415601080-11-13-2025-14-AS-KCUY-DNDTRK-20251113135741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 11/13/2025
Date Signed: 11/13/2025 01:57:45 PM

Document Has Been Signed on 11/13/2025 01:57 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:	COGIR OF BELMONT		FACILITY NUMBER:	415601080
ADMINISTRATOR/ DIRECTOR:	JIM SIDOTI		FACILITY TYPE:	740
ADDRESS:	900 SIXTH AVENUE		TELEPHONE:	(650) 591-2008
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY: 68		CENSUS: 51	DATE:	11/13/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:03 PM
MET WITH:	Administrator, Jim Sidoti		TIME VISIT/ INSPECTION COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On November 13, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 11/4/25. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. The Licensee reported on, 11/4/25 at 7:45pm, Resident 1 (R1) eloped from the facility. According to the Licensee, prior to the elopement, R1 became verbally and physically aggressive towards his/her one-on-one caregiver, instructing the caregiver not to enter his/her room. The one-on-one caregiver left R1's room, leaving R1 alone. R1 then exited the facility without authorization. Police department was immediately notified. R1 was located on the street in front of the community and was escorted back to the facility. During the visit, LPA interviewed the administrator, staff and reviewed R1's file. According to staff interviewed, R1 left through the third floor exit doors and was found outside around the bushes by the first floor entrance. According to staff interviewed, at around 8:15pm, the one-on-one caregiver noticed R1 was not in his/her room and notified the med-tech on shift. Based on file reviewed, R1 has a Parkinson's Disease, is unable to leave the facility unsupervised, has unsafe wandering behaviors, and is at risk for elopement, therefore, the facility worked with the family and the family decided to hire a private caregiver through a third party agency. According to Health and Wellness Director, when a private caregiver starts working with residents at the facility, the Health and Wellness provide orientation and let the private caregivers know that if there is an incident that occurs while assisting a resident, to notify the med-tech on shift. According to the staff interviewed, the one-on-one caregiver did not endorse or notify the facility med-tech that R1 and the caregiver got into an argument and was not with R1 until the one-on-one caregiver noticed R1 was missing. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Curley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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