were two clients present at the facility, the other 3 clients were at their day programs. There are three resident bedrooms, two of which are shared and one that is currently a single private room. All bedrooms were observed to have all required furnishings and in good repair. LPA observed two bathrooms to be clean and odor-free. Water temperature throughout the facility measured between 112-114 degrees F. LPA observed 2 days for perishables and 7 days non-perishables.
First aid kit was observed to be complete.

Dining room and living room were free from tripping hazards. A comfortable temperature of 68 degrees F is maintained and lighting is sufficient for comfort. Medications, sharps, and chemicals were observed locked an inaccessible to clients in care. LPA observed two staff rooms and one office room.

Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of January 2025. Emergency drills are conducted every 3 months and logged. LPA reviewed 5 client records and 2 staff records. Client 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 citations are issued during this visit. Report is reviewed with the Licensee/Administrator and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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